Quality of Life in Children With Chronic Functional Constipation and Their Family Members

Background : Functional constipation (FC) is one of the most common complaints in childhood. The aim of this study was the evaluation of the quality of life in children with chronic FC and their family members. Methods: In this study, 100 children from 2-18 years of age (57 males, 43 females) with chronic FC were selected. The Child Health Questionnaire - Parent Form 50 questionnaire was used for quality of life assessment in children and their family members. Quality of life scores were compared with 100 healthy children from 2-18 years of age. The questionnaire consists of 15 domains, each of which ranges in score from zero to 100. A higher score represents a better quality of life. Results: Quality of life scores in all 15 domains were significantly lower in children with FC than in healthy children ( P < 0.001). Scores of physical functioning, behavior, and mental health were lower in children with FC and fecal incontinence compared to children with FC alone ( P < 0.05). Conclusion: FC impacts on quality of life of the affected children and their family members. Practitioners should be aware of its effects on quality of life to improve the disease course with early assessment and treatment.

. Moreover, in a study carried out by Kianifar et al. in Iran, children with FC showed emotional disturbance (12). In a systematic review by Iraji et a. pooling the investigations of 10 different Iranian provinces, the authors reported that the frequencies of constipation and FC were 1.4-37% and 2.4%-11%, respectively (13).

Objectives
Considering the high prevalence of FC in Iran, it is important to assess the quality of life of these patients. So, here we aimed to address this issue in a sample population of children with FC.

Material and Methods
All children from 2-18 years of age with constipation admitted to Imam Reza pediatric gastroenterology clinic in Shiraz from March 2016 to February 2017 were included. After primary physical examination, 100 children diagnosed with FC according to the Rome III criteria were randomly selected. According to Faleiros and Machado (7) and considering the values of α = 0.01, d = 17.2, power of 99% (β = 0.01), and estimating a withdrawal rate of 20%, the minimum sample size was calculated to be 30 for each control and case group. Finally, 100 children were included in each group. According to the Rome III criteria, in order to diagnose a person with FC, two or more of the following criteria must be fulfilled for at least one month. In children < 4 years old, the items included: (a) two or fewer defecation episodes per week, (b) history of prolonged fecal retention, (c) history of painful intestinal movements, (d) the presence of a large fecal mass in the rectum, (e) history of fecal mass with large diameter blocking up the toilet, (f) additional criteria: not meeting irritable bowel disease criteria. The diagnostic criteria for children > 4 years old were the presence of two or more of the following items for at least one time per week, lasting in at least a two-month period of time. The items included (a) fecal defecation two or fewer times per week, (b) fecal incontinence at least one time per week, (c) history of prolonged fecal retention, (d) history of painful intestinal movements, (e) the presence of a large fecal mass in the rectum, (f) history of fecal mass with large diameter blocking up the toilet, (g) additional criteria: not meeting irritable bowel disease criteria (1).
The healthy children were children with no history of gastrointestinal diseases, all of whom were recruited from kindergartens and schools. One hundred age-and sex-matched children were randomly selected. Children with Hirschsprung disease, muscular disorders, history of surgical procedures on the rectum, spina bifida, mental retardation, hypothyroidism, chronic asthma, cardiovascular and renal diseases, cancer, seizure, chronic allergy, diabetes, skeletal, bone, and joint abnormalities, growth retardation, psychological problems such as autism, depression, anxiety, and sleep disorders, auditory, visual, and verbal problems were excluded. Furthermore, children whose parents had difficulties comprehending Persian or the questions, as well as those who were illiterate or not willing to participate, were not entered in the study. Finally, parents experiencing emotional inflicts such as loss of beloved ones during the past six months were also excluded. The participants were categorized into two age groups, including preschool children (aged 2-6 years old) and school children (aged 7-18 years old). The Child Health Questionnaire -Parent Form 50 (CHQ-PF 50) was used in the present study. We had previously validated the questionnaire. The scores were assigned from zero to 100 according to the instructions of a textbook entitled "Child Health Questionnaire; A user Manual" (14). Higher scores indicated better quality of life.
Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 22.0 software package, applying independent samples student t test (or its non-parametric counterpart; Mann-Whitney U test), chi-squared or Fisher's exact test, and Pearson and Spearman correlation tests.

Results
This study was performed on 100 children with chronic FC and 100 healthy children from 2-18 years of age ( Table 1). The Frequency distribution of clinical symptoms of studied children is indicated in Table 2.
The mean scores for different quality of life aspects among healthy children and those with chronic FC are represented in Table 3. Significant differences in all aspects (in both facets of physical and psychosocial health function) were found in both groups, with lower scores in children with FC.
Considering the association between quality of life dimensions and demographic variables, children in the age group of 7-18 had better performance than those aged between two and six in the FA dimension (P value = 0.03). Sex was significantly associated with GGH, PF, and CH hmj.hums.ac.ir http dimensions, and girls showed a higher quality of life in these dimensions (P = 0.01, 0.02, and 0.04, respectively). Being firstborn or not was only associated with the REB dimension in which first children showed a significantly lower quality of life (P = 0.04). There were no significant associations with these variables and other quality of life dimensions.
In our study, children with soiling showed significantly lower performance in PF, BE, and MH in comparison with their counterparts with no evidence of soiling (Table 4). Children with FC had a significantly lower quality of life in the domain of REB, while other domains were not impacted. The association between quality of life and abdominal pain is depicted in Figure 1. Besides, the correlation between the quality of life and duration of symptoms in children with chronic FC is demonstrated in Table 5. There were significant negative correlations between symptoms duration and quality of life in GGH, PF, BE, CH, and PE aspects.

Discussion
The health-related quality of life has been known as a primary and vital assessment in clinical settings since 1993 (15,16). In the present study, all quality of life aspects were inferior in children with chronic FC in comparison with the healthy children, which is in line with the reports of Wang et al. (4) and Clarke et al (6). According to Faleiros and Machado (7), who used the CHQ-PF 50 questionnaire, all dimensions of quality of life, except the CH dimension, were lower in children with FC in comparison with the healthy children. Furthermore, in      (8), the researchers also found an inverse link between abdominal pain intensity and quality of life score. This was also observed by Wang et al (4), who described deterioration in the quality of life status in those with abdominal pain. Also, in Youssef et al study, parents of constipated children who also had abdominal pain reported lower emotional quality of life scores. In some studies, abdominal massage was shown to significantly improve the quality of life the patients suffering from constipation (17,18). This claim is consistent with our findings. This observation may be rooted in the parents' worries regarding organic causes of abdominal pain, which might engage them emotionally and, therefore, impact their perceptions of the quality of life of their children.
There was a significant inverse association between the length of symptoms and the scores of seven aspects of quality of life, which was also shown by Youssef et al (3) and Wang et al (4). In another study and in support of our observation, the presence of intestinal symptoms was associated with poor quality of life in patients with chronic constipation (19). Likewise, irritable bowel syndrome (IBS) patients with digestive symptoms were reported to have a reduced quality of life which highlights the significant impact of this parameter on quality of life of these patients (20).
The mean duration of symptoms was 25.12 months in our study. This rather long period before seeking medical   In our study, 40% of the children with FC had fecal incontinence who represented the lower quality of life scores in physical, behavioral, and psychological aspects compared to the children without soiling. In Kovacic and colleagues' study (11), in which 55% of children with FC suffered from soiling as well, the overall quality of life score was lower in children with concomitant FC and soiling than those with FC alone. Nevertheless, in a recent study, there was no significant difference in the emotional, social, and educational performance of the children with or without soiling (11). Youssef et al, however, did not report any significant difference in the quality of life of FC children with or without soiling (3). In another study, children with FC and soiling showed lower scores of quality of life in all aspects compared to the counterpart children without this condition (8). The inconsistent results between our study and studies performed by others can be due to the fact that CHQ-PF 50 is a general scale with low specificity toward gastrointestinal symptoms.
Considering the role of sex, only one aspect of quality of life in the physical health dimension (i.e. PE) was lower in boys. On the other hand, no significant differences were noted in the six psychosocial parameters between boys and girls.
The family performance was lower in children with FC who were between two and six years old compared to those from 7-18 years of age. It is comprehensible that younger children require more care and surveillance than older children, and this can contribute to lower family performance.

Conclusion
Our findings showed that chronic FC greatly reduced all dimensions of quality of life. By educating parents regarding the signs of FC, it is possible to expedite diagnosis and improve their quality of life.