ORIGINAL ARTICLE: GASTROENTEROLOGY
Knowledge and Practices of Pediatricians Regarding Functional Constipation in the State of Minas Gerais, Brazil
Marcia R.F. Torres, Maria do Carmo B. de Melo, zFla´via A.C. Purcino, §Joana C. Maia, jj Nata´lia A. Aliani, and yHenrique C. Rocha
ABSTRACT Objectives: The aim of the study was to analyze the knowledge, approaches, and practices of pediatricians participating in a regional pediatric conference regarding functional constipation (FC) to identify knowledge gaps. Methods: Cross-sectional regional study based on a semistructured questionnaire related to the Rome III criteria and the participant profiles. Results: Of 400 questionnaires distributed, 264 (66.0%) were completed. Most pediatricians (76.7%) did not recognize the Rome III criteria, but the majority did recognize the following risk factors for FC: low-fiber diet (97.8%), family history (86.6%), onset of toilet training (76.4%), and weaning (62.4%). Foods considered high in fiber were oats (95.7%), leafy vegetables (95.3%), and wheat bran (93.2%). Digital rectal examination was not performed by 57.7% of nongastroenterologists. Complementary examinations were ordered in 27.5% and 72.5% of patients by general pediatricians and pediatric gastroenterologists, respectively, although the sample of gastroenterologists was not representative. The most prescribed drugs by nongastroenterologists were mineral oil (72.6%), magnesium hydroxide (52.1%), lactulose (41.0%), and polyethylene glycol (25.2%). Pediatric gastroenterologists prescribed magnesium hydroxide (91.7%), polyethylene glycol (91.7%), and mineral oil (58.3%). Most pediatricians (70.0%) considered the average treatment duration to be less than 1 year, although gastroenterologists considered it to be more than 1 year (54.6%). Conclusions: The knowledge of pediatricians regarding FC is inadequate. Constipation may not receive the public health attention it deserves within pediatric residency programs. The authors suggest that better education regarding FC should be included in medical school and residency program curricula to improve patient care. Key Words: attitudes, chronic constipation, health knowledge, practice, treatment
(JPGN 2015;61: 74–79)
Received April 27, 2014; accepted February 13, 2015. From the Department of Pediatrics, Gastroenterology Division, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Minas Gerais, the yUniversidade Federal de Minas Gerais (UFMG), Minas Gerais, the zUniversidade de Sa˜o Paulo (USP), Sa˜o Paulo, the §Santa Casa de Miserico´rdia de Belo Horizonte, and the jjHospital Odilon Behrens, Belo Horizonte, Minas Gerais, Brazil. Address correspondence and reprint requests to Marcia R.F. Torres, Avenida Alfredo Balena 190—CEP: 30130 100, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil (e-mail: [email protected]
). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000768
What Is Known
FC can lead to complications if not recognized early or adequately treated. Despite being very prevalent in childhood, previous studies have shown that there is lack of awareness regarding FC among physicians. A comparison of clinical approaches to constipation in different countries showed significant differences in practices.
What Is New
In the present study, the knowledge of pediatricians regarding FC was found to be inadequate. Pediatric organizations need to be alerted to the importance of proper FC diagnosis and treatment. Better education regarding FC should be included in medical school and residency program curricula to improve patient care.
unctional constipation (FC) is highly prevalent in the pediatric population (0.7% to 29.6%, with a median value of 16%) (1). The different prevalence rates depend on the criteria used to define constipation. According to a recent review of the literature, the overall prevalence of FC ranges from 0.8% to 7.8%, and the male:female ratio ranges from 3:1 to 6:1 (2). In Brazil, the prevalence of constipation also varies widely between 14.7% and 38.4% (3); constipation is the chief complaint in 3% to 5% of pediatric visits and in more than 25% of pediatric gastroenterology consultations (3). The diagnosis of FC is often based on clinical criteria. If not recognized early and/or adequately treated, FC can lead to complications, such as recurrent abdominal pain, appetite suppression, fecal incontinence, low self-esteem, low quality of life, behavioral disturbances, and social withdrawal (1,4–7). The fact that fecal incontinence is present in 82% of children at the time of the diagnosis (2) could be explained by the level of importance given by the family to the child’s symptoms and/or the lack of knowledge of primary care physicians. The lack of awareness of the importance of this topic, even by the Brazilian Society of Pediatrics, can be illustrated by an analysis of the number of questions related to constipation on examinations for board certification in Brazil (the Testing Specialist in Pediatrics, TEP test) between 1995 and 2007: only 5 of 900 multiple choice questions (0.55%) and 1 of 28 clinical cases
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(3.57%) addressed constipation (8). The percentage of those questions correctly answered was between 22.99% and 53.62% (8). The authors recently analyzed the TEP again and did not find any questions addressing constipation from 2008 to 2013 (not published). In a period of 19 years, only 5 of 1200 multiple-choice questions (0.42%) and 1 of 46 clinical cases (2.17%) were related to constipation. A study comparing clinical approaches to constipation in different countries (Italy, the Netherlands, and the United States) showed significant differences in their practices (9). According to Whitlock-Morales et al (10), most primary care physicians in West Virginia (86%) did not know the clinical guidelines for constipation in children. An article published in July 2013 (11) comparing the knowledge and practice styles of medical providers in Saudi Arabia showed significant differences regarding approaches to children with constipation and identified knowledge gaps among the studied population. To our knowledge, this is the first study of this subject in Brazil, where pediatricians see most children with constipation in ambulatory primary care settings. Professional inquiries, such as the present study, can identify knowledge gaps and be used to direct the education of future pediatricians, which contributes to the effectiveness of the treatment of constipation. The aim of the present study was to evaluate the knowledge and practices regarding FC in children of pediatricians attending a regional (state) congress on pediatrics.
METHODS This cross-sectional regional study was performed by analyzing the results of a semistructured questionnaire completed by pediatricians enrolled in the biennial regional congress of pediatrics conducted in 2009 in the third-largest metropolitan area in Brazil. The survey had a cover page asking the pediatricians to voluntarily read and sign the consent form and answer the questionnaire that was distributed anonymously by medical students to all attendees before 1 conference meeting not related to constipation issues that were randomly chosen by the authors but that occurred before any conference meeting that addressed the topic of constipation. An easy-to-read questionnaire was prepared and pilot-tested by pediatric gastroenterologists (PGs), fellows, and pediatric residents and then revised by the authors on the basis of its reproducibility, validity, and length. By means of an analysis, the questionnaire was divided into 2 parts: the first part was used to characterize the participant profiles, including age, year and place of graduation, academic training, subspecialty, and practice location; the second part consisted of 23 questions (with single or multiple answers) designed to assess the knowledge, attitudes, and practices of the professionals regarding FC. The questions were prepared on the basis of the main concepts and knowledge in the current literature on the subject. The pediatricians were asked about the definition of constipation, including the Rome III criteria, the causes, risk factors, clinical presentation, diagnostic workup, and treatment and criteria for referral to a specialist. The questionnaire included yes-or-no questions, multiple-choice questions, and scale questions (eg, rate an answer as frequently, eventually, rarely, or never). The inclusion requirements were as follows: active pediatric board certification in our state (meaning she or he completed a pediatric residency program); answer all or most of the questionnaire; and sign the consent form. Pediatricians were assured that all of the information would be kept confidential. The ethics committee of the university hospital approved the study. Questionnaires answered by medical students, pediatric residents, and physicians with specialties other than pediatrics were excluded. The term ‘‘general pediatrician’’ (GP) was used to define participants who www.jpgn.org
Pediatricians and Functional Constipation had no subspecialty; ‘‘nongastroenterologists’’ (NoPGs) was used for subspecialists who were not PGs. The percentage of pediatricians who responded to each question in the survey was determined, the responses were analyzed, and the results were reported descriptively. The authors used arithmetic means and standard deviations, with Fisher and x2 tests (comparison of proportions) considering P < 0.05 as statistically significant. Data were compiled and analyzed using IBM Statistical Package for Social Science statistics software (12.0).
RESULTS Of the 400 questionnaires distributed, 264 (66%) were returned completed, but 22 (8.3%) were excluded. The average age of participating pediatricians was 44.0 9.8 years, and 74.8% were women. The average years since graduation was 20.2 10.0 years (4–48 years). Among those pediatricians who received information regarding FC during residency, 37% studied in the state capital, whereas 20% studied in other regions of the state; 31.8% studied in public residency programs, and 14.9% studied in private residency programs. Among those pediatricians who claimed to know the Rome criteria (23.3%), 32.6% had graduated within the last 15 years, and 17.9% had graduated more than 15 years ago. These criteria are used in medical practice by 91.7% of PGs, in contrast to only 23.3% of the other professionals (Table 1). Although the number of PGs is not representative, we compared the prevalence of visits because of FC estimated by NoPGs (N ¼ 230) and PGs (N ¼ 12), and the estimates were 0.7% to 29.6% and 25% to 45%, respectively. The items comprising the Rome III criteria were presented in the questionnaire, indirectly and without reference to their origin, to test the ability of the pediatricians to identify them (Table 2). The pediatricians considered the following as causes of FC: dietary inadequacy (58.0%), emotional disturbance (21.2%), slow bowel movements (17.3%), and heredity (3.5%). The risk factors assigned to FC were a low-fiber diet (97.8%), a family history of constipation (86.6%), early toilet training (76.4%), and early TABLE 1. Epidemiological data for the attendees (n ¼ 242) Type of education Public medical school Private medical school Location of pediatric residency State capital Other than state capital Type of medical practice Office (primary care) Public hospital Specialty/subspecialty General pediatrician Neonatologist Pediatric neurologist Pediatric intensivist Pediatric gastroenterologist Other Source of constipation-related information Scientific events Residency Medical school Knowledge of Rome III constipation criteria
Percentage 79.9 21.1 86.8 13.2 86.2 74.2 59.3 9.1 7.1 5.4 5.0 14.1 48.3 33.8 28.2 33.3
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76.6 77.8 74.1 76.1 78.2
100.0 91.7 75.0 100.0 91.7
Torres et al
TABLE 2. Percentage of clinical criteria used by the pediatricians to diagnose FC Rome III criteria Defecation frequency 2 times/wk, % History of retentive defecation posture or retention maneuver, % History of defecation or straining, % Presence of abdominal fecal mass, % History of caliber stools that clog the toilet, % FC ¼ functional constipation.
weaning (62.4%). From a list presented to the pediatricians, the following were considered high-fiber foods: oats (95.7%), leafy vegetables (95.3%), wheat bran (93.2%), cornstarch (31.2%), rice flour (10.3%), red meat (7.3%), and apple peels (3.8%). Although the PG sample was small, comparative data between PGs and NoPGs regarding their approaches to the diagnosis of constipation are presented in Table 3. The complementary tests considered the most important for the differential diagnosis of FC were plain abdominal radiograph (AXR) (70.9%), barium enema (53.7%), and anorectal manometry (49.3%). In relation to the treatment, fecal disimpaction was indicated, eventually or rarely, by 73% of participants. Pediatricians were also asked about the most frequently prescribed laxative in their practice. PGs treat FC with magnesium hydroxide (MH) (milk of magnesia) (91.7%), polyethylene glycol (PEG) (91.7%), and mineral oil (MO) (58.3%); NoPGs treat with MO (72.6%), MH (52.1%), lactulose (41%), and PEG (25.2%). Family involvement was considered the most important factor for the success of FC treatment, and it was classified as very important (94.9%) by pediatricians. School involvement was considered relevant by 97.3%, as well as a high-fiber diet (98.3%). Participants were also asked about the duration of treatment and timing for referral to PGs. Most participants (70.0%) considered the average time of treatment for FC to be less than 1 year, and the remainder (22.5%) less than 6 months. PGs (54.6%) estimated this time to be longer than 1 year, and none of the pediatricians indicated less than 6 months. Most NoPGs (89.2%) only referred their patients with constipation to a PG if patients had severe constipation (73.7%), but others (15.5%) always referred them. Participants were not asked to define severe constipation. Of 230 pediatricians who answered the question about the need for a multidisciplinary
approach to treat patients with FC, only 14.8% have this option in their workplace (Table 3).
DISCUSSION The latest evidence-based recommendations for the evaluation and treatment of FC in infants and children from North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) (13) recommended the use of the Rome III criteria to define FC. The fact that 80% of the pediatricians in the present study did not have knowledge of the Rome III criteria but were able to identify these criteria in practice could be attributed to the knowledge acquired during their training and medical practice. Moreover, this disparity may reflect a lack of standardization of residency programs. The same lack of information regarding FC was recently shown in more than 50% of Saudi Arabian pediatricians surveyed (11). The results of the present study showed that there are gaps in the knowledge and practices of pediatricians with respect to FC. Questions about the digital rectal examination (DRE) were included in the questionnaire (Table 3). Although DRE is not included in the Roma III criteria, it aids in the diagnosis and assessment of the treatment of FC and is part of the differential diagnosis of constipation (14–16) to exclude stenosis, extrinsic masses, and an aganglionic segment in Hirschsprung disease (17) if the diagnosis is uncertain or if alarm signs and symptoms are present (12). A study of 128 patients with constipation in the United States (15) showed that 77.0% had never had a DRE in a primary care facility. The Saudi Arabian study found no differences between pediatricians but did find differences between the 5 studied
TABLE 3. Comparison between answers of pediatric gastroenterologists and nongastroenterologists regarding their approaches to the diagnosis of constipation Questions Do you perform digital rectal examinations? Do you request additional tests? Do you prescribe PEGy? Do you consider laxatives addictive?
Does your workplace have a multidisciplinary team?
Answers Yes No Yes No Yes No Yes No Do not know Yes No Do not know
Nongastroenterologists N (%) 97 131 166 63 48 174 33 158 32 27 173 18
(42.5) (57.5) (72.5) (27.5) (21.6) (78.4) (14.8) (70.9) (14.3) (12.4) (79.4) (8.3)
Gastroenterologists N (%) 12 0 12 0 11 1 0 10 1 7 5 0
(100.0) (0.0) (100.0) (0.0) (91.7) (8.3) (0.0) (90.9) (9.1) (58.3) (41.7) (0.0)