INTRODUCTION

Constipation is a common chronic disorder of pediatric age group, affecting 1 to 30% of children worldwide.¹  Constipation accounts for 3% of all primary pediatric care visit and 10 – 25% of paediatric gastroenterologist visit.²  Management of children with constipation costs 3 times more than the  children without constipation.³  North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)  defines constipation as a delay or difficulty in defecation, present for 2 or more weeks and sufficient to cause significant distress to the patient.⁴ Functional constipation is defined as constipation without objective evidence of a pathologic  condition.⁵  As per ROME IV criteria for ≥4 years childrens functional constipation is defined as presence of  at least two of the followings   with  duration of at least one month: 1) Two or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years. 2) At least one episode of fecal incontinence per week. 3) History of retentive posturing or excessive volitional stool retention. 4) History of painful or hard bowel movements. 5) Presence of a large fecal mass in the rectum. 6) History of large-diameter stools that may obstruct the toilet. (Note: These symptoms cannot be fully explained by another medical condition and symptoms are insufficient to fulfill the diagnostic criteria of irritable bowel syndrome).⁶ Regarding etiology of constipation 95% cases are functional constipation and 5% due to organic causes and from organic causes Hirschsprung`s disease is the most common.^7,8  Functional  constipation usually initiates with a painful bowel movement which leads to voluntary withholding of stools to avoid painful defecation. These events leads to large, hard stool and passage of such stool causes further pain and child become frightens, then avoid defecation by all means.^{9, 10}

Constipation has both physical and psychological effect on children. Many studies have shown that chronic constipation impairs the daily physical activity of children, also has adverse effects on children’s social activity, mental health and even academic performance. It is a common belief that functional constipation does not affect the growth status of children, but it is frequently found that children with underweight or overweight have functional constipation frequently. Some recent studies have shown significant decreasing impacts of constipation on the children’s weight and height growth and constipation treatment and elimination of underlying cause of  constipation improve constipated children’s growth status.^11,12  Simultaneously, some studies have shown  that a high percentage of children with functional constipation having  obesity.^13-15

OBJECTIVE

To study the correlation between functional constipation and growth status of school going children.

METHODOLOGY

It was a Cross sectional descriptive study, done in a rural area of Bangladesh from June, 2019 to August 2019. Children with age 6-16 years attending the school without any organic disease, chronic disease or any red flag signs included in this study. Children with constipation who did not fulfill the Rome IV criteria of functional constipation, children having any organic disease, any chronic disease or any red flag signs, children already on treatment for constipation, children below 6 years and above 16 years were excluded.

Two schools were randomly selected. Then from every school equal number of students was selected randomly. The details clinical history and physical examination findings were recorded in a predesigned standard data sheet. Anthropometric measurements including height and weight were measured following the standardized procedures. .Second group was selected randomly from children, without constipation, having no known organic disease, any chronic disease or any red flag signs were selected randomly.

OPERATIONAL DEFINITION

Diagnosis of constipation by NASPGHAN definition and functional constipation were made by Rome IV criteria, if any red flag sign present, it will be consider as organic cause.  Rome IV criteria along with inclusion criteria were fulfilled by 57 children. Same number of children without constipation, having no organic disease, any chronic disease or any red flag signs were selected randomly. Weight for age and height for age less than 3rd centile was consider as underweight and stunted respectively. BMI more than 85th was considered as overweight, between 5th to 85th percentiles was considered as normal weight, less than 5th centile was considered as underweight. 16

RESULTS

First 66 Children with constipation were selected by open question regarding NASPGHAN definition of constipation. 57 children were fulfilling the criteria of functional constipation (case) then the consecutive 57 normal children taken as control.

Table 1 showing demographic data- age, sex. male- female ratio was almost equal between both group.  Mean age of children with constipation was 9.99±3.46 years and without constipation 10.60±3.33 years and p value was not significant.

Table 1: Demographic characteristics of participants (6-16 years old school going children)

 Table 2 showing associated symptoms analysis between two groups. Here anorexia, nausea and abdominal pain were significantly higher in children with functional constipation and p value was significant.

Table 2: Comparing the symptoms between children with constipation and without constipation

Table 3 showing anthropometric parameter weight for age , height for age and BMI on centile chart of two groups. Here underweight children (weight for age below 3rd centile and BMI for age below 5th centile) were more in children with functional constipation and p value was significant.

Table 3: Weight for age, height for age, BMI for age centile in children with functional constipation and without constipation

Table 4 showing mean Z scores of weight for age, height for age, BMI for age in children with functional constipation and without constipation. Here BMI Z scores in children with functional constipation -0.98±1.26  and without constipation -0.48±1.16 and p was significant.

Table 4: Z scores weight for age, height for age, BMI for age in children with functional constipation and without constipation

DISCUSSION

Constipation has both physical and psychological effect on children. Current study demonstrated that children with symptoms of functional constipation had much less average weight than children without constipation. Z scores of BMI for age were considerably different in two groups. Chao et al. demonstrated the functional constipation of children as the cause of their growth retardation. ¹⁷ Yousefi A et al.also had similar findings.¹¹

Pawlowska et al, demonstrated that pediatric patients with functional gastrointestinal disorders present various growth abnormalities. They found that fat deficiency was more frequent in children with functional constipation; also short stature and stunting was common in patients with functional constipation. ¹⁸

In contrast, some studies have shown a high prevalence of obesity in children with functional constipation. In a study by Ilan et al. most of the children with constipation were obese or overweight. ¹⁹ In a similar study by Dehghani et al, conducted on 100 Iranian children younger than 18 years old with functional constipation, found a higher obesity rate and higher BMI and weight Z scores in constipated patients compared to healthy control group. ²⁰ But in our study there was no significant findings regarding overweight and obesity.

Current study also found that anorexia, nausea and abdominal pain were significantly higher in functional constipation group. NASPGHAN,2006 have emphasized the significant effects of constipation on the children’s alimentary habits and on their developmental parameters, which can return to normal growth by treatment of anorexia or the elimination of organic causes associated with constipation.^4,11 Our study recognizes poor intake due to anorexia-nausea, emotional disorders caused by abdominal pain, painful defecation and other diagnostic criteria for functional constipation as the likely causes of delay in children’s weight gain.

CONCLUSION

Children with functional constipation may have retarded growth (weight for age and BMI) and poor intake due to anorexia, nausea, and abdominal pain may play contributory role.

LIMITATIONS
Small sample size and samples were taken from one specific region.

RECOMMENDATION
Larger sample size and multicenter study.

CONFLICT OF INTEREST          
The authors declare no conflict of interest.

FUNDING
This study was funded by the authors. No external sources of funding were used.

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