O1047: Predictors of Successful Transitions in a Bowel Management Program

Background: Functional constipation is a pervasive problem in children, particularly in patients with diagnoses of idiopathic constipation, neurodiverse disorder, and congenital anatomic abnormalities. Hope for these patients exists through bowel management programs (BMP), which have been demonstrated to effectively treat severe constipation and encopresis in children. In this study, we aimed to evaluate the transition rate from more invasive to less invasive treatments (e.g. enema to laxative therapy), and identify clinical characteristics associated with downgrading treatment over time.

Methods: Patients participating in our institution’s BMP from 2020-2024 were identified from an internal registry. Patients were excluded if they did not have subsequent follow-up after BMP induction. Patients were stratified by primary diagnosis, then follow-up collected at 6-, 12-, 18-, and 24-month clinic visits. Patients were classified as ‘downgraded’ if they were able to transition from enemas to laxatives or from laxatives to no medications at each time point. Success was defined as no stool soiling or < 2 stool smears per week. A multivariate logistic regression model was then used to ascertain the effect size of sex, initial diagnosis, genetic or behavioral disorder, induction age, follow-up duration, anorectal manometry abnormality, and pelvic floor physical therapy on the likelihood to downgrade regimens.

Results: 163 patients were identified; 65 patients were lost to follow-up after induction and were excluded. Of the remaining 98 patients, the majority were male (63%), with a median age of 8.8 years at induction (IQR 5.7-10.9). A behavioral diagnosis was present in 33.7% of the cohort, most commonly anxiety (18.4%). A primary diagnosis of functional constipation was made in 71% of patients, and 62.2% of the overall cohort were started on induction therapy of large volume enemas. Median follow-up duration was 32.7 months (IQR 15.8 - 62.3).
Downgrade occurred in 48 patients (49%) with a median time to downgrade of 6.3 months (IQR 5.8 – 12.4). Fifty-six (69.1%) had a primary diagnosis of functional constipation, 5 (10.4%) Hirschsprung’s Disease (HD), and 1 (2.1%) anorectal malformation (ARM). No patients with spina bifida or rectal prolapse downgraded.
Multivariable logistic regression was performed to identify factors most influential to downgrade. Duration of follow-up was found to be significant (OR 1.002, p< 0.05 95% CI 1.00-1.003), indicating that for each day of follow-up the odds of downgrade increased by 0.2%. Sex, pelvic floor physical therapy, age at induction, genetic disorder, behavior disorder, and abnormal anorectal manometry were not significant.

Conclusion: Our bowel management program demonstrated the ability to downgrade from enema and/or laxative use with ongoing active management. We found that nearly half of patients required less intensive therapy at 2 years, with downgraded therapy most often experienced in patients with underlying diagnoses of functional constipation.