www.jped.com.br
REVIEW
ARTICLE
Water
and
fluid
intake
in
the
prevention
and
treatment
of
functional
constipation
in
children
and
adolescents:
is
there
evidence?
夽
,
夽夽
Sabine
Nunes
Boilesen
a,
Soraia
Tahan
b,
Francine
Canova
Dias
c,
Lígia
Cristina
Fonseca
Lahoz
Melli
d,
Mauro
Batista
de
Morais
b,∗aUniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),ProgramadePós-graduac¸ãoemPediatriae
CiênciasaplicadasàPediatria,SãoPaulo,SP,Brazil
bUniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),DisciplinadeGastroenterologiaPediátrica,São
Paulo,SP,Brazil
cUniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),ProgramadePós-graduac¸ãoemNutric¸ão,São
Paulo,SP,Brazil
dCentroUniversitárioUNIFIEO,DepartamentodeCiênciasBiológicasedeSaúde,Osasco,SP,Brazil
Received18March2016;accepted2January2017 Availableonline25April2017
KEYWORDS
Constipation; Child; Fluidintake; Adolescent
Abstract
Objective: Tostudytheevidenceontheroleofwaterandfluidintakeinthepreventionand treatmentoffunctionalintestinalconstipationinchildrenandadolescents.
Sourceofdata: AsearchwascarriedoutintheMedlinedatabase(between1966and2016)for allpublishedarticlescontainingthefollowingwords:constipation,water,andfluids,published inPortuguese,English,andSpanish.Alloriginalarticlesthatassessedchildrenandadolescents wereselectedbytitleandabstract.Thereferencesofthesearticleswerealsoevaluated.
Synthesisofdata: Atotalof1040articleswereretrieved.Ofthese,24wereselectedfor read-ing.Thestudyincluded11articlesthatassessedchildrenandadolescents.Thearticleswere dividedintotwocategories, thosethatevaluatedwaterandfluidintakeasariskfactor for intestinalconstipationandthosethatevaluatedtheirroleinthetreatmentofintestinal consti-pation.Fivearticleswereincludedinthefirstcategory.Thecriteriaforassessingfluidintake andbowelrhythmwere differentineachstudy.Three studiesdemonstratedanassociation betweenlowfluidintakeandintestinalconstipation.Regardingtreatment,fivearticleswith heterogeneousmethodologieswerefound.Noneofthemclearlyidentifiedthefavorablerole offluidintakeinthetreatmentofintestinalconstipation.
夽
Pleasecitethisarticleas:BoilesenSN,TahanS,DiasFC,MelliLC,MoraisMB.Waterandfluidintakeinthepreventionandtreatmentof functionalconstipationinchildrenandadolescents:isthereevidence?JPediatr(RioJ).2017;93:320---7.
夽夽
ThisstudywascarriedoutatUniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),Disciplinade Gastroen-terologiaPediátrica,SãoPaulo,SP,Brazil.
∗Correspondingauthor.
E-mail:maurobmorais@gmail.com(M.B.Morais). http://dx.doi.org/10.1016/j.jped.2017.01.005
Conclusion: Therearefewarticlesontheassociationbetweenfluidintakeandintestinal con-stipation.Epidemiologicalevidenceindicates anassociationbetweenlowerfluid intakeand intestinal constipation.Further clinical trialsand epidemiologicalstudies thatconsiderthe internationalrecommendationsforfluidintakebychildrenandadolescentsarerequired. ©2017SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
PALAVRAS-CHAVE
Constipac¸ão intestinal; Crianc¸a;
Ingestãodelíquidos; Adolescente
Ingestãodeáguaelíquidosnaprevenc¸ãoenotratamentodaconstipac¸ãointestinal funcionalemcrianc¸aseadolescentes:existemevidências?
Resumo
Objetivo: Estudarasevidênciassobreopapeldoconsumodeáguaelíquidosnaprevenc¸ãoe notratamentodaconstipac¸ãointestinalfuncionalemcrianc¸aseadolescentes.
Fontesdedados: Foipesquisado nabasededadosdo Medline(entre 1966e2016)todosos artigospublicadoscomasseguintespalavras:constipac¸ão,águaelíquidos,nosidiomas por-tuguês,inglêseespanhol.Foramselecionados,pelotítuloeresumo,todososartigosoriginais comcrianc¸aseadolescentes.Asreferênciasdessesartigostambémforamavaliadas.
Síntesededados: Foramencontrados1040artigos.Desses,24foramselecionadosparaleitura. Foramincluídos11artigosqueestudaramcrianc¸aseadolescentes.Osartigosforamdistribuídos emduascategorias,osqueavaliaramoconsumodeáguaelíquidoscomofatorderiscopara constipac¸ãointestinaleosqueavaliaramoseupapelnaterapêuticadaconstipac¸ãointestinal. Cincoartigosseenquadraramnaprimeiracategoria.Oscritériosparaavaliarconsumode líqui-doseritmointestinalforamdiferentesemcadaestudo.Trêsestudosdemonstraramrelac¸ão entrebaixoconsumodelíquidoseconstipac¸ãointestinal.Quantoaotratamento,foram encon-tradoscincoartigoscommetodologiasheterogêneas.Emnenhumdelesfoipossívelidentificar comclarezaopapelfavoráveldoconsumodelíquidosnotratamentodaconstipac¸ãointestinal.
Conclusão: Existempoucos artigossobrearelac¸ãoentreconsumo delíquidoseconstipac¸ão intestinal. Evidências epidemiológicas indicamassociac¸ão entremenor consumo delíquidos comconstipac¸ãointestinal.Sãonecessáriosoutrosensaiosclínicoseestudosepidemiológicos que levemem considerac¸ão asrecomendac¸ões internacionaispara consumo delíquidos por crianc¸aseadolescentes.
©2017SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4. 0/).
Introduction
Intestinalconstipationisacommonclinicalmanifestationin thepediatricpopulation,andover90%ofcasesare classi-fiedasfunctionalgastrointestinaldisorders.1---3Asobserved in other functional gastrointestinal disorders, childhood intestinalconstipationresults fromtheinteractionof bio-logical,dietary,andpsychosocialfactorsthatinterferewith intestinal motility.4 The main factors related to diet are wateranddietaryfiberconsumption.3---6
Accordingtotheguidelines,functionalintestinal consti-pation treatment includes fecaloma clearing and mainte-nancetherapyusinglaxativestoavoidfecalre-impaction, toilettraining,andguidelinesforincreasingfiberandwater intake.4,7---9However,theguidelinesoftheEuropeanSociety for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)/NorthAmericanSocietyforPediatric Gastroen-terology,Hepatology,andNutrition(NASPGHAN),published in2014,questionstheefficacyofincreasedwaterintakein intestinalconstipationtherapyandsuggeststhat,according totheevidence, an increasein fluidintakefor the treat-ment of functional intestinal constipation should not be
recommended.10 When analyzing the evidence supporting thisposition,itcanbeverifiedthatthiswasbasedononly oneclinicaltrial,publishedin1998.11
Considering that increased water intakeis part of the treatment of functional intestinal constipation in other guidelines7---9 andin clinical practice,thisrecent position-ingmotivatedthedevelopmentofthepresentstudy,which aimedtoassesstheevidenceontheroleofwaterandfluid intakeinthepreventionandtreatmentoffunctional intesti-nalconstipationinchildrenandadolescents.
Methodology
and‘‘líquidos’’; ‘‘estre˜nimiento’’ and‘‘neto’’,inEnglish, Portugueseand Spanish.Alloriginal articlesthat included childrenandadolescentswereselectedbyreadingthetitle andabstracts.The searchwasnotrestrictedtothe exclu-siveevaluationofcontrolledandrandomizedclinicaltrials. Noreviewarticles,editorials,andcommentswereincluded inthisselection.
Moreover,thereferencelistoftheselectedarticleswas assessedtoobtainothernon-indexedarticles.Theselected articles were analyzed by two authors for the final data extraction.
Results
Atthebeginningofthesearch,1040articleswereretrieved. All articlesthat assessed the association between consti-pationandwater intakeor thatusedfluidsaspart ofthe therapywereselected.Thus,26articles11---36wereselected for reading. Of these, only the 11 articles11,22,24---30,32,36 thataddressed children andadolescents wereincluded in this review.After analysis, the articles weredivided into twocategories:thosethatassessedwaterandfluidintake as a possible risk factor for intestinal constipation and those that assessed their role in intestinal constipation treatment.
Of the retrieved articles, six evaluated water and/or fluid intake as a possible risk factor for intestinal constipation.22,24,25,28,30,36 These studies were carried out in Spain,22 Hong Kong,24,28 United Kingdom,25 Thailand,30 andKorea.36 The studied samplesranged from84to1426 individuals. The criteria used to evaluate fluid intake and intestinal rhythm were different in each study. The main results are shown in Table 1. Four articles showed an association between low fluid intake and intestinal constipation.22,28,30,36 The other two studies found lower fluidintake in children with intestinal constipation; how-ever,thedifferencewasnotstatisticallysignificant.24,25
Fluid intake as treatment of intestinal constipation wasassessedinfivearticles,11,26,27,29,32 withheterogeneous methodologies.Thestudies wereconductedin theUnited States,11,26,29 Korea,27 and Greece.32 Of these, only one founda positiveeffectofhigherfluidintakein the treat-ment of intestinal constipation; the positive effect was observedwhenthetreatmentincludedpolyethyleneglycol 4000.27Twoarticlesassessedtheincreaseinfluid consump-tion after a behavioral intervention with29 and without26 fluidintakeencouragementinchildrenwithretentive enco-presis(fecalincontinencecausedbyretention).Anincrease in fluid intake was observed in both studies. Moreover, therewasalso an increase in evacuationfrequency26 and adecreaseintheoccurrenceoffecalincontinence.29Inthe otherarticles,therewasnostatisticallysignificanteffectof increasedfluidintakeonthetreatmentofintestinal consti-pation(Table2).11,32
Discussion
This review showed that few studies evaluated low fluid intakeasafactorassociatedwithintestinalconstipationor theroleoffluidintakeinthetreatmentofconstipation.Of theelevenarticlesretrieved,six22,24,25,28,30,36 analyzedthe
association between water and fluidintakeand intestinal constipationandfive,theirroleinthetreatmentof intesti-nalconstipation.11,26,27,29,32
The association between intestinal constipation and lowerfluid intakeinsamples fromthegeneral population indicatethepossibilityofacausalassociationbetweenthe twovariables. Thus,in four22,28,30,36 of thesix22,24,25,28,30,36 articles, a statistically significant association was found betweenlowfluidintakeandevidenceofintestinal consti-pation.Intheothertwoarticles,24,25fluidintakebychildren with intestinal constipation was lower; however, the dif-ferencewasnotstatisticallysignificant.Thesearticlesare heterogeneous and difficult to compare due to how the variableswerequantifiedandtothemethodsusedtostudy theassociationbetweenvariables.
Infourarticles,22,28,30,36 theoddsratiowasanalyzedto analyze the association between lower fluid intake and higher probability of intestinal constipation. In Thailand, fluid intake of less than 1800mL/day in individuals aged between 10and18 yearswasassociatedwithan increase of20%intheriskoffewerthanthreebowelmovementsa week.30 InSpanishchildren,regardingtheintakeoffewer than fourglasses aday (800mL),a 2.5-foldprobabilityof intestinalconstipationwasverified.
When fluid intakewas fourto eightglasses a day, the decrease was 5.8 times.22 In Hong Kong,an intake of up totwo glasses a day (400mL) wasconsidered as the cut-off.Itwasfoundthattheconsumptionof600---800mLaday andofmorethan1000mLwasassociatedwithadecrease inthechanceofintestinalconstipationofeightto14times, respectively.28 In Korea, intake of less than 500mL/day between 25 and 84 months of age was associated with an increased riskof intestinal constipation.36 As shown in
Table1,differentcriteriawereusedtoassessbowelhabits, butallstudiesindicatedastatisticallysignificantassociation between lower water consumption and signs of intestinal constipation.
Table1 Characteristicsofstudiesinchildrenthatevaluatedwaterorfluidintakeasariskfactorforintestinalconstipation.
Authors/year/participants/place Methodology Mainresults
ComasVivesetal.,200522 898childrenfromSpainaged between4monthsand15 years(meanof6.7years).
Intestinalconstipationwasconsideredas fewerthanthreebowelmovementsper week,accompaniedbypainanddifficulty. Thecontrolgroupconsistedofchildrenwho underwentmedicalconsultationsforany otherreasonandhadnoprevioushistoryof constipation.
Fluidintake(waterandjuice)amountingto fewerthanfourglassesofwateradaywas observedin73.4%ofthechildrenwith intestinalconstipationandin26.8%ofthe childrenwithoutintestinalconstipation (p<0.05).Logisticregressionshowedthat, comparedwiththeintakeoffewerthan fourglassesaday,theintakeoffourto eightglassesreducedtheriskof constipationto0.42andintakeofmore thaneightglasses,to0.17.
Leeetal.,200824
368childrenagedbetween3 and5yearsfromHongKong.
Intestinalconstipationwasdiagnosedbased ontheRomeIIcriteria.Childrenwith normalbowelhabitswereconsideredasthe controlgroup.Fluidintakerecordwas carriedoutforthreedays.
Thetotalfluidvolumeconsumedinthe groupwithintestinalconstipation(624mL) andinthecontrolgroup(685mL)didnot showastatisticallysignificantdifference (p=0.58).
Jenningsetal.,200925 84Englishschoolchildren agedbetween7and10 years.
Intestinalconstipationwasdiagnosedbased ontheRomeIIcriteria.Theintestinalhabit wasevaluatedthroughaseven-day bowel-movementdiary.Fluidintakerecord wascarriedoutforsevendays.
Childrenwithintestinalconstipationhad lowerwaterintake(mean832g)compared tochildrenwithoutintestinalconstipation (mean925g);however,therewasno statisticallysignificantdifference. Chan&Chan,201028
383schoolchildrenaged between8and10yearsin HongKong.
Intestinalconstipationwasdiagnosed throughaconstipationscale.A
questionnairewasapplied,whichincluded demographicinformation,clinicaldata,and medications,diet,andenvironmental factors.
Studentswhohadafluidintakeofthreeto fourglasses(200mL/glass;OR=0.12,95% CI:0.05---0.34)andfiveglassesormore (OR=0.07,95%CI:0.03---0.18)wereless likelytohaveintestinalconstipationthan studentswhoconsumedtwoglasses. Chienetal.,201130
1426Thaistudentsaged between10and18years
Intestinalconstipationwasconsideredonly withafrequencyofbowelmovementsless thanthreetimesaweek.Consumptionof fluids,fruits,andvegetableswasassessed byaquestionnaire.
Amultivariatelogisticanalysisshowedthat lowdailyintakeoffluids(<1.8L,OR=1.2, 95%CI1.07---1.43),fruit(<1portion, OR=1.6,95%CI:1.42---1.84),vegetables(<1 portion,OR=1.4,95%CI:1.25---1.67),and wholegrains(OR=1.2,95%CI:1.08---1.38), wereindependentlyassociatedwithan increasedriskofbowelfrequencylessthan threetimesaweek.
Parketal.,201636 212childrenaged25---84 months
Intestinalconstipationwasdiagnosedbased ontheRomeIIIcriteria.Informationon dietaryhabitswasassessedbya questionnaire.
Multivariatelogisticanalysisshowedthat theintakeof500mLorlessofwater (OR=9.9;95%CI:0.9---99.5)wasastrong predictorofintestinalconstipationin children.
In adults, five of the six published articles showed an association between low fluid intake and intestinal constipation.14,23,31,33,34 In the elderly, six articles were retrieved,13,15,17,19,21,35 and five15,17,19,21,35 did not identify anassociationbetweenfluidintakeandintestinal constipa-tion.Therefore,in bothchildrenandadults,theevidence indicates an association between lower fluid intake and intestinalconstipation.Fromtheexperimentalstandpoint, ithasbeendemonstratedthatfluidrestrictioninratsleads tolowerfeedintakeandlessstoolelimination.When con-trolling for the effect of decreased feed intake, it was confirmedthatwaterintakerestrictionisassociatedwitha reductioninfecalweight.38Inhealthyhumanadults,itwas observedthatfluiddeprivationdecreasesthefrequencyof bowelmovementsandfecalweight.14
Thesearticleswithsamplesfromthegeneralpopulation didnot considerwhether thefluid intakeof the assessed individuals was within the internationally recommended range.Therearetworecommendationsforfluidintake,one forNorthAmerica(DietaryReferencesIntake)39andanother forEurope(EuropeanCommunity).40InBrazil,itissuggested thattheNorthAmericanrecommendationsbefollowed.41
Table2 Characteristics ofthe studiesin children that evaluated therole of water intakeinthe treatment ofintestinal constipation.
Authors/year/participants/place Methodology Mainresults
Youngetal.,199811
90North-Americanchildren withintestinalconstipation agedbetween2and12 years.
Afteroneweekoffluidintakerecording, 108patientswithconstipationweredivided intothreegroups:1.Control,2.Increasein waterintakeby50%inrelationtobaseline, 3.Increaseinthesupplyofhyperosmolar fluid(>600mOsm/L).Dietwasassessedby athree-dayfooddiary.Thefrequencyof bowelmovementsandstoolconsistency wererecorded.Theinterventionlastedtwo weeks.
Thestudywascompletedby90patients. Nostatisticallysignificantvariationwas observedinanyofthethreegroupsatthe endofthesecondandthirdweeksof interventionregardingbowelmovement frequency,stoolconsistency,anddifficulty toevacuate.
Kuhletal.,200926
26North-Americanchildren aged3---11yearswithfecal incontinenceduetostool retention(retentive encopresis).
Fivetosixsessionsofbehavioral
interventionwerecarriedout,coveringthe followingtopics:physiologyofretentive encopresis,medications,importanceof dietaryfiberandclearliquids,toilet training,andtreatmentmaintenance. Recommendationonfluidintake:first session,explanationontheimportanceof consumptionandrecommendationofintake ([age+5goffiber]×28mL[1ounce])and thesecondsession:recommendationof fluidintake([age+10goffiber]×28mL[1 ounce]).Dietwasassessedthroughafood diary.
Bowelmovementfrequencyincreasedfrom 12.0to16.1perweek,whencomparingthe firstandlastweeksoftreatment.Themean fluidintakeincreasedsignificantlyfrom 480mLto720mL,comparingthefirstwith thelastweeksoftreatment(p≤0.001). Therewasnocontrolgroupforcomparison.
Kuhletal.,201029
37North-Americanchildren aged4---12yearswith retentiveencopresis.
Twotypesoftreatmentwerecomparedfor sixtosevenweeks:1.Behavioral
interventionand2.Behavioralintervention plusfluidintakeencouragement,session 3=(age[inyears]+5)×28mL(1ounce)and session5=(age[inyears]+10)×28mL(1 ounce).Clinicalanddietarydatawere obtainedby:reviewofmedicalrecords (retrospective,2005and2007);behavioral interventionandencouragementto increasewaterintake(prospective,2008 and2009).Therecommendationsforwater volumeintakewereexplainedwithgames andactivitiesadaptedtothechild’sage. Thechildrenreceiveda450-mLbottleto helpthemtocontrolfluidintake.
Fluidintakewashigherinthegroup receivingaspecificencouragementto increaseintakeattheintermediate treatmentstage(448mLvs.224mL)andat thefinalstage(532mLvs.280mL;
p≤0.001)
Thefrequencyofbowelmovementsand fecalincontinenceepisodesinthefirst weekwasthesameinbothgroups.When comparingthebeginningandtheendofthe treatment,thegroupwithinterventionand encouragementshowedadecreaseinthe occurrenceoffecalincontinence(p≤0.05) andtendencytoincreasetheevacuation frequency(p=0.08).
Baeetal.,201027
27Koreanchildrenaged between2and14yearswith intestinalconstipation
Themedicalrecordsofchildrenwhowere onmedication(Polyethyleneglycol4000 andlactulose)wereselectedfor maintenanceofintestinalconstipation control.Themedicationdosewasstablefor overthreemonthsandtheparticipantshad abowelmovementdiarycontaining informationonevacuationfrequency,stool consistency,andamountoffluids
consumed.Fluidrecommendationwas basedonbodyweight.Theevaluationof bowelmovementfrequencyandstool consistencywasperformedusingascoring system.
Thegrouptreatedwithpolyethyleneglycol 4000(n=14)showedahigherbowel movementfrequencyduringtheperiodof higherfluidintake,whencomparedtothe periodoflowerfluidintake(mediansof 27.7and25.1,respectively,p=0.009)and lowerstoolconsistency(mediansof20.0 and15.0,respectively,p=0.002).
Table2(Continued)
Authors/year/participants/place Methodology Mainresults
Karagiozoglou-Lampoudi etal.,201232
86Greekchildrenaged1---11 yearswithintestinal constipationaccordingto theNASPGHANcriteria (2006)7
Participantswererandomizedintotwo groups.Bothgroupsweretreatedwith lactulose.Onegroupreceivedwritten instructionsonthediet,recommendedby thegastroenterologistandintheother group,adietitianprescribedapersonalized dietforsevendays,calculatingtheenergy, nutrient,water,anddietaryfiberneeds. Foodevaluationwascarriedoutwiththe useoftwo24-hourfoodrecalls,onthefirst visitandafteronemonth,respectively.
Afteronemonthoftreatmentafavorable responsewasobserved(bowelmovement frequency≥3timesperweek,absenceof painfulevacuationandabsenceofhard stools)inbothgroups.Thegroupthat receivedapersonalizeddietshowedan increaseinenergy,carbohydrate,lipid, fiber,andwaterconsumption,whilethe othergroupshowedonlyfiberconsumption increase(p=0.013).Thegroupwith individualizeddietaryinterventionhada higherincreaseindietaryfiber
(0.83g/kg/dayversus0.24g/kg/day, p=0.001)andwaterintake(29.9mL/kg/day versus1.89mL/kg/day,p<0.001)when comparedwiththeothergroup.
NASPGHAN,NorthAmericanSocietyforPediatricGastroenterology,Hepatology,andNutrition.
Thesevaluesshouldbecomparedtotheexisting recommen-dationsforfluidintakebythepediatricpopulation.
The NASPGHAN/ESPGHAN10 guideline saysthat, due to thelackofscientificevidence,increasedfluidintakeshould notbe partof the functionalintestinal constipation ther-apeuticprogram. Theyonly mentionthearticle published in1998byYoungetal.11(Table2).Thisrandomizedclinical trialcomparedtwointerventionswithincreasedfluidintake in agroup thatdidnot receivethis typeof recommenda-tion.Theprojectbringsasimpleconsideration:whatwould theplacebobeinthisstudythatcouldbeusedforittobe double-blind?Thus,this clinicaltrial involving 90patients failedtoobserveanydifferenceregardingclinicalresponse tothethreeinterventionsrelatedtohigherfluidintake.The articledoesnotreportwhetherpatientsweretreated simul-taneouslyusingotherconductsthatcouldmasktheroleof fluidintakeintheevolutionofintestinalconstipation.The otherfourarticles26,27,29,32werenotprospectiveclinical tri-als.The articlesbyKuhletal.26,29 evaluatedtheeffectof astandardizedguidelineintheincreasefluidintakeaspart ofthetreatmentofretentiveencopresis(fecalincontinence causedbyretention).Apparently,theauthorsassumedthat increasedwaterintakeisameasurethatispartof intesti-nal constipation treatment. The first article showed that thepatients hadincreasedfluid intakeandthefrequency ofevacuationsattheendofthefollow-up;however,since therewasnocontrolgroup,itwasnotpossibletoattribute theeffect,or part ofit, tothefluid intakeincrease.26 In thesecondarticle,29agroupwasprospectivelytreatedand comparedwithdatafromthemedicalfilesofother previ-ouslytreatedpatients.Itwasverifiedthattheintervention resulted ingreaterfluidintake;however,noimprovement inclinicalresponsewasobserved.Thesetwostudies,whose designwasnotspecificallyaimedatassessingthe efficacy ofincreasingfluidintakeinthetreatmentofconstipation, didnotofferevidenceontheefficacyoffluidsincontrolling intestinalconstipationassociatedwithretentiveencopresis. Another article onthis subjectwasa randomized clin-ical trial.32 It was performed to compare two types of
treatment: (1) standardized diet and (2) personalized dietaryintervention. It wasobserved that the group that received personalized dietary intervention had a higher increaseinwaterintakethanthegroupwithastandardized diet.However,bothgroupsshowedsimilarimprovementin evacuationfrequency anddifficulty, aswell as in pain to evacuate.Bothgroupsreceivedlactuloseduringthe obser-vationperiod.32 The lactulosedose usedinthe study was not reported,nor whether it remained the same in both groupsduringthefollow-upperiod.Themostrecentarticle retrievedintheliteraturesearchwascarriedoutinKorea.36 The filesof patients withconstipationwho hadbeen sta-bleforatleasttwomonthsandhadrecordedfluidintake, stoolconsistency,andfrequencyofbowelmovementswere retrospectivelyevaluated.The articledidnotdefinewhat wasconsideredhigherandlowerfluidintake.Moreover,the articledidnotspecify howtheconsistency andfrequency of evacuationscores were calculatedbased on the infor-mation in the medical records. The information on each patientwasstudiedattwodifferentmoments.Theresults showedthattherewasanassociationbetweengreater evac-uationfrequencyandlowerstoolconsistencywiththeuseof polyethyleneglycol4000inperiodswithhigherfluidintake. However,duetoitslimitations,theclinicalrelevanceofthe observeddifferencesmaybeconsidereddebatable. There-fore,the analysisofthesearticlestoevaluatetheroleof fluidintakeinthetreatmentof intestinalconstipationdid notshowanyconsistentresults.
intakeortothehigherdietaryfiberintake,orevendueto thesynergisticeffectofthetwointerventions.
Thus,basedontheliterature analysis,itwasobserved that few studies have assessed the association between waterand/orfluidintakeandintestinalconstipation. More-over, these studies are heterogeneous and difficult to compare.Theresultsofstudies withasample ofthe gen-eralpopulationsuggestthatalowerintakeofwaterand/or fluidsis associatedwithintestinal constipation.Regarding therole ofwater in the treatment ofintestinal constipa-tion,thefewexistingarticlesdidnotshowanadvantageof agreaterfluidintakeinthetreatment.Conversely,studies withsamplesfromthegeneralpopulationshowafavorable effectofincreasingwater/fluidintaketoimproveintestinal habits.Thereisalsoevidencethatnormalchildrenand ado-lescentsdonotmeetdailyfluidintakerecommendations.In thiscontext,itisconsideredthattheadequateintakeof liq-uidsanddietaryfiberispartofwhatareconsideredhealthy eatinghabits. Thesemayconstitute apreventivemeasure andaninitialtherapyforcasesofmildintestinal constipa-tion.In contrast,moresevere patientswithfecalomaand fecalincontinencemustundergoatreatmentprogramthat involvestherapeuticmeasuresfordisimpactionand medica-tiontoensurethattheintestinalrhythmisnormalized.For thesepatients, althoughthereisnoevidence,itis impor-tanttoevaluatefluidintake.Ifnecessary,anincreaseinfluid intakeshouldberecommended,sothatthepatientreaches atleastwhatisrecommendedworldwide.
Therefore,theauthors concludetherearefewarticles thatassessedtheassociationbetweenwaterandfluidintake andintestinalconstipationinchildrenandadolescents.The resultssuggestthatalowerwaterintakeisassociatedwitha higherriskofintestinalconstipation.Thus,itcanbe specu-lated,basedonstudiescarriedoutwithcommunitysamples, thatagreaterwaterintakemaybebeneficialforthe preven-tionandtreatmentofmildintestinalconstipation.Further studiesarenecessarytobetterunderstandtheroleofwater andfluidsintheetiologyandtreatmentofintestinal consti-pationinchildrenandadolescents.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.OliveiraJN,TahanS,GoshimaS,Fagundes-NetoU,MoraisMB. Prevalênciadeconstipac¸ãoemadolescentesmatriculadosem escolasdeSãoJosédosCampos,SP,eemseuspais.Arq Gas-troenterol.2006;43:50---4.
2.MoraisMB,MaffeiHV. Constipac¸ãocrônica.JPediatr (RioJ). 2000;76:S147---56.
3.HyamsJ, CollettiR,Faure C,Gabriel-MartinezE,MaffeiHV, MoraisMB,etal.Functionalgastrointestinaldisorders:working groupreportoftheFirstWorldCongressofPediatric Gastroen-terology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr.2002;35:S110---7.
4.RasquinA,LorenzoCD,ForbesD,GuiraldesE,HyamsJS, Sta-ianoA,etal.Childhoodfunctionalgastrointestinaldisorders: child/adolescent.Gastroenterology.2006;130:1527---37.
5.Morais MB, Tahan S. Constipac¸ão intestinal. Pediatr Mod. 2009;45:79---98.
6.MaffeiHV,MoreiraFL,KissimotoM,ChavesSM,FaroSE,Aleixo AM. História clínica e alimentar de crianc¸as atendidas em ambulatóriodegastroenterologiapediátricacomconstipac¸ão intestinal crônica funcionalesuas possíveiscomplicac¸ões. J Pediatr(RioJ).1994;70:280---6.
7.ConstipationGuidelineCommitteeoftheNorthAmerican Soci-etyforPediatricGastroenterology,HepatologyandNutrition. Evaluationandtreatmentofconstipationininfantsand chil-dren: recommendations of the North American Society for PediatricGastroenterology,HepatologyandNutrition.JPediatr GastroenterolNutr.2006;43:e1---13.
8.National Collaborating Centre for Women’s and Children’s Health (UK). Constipation in children and young people: diagnosis and management of idiopathic childhood con-stipation in primary and secondary care. London: RCOG Press; 2010 [NICE Clinical Guidelines, No. 99], available from: http://www.ncbi.nlm.nih.gov/books/NBK65365/ [cited 9.11.16].
9.LindbergG,HamidSS,MalfertheinerP,ThomsenOO, Fernan-dezLB,GarischJ,etal.WorldGastroenterologyOrganization global guideline: constipation --- a global perspective. JClin Gastroenterol.2011;45:483---7.
10.TabbersMM,DiLorenzoC,BergerMY,FaureC,LangendamMW, NurkoS,etal.Evaluationandtreatmentoffunctional constipa-tionininfantsandchildren:evidence-basedrecommendations fromESPGHAN and NASPGHAN.JPediatrGastroenterolNutr. 2014;58:258---74.
11.Young RJ, Beerman LE, Vanderhoof JA. Increasing oral flu-ids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156---61.
12.Hope AK, Down EC. Dietary fiber and fluid in the control of constipation in a nursing home population. Med J Aust. 1986;144:306---7.
13.Whitehead WE, DrinkwaterD, Cheskin LJ, HellerBR, Schus-terMM.Constipationintheelderlylivingathome.Definition, prevalence,andrelationshiptolifestyleandhealthstatus.JAm GeriarSoc.1989;37:423---9.
14.Klauser AG,Beck A, Schindlbeck NE, Müller-Lissner SA. Low fluidintakelowersstooloutputinhealthymalevolunteers.Z Gastroenterol.1990;28:606---9.
15.CampbellAJ,BusbyWJ,HorwathCC.Factorsassociatedwith constipation in a community based sample of people ages 70years and over. JEpidemiol CommunityHealth.1993;47: 23---6.
16.Rodrigues-FisherL,BourguignonC,GoodBV.Dietaryfiber nurs-ingintervention:preventionofconstipationinolderadults.Clin NursRes.1993;2:464---77.
17.TowersAL,BurgioKL,LocherJL,MerkelIS,SafaeianM,Wald A. Constipation in the elderly:influence of dietary, psycho-logical,andphysiologicalfactors.JAmGeriatrSoc.1994;42: 701---6.
18.AntiM,PignataroG,ArmuzziA,ValentiA,LasconeE,Marmo R,etal. Watersupplementationenhancestheeffectofhigh fiberdietonstoolfrequencyandlaxativeconsumptioninadult patientswithfunctionalconstipation.Hepatogastroenterology. 1998;45:727---32.
19.MeiringPJ,JoubertG.Constipationinelderlypatients attend-ingapolyclinic.SAfrMedJ.1998;88:888---90.
20.ChungBD,ParekhU,SellinJH.Effectofincreasedfluidintakeon stooloutputinnormalhealthyvolunteers.JClinGastroenterol. 1999;28:29---32.
21.LindemanRD,RomeroLJ,LiangHC,BaumgartnerRN,Koehler KM,GarryPJ.Doelderlypersonsneedtobeencouragedtodrink morefluid?JGerontolABiolSciMedSci.2000;55:M361---5. 22.ComasVivesA,PolancoAlluéI,GrupodeTrabajoEspa˜nolparael
23.MurakamiK,SasakiS,OkuboH,TakahashiY,HosoiY,Itabashi M,etal.Associationbetweendietaryfiber,waterand magne-siumintakeandfunctionalconstipationamongYoungJapanese women.EurJClinNutr.2007;61:616---22.
24.LeeWT,IpKS,ChanJS,LuiNW,YoungBW.Increasedprevalence ofconstipationinpre-schoolchildrenisattributableto under-consumptionofplantfood:acommunity-basedstudy.JPaediatr ChildHealth.2008;44:170---5.
25.Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116---27.
26.KuhlES,FeltBT, PattonSR.Briefreport: adherenceto fluid recommendationinchildrenreceivingtreatmentforretentive encopresis.JPediatrPsychol.2009;34:1165---9.
27.BaeSH,SonJS,LeeR.Effectoffluidintakeontheoutcomeof constipationinchildren:PEG4000versuslactulose.PediatrInt. 2010;52:594---7.
28.ChanMF,ChanYL.Investigatingfactorsassociatedwith func-tionalconstipationofprimaryschoolchildreninHongKong.J ClinNurs.2010;19:3390---400.
29.Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasingdailywaterintake andfluidadherenceinchildren receivingtreatmentforretentiveencopresis.JPediatrPsychol. 2010;33:1144---51.
30.Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwaneseadolescents:associationwithdietaryintake, phys-icalactivity and sedentary behavior.J Pediatr Child Health. 2011;47:381---5.
31.Lazebnik LB, Prilepskaia SI, Baryshnikov EN, Parfenov AI, KosachevaTN.Prevalence and riskfactorsof constipationin theadultpopulationofMoscow(accordingtopopulation-based studyMUSA).EkspKlinGastroenterol.2011;3:68---73.
32.Karagiozoglou-LampoudiT,DaskalouE,AgakidisC,SavvidouA, ApostolouAm,VlahavasG.Personalizeddietmanagementcan optimizecomplianceto a high-fiber, high-waterdiet in chil-drenwithrefractoryfunctionalconstipation.JAcadNutrDiet. 2012;112:725---9.
33.MarklandAD,PalssonO,GoodePS,BurgioKL,Busby-Whitehead J, Whitehead WE. Associationof low dietary intake offiber and liquids with constipation: evidence from the National HealthandNutritionExaminationSurvey.AmJGastroenterol. 2013;108:796---803.
34.Mazlyn MM, Nagarajah LH, Fatimah A, NorimahAK, Goh KL. Stool patterns of Malaysian adults withfunctional constipa-tion:associationwithdietandphysicalactivity.MalaysJNutr. 2013;19:53---64.
35.Vargas-Garcías EJ, Vargas-Salado E. Food intake, nutritional status and physical activity between elderly with and with-out chronic constipation. A comparative study. Cir Cir. 2013;81:214---20.
36.ParkM,BangYG,ChoKY.Riskfactorsforfunctionalconstipation inyoungchildrenattendingdaycarecenters.JKoreanMedSci. 2016;31:1262---5.
37.ThompsonWG,LongstrethGF,DrossmanDA,HeatonKW,Irvine EJ,Müller-LissnerSA.Functionalboweldisordersandfunctional abdominalpain.Gut.1999;45:43---7.
38.Andrade SM,Dias DV, SperidiãoPG, MoraisMB [dissertation] Efeitodaingestãohídricanopesofecal:estudoexperimental emratosrecémdesmamado.SãoPaulo(SP):Disciplinade Gas-troenterologiaPediátricadaUniversidadeFederaldeSãoPaulo; 2012.
39.InstituteofMedicineFood,NutritionBoard.Dietaryreference intakes for water, potassium, sodium, chloride and sulfate. WashingtonDC:NationalAcademyPress;2005.
40.EFSA. Draft dietary reference values for water. Scientific opinion of the panel on dietetic products, nutrition and allergies; 2008. Available from https://www.reading.ac.uk/ foodlaw/pdf/eu-08021-efsa-drv-principles-water.pdf [cited 8.4.11].
