Home transcutaneous electrical stimulation to treat children with slow-transit constipation

doi:10.1016/j.jpedsurg.2012.03.037

Journal of Pediatric Surgery

Volume 47, Issue 6, June 2012, Pages 1285-1290

https://doi.org/10.1016/j.jpedsurg.2012.03.037 Get rights and content

Abstract

Purpose

This study aimed to test the effectiveness of home transcutaneous electrical stimulation (TES) when patients with slow-transit constipation (STC) were trained by a naive clinician.

Methods

A surgeon was trained to teach the TES method to STC children who then self-administered at home (1 hour a day, 3-6 months) using a battery-powered interferential stimulator. Bowel diaries, PedsQL4.0 questionnaires, and radio-nuclear colonic transit studies were completed before and after treatment.

Results

Thirty-two children (16 female; mean age, 8.3 years; range, 3-17 years) self-administered 3 to 6 months of TES. Three did not return diaries. Group 1 (n = 13) started with less than 3 bowel actions per week, and group 2 (n = 16), with more than 3 bowel actions per week. Defecation frequency increased in 69% of group 1 (mean, 1.4-3.0 per week; P = .02). Soiling frequency decreased in 50% of group 2 (5.4-1.9 per week, P = .04). Of 13 patients, 7 improved with development of urge-initiated defecation. Abdominal pain decreased in 48% (1.6 episodes per week to 0.9 per week, P = .06). Stool consistency improved in 56%. There was significant improvement in child-reported and parent-reported PedsQL Scores. Colonic transit improved in 13 of 25 patients.

Conclusion

Home TES provides a new treatment for STC children, with 50% of treatment-resistant patients benefited. Success requires clinician training and close patient contact. Transcutaneous electrical stimulation increased defecation and reduced soiling.

Section snippets

Patient group

This was a prospective study of STC children at a tertiary pediatric hospital. This study was approved by the institutional ethics committee (HREC 26173). All children had chronic constipation and soiling for a minimum of 2 years and had failed to respond to medical treatments such as dietary modifications, behavioral therapy, and oral and/or rectal laxatives and were investigated by NTS. The diagnosis of STC was made by NTS as described previously [2], [3], [4], specifically if there was ≥ 40%

Results

Thirty-eight STC children were enrolled. The first 6 were used for learning, and data were not analyzed. Thirty-two children (16 female; mean age, 8.3 years; range, 3-17 years) underwent 3 to 6 months of TES at home with stimulation for 60 minutes a day. All completed the treatment successfully; however, 3 did not return completed bowel diaries after TES.

In 16 children who started with more than 3 BAs per week, 6 had an increase in defecation frequency, but there was no significant increase in

Discussion

Transcutaneous electrical stimulation is a new treatment for children with STC. The battery-operated interferential stimulator made treatment possible at home. This treatment was well accepted by children and their parents if they were taught and understood the safe administration of TES. Six children were needed for the clinician to learn how to teach the use and application of TES at home and to collect data. The next 32 children were able to complete the treatment successfully. Importantly,

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Cited by (51)

Non-pharmacologic approach to pediatric constipation
2021, Complementary Therapies in Medicine
Citation Excerpt :
They may also act on the bowel directly through neuromodulation of the excitatory and the inhibitory neural reflexes of the colon.95 A few Australian studies described improvements in quality of life, defecation frequency, and fecal soiling with home TES therapy three times per week in children with slow-transit constipation and found TES to be safe.96–100 Stool consistency improved immediately after stimulation (p < 0.0001) but returned to baseline at long term follow up (mean 3.5y) while fecal incontinence scores showed persistent improvement in 17 of 21 children (P = 0.0002).122
Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.
Electro-Neuromodulation for Colonic Disorders—Review of Meta-Analyses, Systematic Reviews, and RCTs
2020, Neuromodulation
In the last 20 years, studies have shown that large bowel function can be modified by neural stimulation. While still in its infancy, this area of research is beginning to show promise.
This overview brings together systematic reviews and meta-analyses of electrical stimulation used to treat colonic disorders (fecal incontinence, constipation, slow transit constipation [STC], irritable bowel syndrome [IBS-C], and spina bifida-neurogenic bowel). Different methods of electrical stimulation including through sacral nerves, paraspinal, transabdominal, and using electroacupuncture over the ankle or knee and direct stimulation of the bowel are reviewed.
Most evidence is low level (pilot and small cohort studies) but with more RCTs appearing. Sacral nerve stimulation (SNS) does improve urinary dysfunction and fecal incontinence but not constipation. It is expensive with high rates of reoperation. Transcutaneous stimulation with interferential current (IFC, alternating current at KHz frequency with 2 channels out of phase) does improve constipation and may provide benefit as an adjuvant to behavioral or exercise therapies. Acupuncture and electro-acupuncture (low/very low-level evidence) may have a benefit for constipation.
SNS is effective but expensive and limited to extreme patients. Transcutaneous stimulation is noninvasive and cheap and IFC may be effective for constipation, but many parameters need to be optimized and higher level evidence provided from studies (sham, blinding, and larger patient numbers). The next 20 years should be exciting in the field as higher level studies are performed.
Chronic Abdominal Pain of Childhood and Adolescence
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Chronic abdominal pain is common in children and in the majority of cases is functional in nature. For children with abdominal pain lasting 2 months or longer, the Rome IV criteria should be used to diagnose a functional abdominal pain disorder (FAPD). Recent advances have furthered our understanding of the pathogenesis, evaluation, and management of pediatric FAPDs, but these disorders remain challenging to recognize and treat successfully. Effective management requires an understanding of the many factors that can contribute to an individual child’s presentation. Treatment of an FAPD should be tailored to the individual and can include a combination of pharmacologic, dietary, and psychosocial interventions.
Constipation: A Symptom of Chronic Food Intolerance?. A Symptom of Chronic Food Intolerance?
2019, Dietary Interventions in Gastrointestinal Diseases: Foods, Nutrients, and Dietary Supplements
Chronic constipation in children is occasionally organic, but in most cases no organic cause has been found. Using gastrointestinal scintigraphy, we have shown that children with intractable constipation have slow transit in the colon, but some have rapid transit in the proximal colon with anorectal retention. Rapid transit (i.e., occult diarrhea) is often secondary to food intolerance, so we tested whether children with chronic constipation may have a form of irritable bowel syndrome and found many have abnormal breath hydrogen tests with malabsorption of fructose, lactose, or other sugars. Most importantly, we now recognize that in most children with chronic constipation the symptoms resolve with an exclusion diet of the sugar(s) identified by hydrogen/methane breath tests.
Short-Term Interferential Transabdominal Electrical Stimulation Did Not Change Oral-Rectal Transit Time in Piglets
2018, Neuromodulation
Transcutaneous electrical stimulation (TES) using interferential current (IFC) is a new therapeutic treatment for constipation. Clinical studies show that TES-IFC for 3–6 months improves colonic transit, but it is not clear if short-term stimulation affects transit or the effect requires longer to develop. The aim of this study was to determine if TES-IFC for only four days affects oral-rectal transit time in healthy pigs.
Twenty-two 4–5-week old large white female piglets had transit studies during week 4 and week 5 by placing a capsule containing 18 radiopaque plastic markers in the esophagus under anesthetic followed by x-rays at 6, 30, 54, and 78 hours. Animals were randomly assigned to active or control groups. The active group received TES for 30 min daily for four days. Interferential current was applied through four electrodes (4 × 4 cm), with two para-spinal just below the last rib and two on the belly at the same level. Stimulation was at 4000 Hz and 4080–4160 Hz with currents crossing through the abdominal cavity.
Whole bowel transit times ranged from 7.7 to 72.2 hours, stomach transit from <1 to 63 hours, and bowel with rectum transit time from 5 to 53 hours. Transit times were the same for the control (median 28.4 hours) and TES-IFC (23.0 hours) groups in the prestimulation and stimulation weeks (control 23.0, TES-IFC 19.8 hours) with no change within or between groups.
Four days of half-hour TES-IFC daily in healthy 5-week-old piglets did not change oral-rectal transit time.
Home-Based Transabdominal Interferential Electrical Stimulation for Six Months Improves Paediatric Slow Transit Constipation (STC)
2018, Neuromodulation
Transcutaneous electrical stimulation (TES) for one to two months has produced some improvement in treatment-resistant slow-transit constipation (STC) in children. Optimal parameters for treatment are not known. It is possible that more improvement would occur with stimulation for longer. This study examined the effectiveness of stimulation for six months.
Children with STC confirmed by nuclear transit study (NTS) were enrolled prospectively. All had chronic constipation for greater than two years and had failed medical treatment. TES was performed for one hour/day for six months using the INF 4160 (Fuji Dynamics) portable stimulator and 4 cm × 4 cm electrodes near the belly button and on the back. Families kept bowel diaries and completed PEDSQLCore QOL (4.0) questionnaires before and at end of treatment.
Sixty-two children (34 females; seven years, 2–16 year) with STC were studied. Defecation frequency increased in 57/62 (91%, mean ± SEM pre- 1.49 ± 0.20 vs. post- 3.25 ± 0.25 defecation/week, p < 0.0001) with the number with ≥3BA increasing from 6 to 37 (10–59%). Soiling frequency decreased from 4.8 to 1.1 days/week (p <0.001). Abdominal pain decreased from 1.7 to 0.3 days/week (<0.0001), and spontaneous urge to defecate improved. Quality of life (p < 0.01), mean transit index and gastric emptying on NTS improved (p < 0.005).
Treatment-resistant STC responds to TES using interferential current across the abdomen when given daily for many months. Battery operated stimulators allowed stimulation at home for an hour each day. Stimulation for six months produced clinically significant improvement in defecation frequency, soiling, abdominal pain, urge to defecate, and quality of life in half of these chronic patients.

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^☆: This project was supported by the Victorian Government's Operational Infrastructure Support Program.

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AAP paperHome transcutaneous electrical stimulation to treat children with slow-transit constipation☆

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Patient group

Results

Discussion

J Pediatr Surg

J Pediatr Surg

Urology

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Total and segmental colonic transit time and anorectal manometry in children with chronic idiopathic constipation

J Pediatr Gastroenterol Nutr

AAP paper
Home transcutaneous electrical stimulation to treat children with slow-transit constipation☆