Water and fluid intake in the prevention and treatment of functional constipation in children and adolescents: is there evidence? Please cite this article as: Boilesen SN, Tahan S, Dias FC, Melli LC, Morais MB. Water and fluid intake in the prevention and treatment of functional constipation in children and adolescents: is there evidence? J Pediatr (Rio J). 2017;93:320-7. , ☆☆ ☆☆ This study was carried out at Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Disciplina de Gastroenterologia Pediátrica, São Paulo, SP, Brazil.

Sabine Nunes Boilesen Soraia Tahan Francine Canova Dias Lígia Cristina Fonseca Lahoz Melli Mauro Batista de Morais About the authors

Abstract

Objective:

To study the evidence on the role of water and fluid intake in the prevention and treatment of functional intestinal constipation in children and adolescents.

Source of data:

A search was carried out in the Medline database (between 1966 and 2016) for all published articles containing the following words: constipation, water, and fluids, published in Portuguese, English, and Spanish. All original articles that assessed children and adolescents were selected by title and abstract. The references of these articles were also evaluated.

Synthesis of data:

A total of 1040 articles were retrieved. Of these, 24 were selected for reading. The study included 11 articles that assessed children and adolescents. The articles were divided into two categories, those that evaluated water and fluid intake as a risk factor for intestinal constipation and those that evaluated their role in the treatment of intestinal constipation. Five articles were included in the first category. The criteria for assessing fluid intake and bowel rhythm were different in each study. Three studies demonstrated an association between low fluid intake and intestinal constipation. Regarding treatment, five articles with heterogeneous methodologies were found. None of them clearly identified the favorable role of fluid intake in the treatment of intestinal constipation.

Conclusion:

There are few articles on the association between fluid intake and intestinal constipation. Epidemiological evidence indicates an association between lower fluid intake and intestinal constipation. Further clinical trials and epidemiological studies that consider the international recommendations for fluid intake by children and adolescents are required.

KEYWORDS
Constipation; Child; Fluid intake; Adolescent

Resumo

Objetivo:

Estudar as evidências sobre o papel do consumo de água e líquidos na prevenção e no tratamento da constipação intestinal funcional em crianças e adolescentes.

Fontes de dados:

Foram pesquisados na base de dados do Medline (entre 1966 e 2016) todos os artigos publicados com as seguintes palavras: constipação, água e líquidos, nos idiomas português, inglês e espanhol. Foram selecionados, pelo título e resumo, todos os artigos originais com crianças e adolescentes. As referências desses artigos também foram avaliadas.

Síntese de dados:

Foram encontrados 1.040 artigos. Desses, 24 foram selecionados para leitura. Foram incluídos 11 artigos que estudaram crianças e adolescentes. Os artigos foram distribuídos em duas categorias, os que avaliaram o consumo de água e líquidos como fator de risco para constipação intestinal e os que avaliaram o seu papel na terapêutica da constipação intestinal. Cinco artigos se enquadraram na primeira categoria. Os critérios para avaliar consumo de líquidos e ritmo intestinal foram diferentes em cada estudo. Três estudos demonstraram relação entre baixo consumo de líquidos e constipação intestinal. Quanto ao tratamento, foram encontrados cinco artigos com metodologias heterogêneas. Em nenhum deles foi possível identificar com clareza o papel favorável do consumo de líquidos no tratamento da constipação intestinal.

Conclusão:

Existem poucos artigos sobre a relação entre consumo de líquidos e constipação intestinal. Evidências epidemiológicas indicam associação entre menor consumo de líquidos com constipação intestinal. São necessários outros ensaios clínicos e estudos epidemiológicos que levem em consideração as recomendações internacionais para consumo de líquidos por crianças e adolescentes.

PALAVRAS-CHAVE
Constipação intestinal; Criança; Ingestão de líquidos; Adolescente

Introduction

Intestinal constipation is a common clinical manifestation in the pediatric population, and over 90% of cases are classified as functional gastrointestinal disorders.11 Oliveira JN, Tahan S, Goshima S, Fagundes-Neto U, Morais MB. Prevalência de constipação em adolescentes matriculados em escolas de São José dos Campos, SP, e em seus pais. Arq Gastroenterol. 2006;43:50-4.

2 Morais MB, Maffei HV. Constipação crônica. J Pediatr (Rio J). 2000;76:S147-56.
-33 Hyams J, Colletti R, Faure C, Gabriel-Martinez E, Maffei HV, Morais MB, et al. Functional gastrointestinal disorders: working group report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2002;35:S110-7. As observed in other functional gastrointestinal disorders, childhood intestinal constipation results from the interaction of biological, dietary, and psychosocial factors that interfere with intestinal motility.44 Rasquin A, Lorenzo CD, Forbes D, Guiraldes E, Hyams JS, Staiano A, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130:1527-37. The main factors related to diet are water and dietary fiber consumption.33 Hyams J, Colletti R, Faure C, Gabriel-Martinez E, Maffei HV, Morais MB, et al. Functional gastrointestinal disorders: working group report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2002;35:S110-7.

4 Rasquin A, Lorenzo CD, Forbes D, Guiraldes E, Hyams JS, Staiano A, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130:1527-37.

5 Morais MB, Tahan S. Constipação intestinal. Pediatr Mod. 2009;45:79-98.
-66 Maffei HV, Moreira FL, Kissimoto M, Chaves SM, Faro SE, Aleixo AM. História clínica e alimentar de crianças atendidas em ambulatório de gastroenterologia pediátrica com constipação intestinal crônica funcional e suas possíveis complicações. J Pediatr (Rio J). 1994;70:280-6.

According to the guidelines, functional intestinal constipation treatment includes fecaloma clearing and maintenance therapy using laxatives to avoid fecal re-impaction, toilet training, and guidelines for increasing fiber and water intake.44 Rasquin A, Lorenzo CD, Forbes D, Guiraldes E, Hyams JS, Staiano A, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130:1527-37.,77 Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43:e1-13.

8 National Collaborating Centre for Women's and Children's Health (UK). Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: RCOG Press; 2010 [NICE Clinical Guidelines, No. 99], available from: http://www.ncbi.nlm.nih.gov/books/NBK65365/ [cited9.11.16].
http://www.ncbi.nlm.nih.gov/books/NBK653...
-99 Lindberg G, Hamid SS, Malfertheiner P, Thomsen OO, Fernandez LB, Garisch J, et al. World Gastroenterology Organization global guideline: constipation - a global perspective. J Clin Gastroenterol. 2011;45:483-7. However, the guidelines of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)/North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), published in 2014, questions the efficacy of increased water intake in intestinal constipation therapy and suggests that, according to the evidence, an increase in fluid intake for the treatment of functional intestinal constipation should not be recommended.1010 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58:258-74. When analyzing the evidence supporting this position, it can be verified that this was based on only one clinical trial, published in 1998.1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.

Considering that increased water intake is part of the treatment of functional intestinal constipation in other guidelines77 Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43:e1-13.

8 National Collaborating Centre for Women's and Children's Health (UK). Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: RCOG Press; 2010 [NICE Clinical Guidelines, No. 99], available from: http://www.ncbi.nlm.nih.gov/books/NBK65365/ [cited9.11.16].
http://www.ncbi.nlm.nih.gov/books/NBK653...
-99 Lindberg G, Hamid SS, Malfertheiner P, Thomsen OO, Fernandez LB, Garisch J, et al. World Gastroenterology Organization global guideline: constipation - a global perspective. J Clin Gastroenterol. 2011;45:483-7. and in clinical practice, this recent positioning motivated the development of the present study, which aimed to assess the evidence on the role of water and fluid intake in the prevention and treatment of functional intestinal constipation in children and adolescents.

Methodology

The Medline database was used for the search. The period evaluated was January 1966 to November 2016. Research was carried out on articles that analyzed the role of water and/or fluid intake in the treatment and prevention of intestinal constipation in children and adolescents. As for the strategy, a broad search was made using the following pairs of words: "constipation" and "water"; "constipação" and "água"; "estreñimiento" and "agua"; "constipation" and "fluid"; "constipação" and "líquidos"; "estreñimiento" and "neto", in English, Portuguese and Spanish. All original articles that included children and adolescents were selected by reading the title and abstracts. The search was not restricted to the exclusive evaluation of controlled and randomized clinical trials. No review articles, editorials, and comments were included in this selection.

Moreover, the reference list of the selected articles was assessed to obtain other non-indexed articles. The selected articles were analyzed by two authors for the final data extraction.

Results

At the beginning of the search, 1040 articles were retrieved. All articles that assessed the association between constipation and water intake or that used fluids as part of the therapy were selected. Thus, 26 articles1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.

12 Hope AK, Down EC. Dietary fiber and fluid in the control of constipation in a nursing home population. Med J Aust. 1986;144:306-7.

13 Whitehead WE, Drinkwater D, Cheskin LJ, Heller BR, Schuster MM. Constipation in the elderly living at home. Definition, prevalence, and relationship to lifestyle and health status. J Am Geriar Soc. 1989;37:423-9.

14 Klauser AG, Beck A, Schindlbeck NE, Müller-Lissner SA. Low fluid intake lowers stool output in healthy male volunteers. Z Gastroenterol. 1990;28:606-9.

15 Campbell AJ, Busby WJ, Horwath CC. Factors associated with constipation in a community based sample of people ages 70 years and over. J Epidemiol Community Health. 1993;47:23-6.

16 Rodrigues-Fisher L, Bourguignon C, Good BV. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res. 1993;2:464-77.

17 Towers AL, Burgio KL, Locher JL, Merkel IS, Safaeian M, Wald A. Constipation in the elderly: influence of dietary, psychological, and physiological factors. J Am Geriatr Soc. 1994;42:701-6.

18 Anti M, Pignataro G, Armuzzi A, Valenti A, Lascone E, Marmo R, et al. Water supplementation enhances the effect of high fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. 1998;45:727-32.

19 Meiring PJ, Joubert G. Constipation in elderly patients attending a polyclinic. S Afr Med J. 1998;88:888-90.

20 Chung BD, Parekh U, Sellin JH. Effect of increased fluid intake on stool output in normal healthy volunteers. J Clin Gastroenterol. 1999;28:29-32.

21 Lindeman RD, Romero LJ, Liang HC, Baumgartner RN, Koehler KM, Garry PJ. Do elderly persons need to be encouraged to drink more fluid?. J Gerontol A Biol Sci Med Sci. 2000;55:M361-5.

22 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.

23 Murakami K, Sasaki S, Okubo H, Takahashi Y, Hosoi Y, Itabashi M, et al. Association between dietary fiber, water and magnesium intake and functional constipation among Young Japanese women. Eur J Clin Nutr. 2007;61:616-22.

24 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.

25 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27.

26 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.

27 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7.

28 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.

29 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51.

30 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.

31 Lazebnik LB, Prilepskaia SI, Baryshnikov EN, Parfenov AI, Kosacheva TN. Prevalence and risk factors of constipation in the adult population of Moscow (according to population-based study MUSA). Eksp Klin Gastroenterol. 2011;3:68-73.

32 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9.

33 Markland AD, Palsson O, Goode PS, Burgio KL, Busby-Whitehead J, Whitehead WE. Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol. 2013;108:796-803.

34 Mazlyn MM, Nagarajah LH, Fatimah A, Norimah AK, Goh KL. Stool patterns of Malaysian adults with functional constipation: association with diet and physical activity. Malays J Nutr. 2013;19:53-64.

35 Vargas-Garcías EJ, Vargas-Salado E. Food intake, nutritional status and physical activity between elderly with and without chronic constipation. A comparative study. Cir Cir. 2013;81:214-20.
-3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. were selected for reading. Of these, only the 11 articles1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.,2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.

25 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27.

26 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.

27 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7.

28 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.

29 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51.
-3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. that addressed children and adolescents were included in this review. After analysis, the articles were divided into two categories: those that assessed water and fluid intake as a possible risk factor for intestinal constipation and those that assessed their role in intestinal constipation treatment.

Of the retrieved articles, six evaluated water and/or fluid intake as a possible risk factor for intestinal constipation.2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. These studies were carried out in Spain,2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5. Hong Kong,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400. United Kingdom,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27. Thailand,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5. and Korea.3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. The studied samples ranged from 84 to 1426 individuals. The criteria used to evaluate fluid intake and intestinal rhythm were different in each study. The main results are shown in Table 1. Four articles showed an association between low fluid intake and intestinal constipation.2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. The other two studies found lower fluid intake in children with intestinal constipation; however, the difference was not statistically significant.2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27.

Table 1
Characteristics of studies in children that evaluated water or fluid intake as a risk factor for intestinal constipation.

Fluid intake as treatment of intestinal constipation was assessed in five articles,1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.,2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.,2727 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7.,2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51.,3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9. with heterogeneous methodologies. The studies were conducted in the United States,1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.,2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.,2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51. Korea,2727 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7. and Greece.3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9. Of these, only one found a positive effect of higher fluid intake in the treatment of intestinal constipation; the positive effect was observed when the treatment included polyethylene glycol 4000.2727 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7. Two articles assessed the increase in fluid consumption after a behavioral intervention with2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51. and without2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9. fluid intake encouragement in children with retentive encopresis (fecal incontinence caused by retention). An increase in fluid intake was observed in both studies. Moreover, there was also an increase in evacuation frequency2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9. and a decrease in the occurrence of fecal incontinence.2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51. In the other articles, there was no statistically significant effect of increased fluid intake on the treatment of intestinal constipation (Table 2).1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.,3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9.

Table 2
Characteristics of the studies in children that evaluated the role of water intake in the treatment of intestinal constipation.

Discussion

This review showed that few studies evaluated low fluid intake as a factor associated with intestinal constipation or the role of fluid intake in the treatment of constipation. Of the eleven articles retrieved, six2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. analyzed the association between water and fluid intake and intestinal constipation and five, their role in the treatment of intestinal constipation.1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161.,2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.,2727 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7.,2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51.,3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9.

The association between intestinal constipation and lower fluid intake in samples from the general population indicate the possibility of a causal association between the two variables. Thus, in four2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. of the six2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. articles, a statistically significant association was found between low fluid intake and evidence of intestinal constipation. In the other two articles,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27. fluid intake by children with intestinal constipation was lower; however, the difference was not statistically significant. These articles are heterogeneous and difficult to compare due to how the variables were quantified and to the methods used to study the association between variables.

In four articles,2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. the odds ratio was analyzed to analyze the association between lower fluid intake and higher probability of intestinal constipation. In Thailand, fluid intake of less than 1800 mL/day in individuals aged between 10 and 18 years was associated with an increase of 20% in the risk of fewer than three bowel movements a week.3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5. In Spanish children, regarding the intake of fewer than four glasses a day (800 mL), a 2.5-fold probability of intestinal constipation was verified.

When fluid intake was four to eight glasses a day, the decrease was 5.8 times.2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5. In Hong Kong, an intake of up to two glasses a day (400 mL) was considered as the cutoff. It was found that the consumption of 600-800 mL a day and of more than 1000 mL was associated with a decrease in the chance of intestinal constipation of eight to 14 times, respectively.2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400. In Korea, intake of less than 500 mL/day between 25 and 84 months of age was associated with an increased risk of intestinal constipation.3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. As shown in Table 1, different criteria were used to assess bowel habits, but all studies indicated a statistically significant association between lower water consumption and signs of intestinal constipation.

The strength of the associations expressed by the odds ratio showed great variability. The only two articles2323 Murakami K, Sasaki S, Okubo H, Takahashi Y, Hosoi Y, Itabashi M, et al. Association between dietary fiber, water and magnesium intake and functional constipation among Young Japanese women. Eur J Clin Nutr. 2007;61:616-22.,2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5. that did not disclose a statistically significant association between constipation and lower fluid consumption used the Rome II criteria3737 Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Müller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999;45:43-7. for characterization of intestinal constipation. Based on these articles, it is possible to speculate that the Rome II criteria were very strict to characterize intestinal constipation in the samples that did not originate from specialized outpatient clinics. That is, the Rome II criteria can be considered more appropriate for patients with severe intestinal constipation treated at specialized services; however, it presents a lower positivity in studies carried out with samples from the general population.33 Hyams J, Colletti R, Faure C, Gabriel-Martinez E, Maffei HV, Morais MB, et al. Functional gastrointestinal disorders: working group report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2002;35:S110-7. Although the fluid intake by children with intestinal constipation was lower, the statistical analysis showed no significance (Table 1). These two articles2424 Lee WT, Ip KS, Chan JS, Lui NW, Young BW. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant food: a community-based study. J Paediatr Child Health. 2008;44:170-5.,2525 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fiber, fluid and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009;13:116-27. included fewer children than the others,2222 Comas Vives A, Polanco Allué I. Case-control study of risk factors associated with constipation. The FREI Study. An Pediatr (Barc). 2005;62:340-5.,2828 Chan MF, Chan YL. Investigating factors associated with functional constipation of primary school children in Hong Kong. J Clin Nurs. 2010;19:3390-400.,3030 Chien LY, Liou YM, Chang P. Low defaecation frequency in Taiwanese adolescents: association with dietary intake, physical activity and sedentary behavior. J Pediatr Child Health. 2011;47:381-5.,3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. which may have influenced the lack of association between water intake and intestinal constipation. Thus, based on the studies that expressed their results as odds ratios, despite the great variability in outcome characterization, all of them indicated an association between lower fluid intake and signs suggestive of intestinal constipation. When the same theme was analyzed in adults and the elderly, it was observed that the available information is also limited.

In adults, five of the six published articles showed an association between low fluid intake and intestinal constipation.1414 Klauser AG, Beck A, Schindlbeck NE, Müller-Lissner SA. Low fluid intake lowers stool output in healthy male volunteers. Z Gastroenterol. 1990;28:606-9.,2323 Murakami K, Sasaki S, Okubo H, Takahashi Y, Hosoi Y, Itabashi M, et al. Association between dietary fiber, water and magnesium intake and functional constipation among Young Japanese women. Eur J Clin Nutr. 2007;61:616-22.,3131 Lazebnik LB, Prilepskaia SI, Baryshnikov EN, Parfenov AI, Kosacheva TN. Prevalence and risk factors of constipation in the adult population of Moscow (according to population-based study MUSA). Eksp Klin Gastroenterol. 2011;3:68-73.,3333 Markland AD, Palsson O, Goode PS, Burgio KL, Busby-Whitehead J, Whitehead WE. Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol. 2013;108:796-803.,3434 Mazlyn MM, Nagarajah LH, Fatimah A, Norimah AK, Goh KL. Stool patterns of Malaysian adults with functional constipation: association with diet and physical activity. Malays J Nutr. 2013;19:53-64. In the elderly, six articles were retrieved,1313 Whitehead WE, Drinkwater D, Cheskin LJ, Heller BR, Schuster MM. Constipation in the elderly living at home. Definition, prevalence, and relationship to lifestyle and health status. J Am Geriar Soc. 1989;37:423-9.,1515 Campbell AJ, Busby WJ, Horwath CC. Factors associated with constipation in a community based sample of people ages 70 years and over. J Epidemiol Community Health. 1993;47:23-6.,1717 Towers AL, Burgio KL, Locher JL, Merkel IS, Safaeian M, Wald A. Constipation in the elderly: influence of dietary, psychological, and physiological factors. J Am Geriatr Soc. 1994;42:701-6.,1919 Meiring PJ, Joubert G. Constipation in elderly patients attending a polyclinic. S Afr Med J. 1998;88:888-90.,2121 Lindeman RD, Romero LJ, Liang HC, Baumgartner RN, Koehler KM, Garry PJ. Do elderly persons need to be encouraged to drink more fluid?. J Gerontol A Biol Sci Med Sci. 2000;55:M361-5.,3535 Vargas-Garcías EJ, Vargas-Salado E. Food intake, nutritional status and physical activity between elderly with and without chronic constipation. A comparative study. Cir Cir. 2013;81:214-20. and five1515 Campbell AJ, Busby WJ, Horwath CC. Factors associated with constipation in a community based sample of people ages 70 years and over. J Epidemiol Community Health. 1993;47:23-6.,1717 Towers AL, Burgio KL, Locher JL, Merkel IS, Safaeian M, Wald A. Constipation in the elderly: influence of dietary, psychological, and physiological factors. J Am Geriatr Soc. 1994;42:701-6.,1919 Meiring PJ, Joubert G. Constipation in elderly patients attending a polyclinic. S Afr Med J. 1998;88:888-90.,2121 Lindeman RD, Romero LJ, Liang HC, Baumgartner RN, Koehler KM, Garry PJ. Do elderly persons need to be encouraged to drink more fluid?. J Gerontol A Biol Sci Med Sci. 2000;55:M361-5.,3535 Vargas-Garcías EJ, Vargas-Salado E. Food intake, nutritional status and physical activity between elderly with and without chronic constipation. A comparative study. Cir Cir. 2013;81:214-20. did not identify an association between fluid intake and intestinal constipation. Therefore, in both children and adults, the evidence indicates an association between lower fluid intake and intestinal constipation. From the experimental standpoint, it has been demonstrated that fluid restriction in rats leads to lower feed intake and less stool elimination. When controlling for the effect of decreased feed intake, it was confirmed that water intake restriction is associated with a reduction in fecal weight.3838 Andrade SM, Dias DV, Speridião PG, Morais MB [dissertation] Efeito da ingestão hídrica no peso fecal: estudo experimental em ratos recém desmamado. São Paulo (SP): Disciplina de Gastroenterologia Pediátrica da Universidade Federal de São Paulo; 2012. In healthy human adults, it was observed that fluid deprivation decreases the frequency of bowel movements and fecal weight.1414 Klauser AG, Beck A, Schindlbeck NE, Müller-Lissner SA. Low fluid intake lowers stool output in healthy male volunteers. Z Gastroenterol. 1990;28:606-9.

These articles with samples from the general population did not consider whether the fluid intake of the assessed individuals was within the internationally recommended range. There are two recommendations for fluid intake, one for North America (Dietary References Intake)3939 Institute of Medicine Food, Nutrition Board. Dietary reference intakes for water, potassium, sodium, chloride and sulfate. Washington DC: National Academy Press; 2005. and another for Europe (European Community).4040 EFSA. Draft dietary reference values for water. Scientific opinion of the panel on dietetic products, nutrition and allergies; 2008. Available from https://www.reading.ac.uk/foodlaw/pdf/eu-08021-efsa-drv-principles-water.pdf [cited8.4.11].
https://www.reading.ac.uk/foodlaw/pdf/eu...
In Brazil, it is suggested that the North American recommendations be followed.4141 Sociedade Brasileira de Pediatria. Manual de orientação para a alimentação do lactente, do pré-escolar, do escolar, do adolescente e na escola. Departamento de Nutrologia. 3 ed. Rio de Janeiro (RJ): SBP; 2012.

It should be noted that both recommendations consider not only the amount of water consumed as liquids (water, juice, and soft drinks), but also the water contained in food. The pediatric studies compiled in this review did not consider the water present in food, but only in the form of liquids. Thus, in the future, epidemiological studies should be planned to consider not only the volume and quality of consumed liquids, but also the estimation of water in food. These values should be compared to the existing recommendations for fluid intake by the pediatric population.

The NASPGHAN/ESPGHAN1010 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58:258-74. guideline says that, due to the lack of scientific evidence, increased fluid intake should not be part of the functional intestinal constipation therapeutic program. They only mention the article published in 1998 by Young et al.1111 Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gastroenterl Nurs. 1998;21:156-161. (Table 2). This randomized clinical trial compared two interventions with increased fluid intake in a group that did not receive this type of recommendation. The project brings a simple consideration: what would the placebo be in this study that could be used for it to be double-blind? Thus, this clinical trial involving 90 patients failed to observe any difference regarding clinical response to the three interventions related to higher fluid intake. The article does not report whether patients were treated simultaneously using other conducts that could mask the role of fluid intake in the evolution of intestinal constipation. The other four articles2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.,2727 Bae SH, Son JS, Lee R. Effect of fluid intake on the outcome of constipation in children: PEG 4000 versus lactulose. Pediatr Int. 2010;52:594-7.,2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51.,3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9. were not prospective clinical trials. The articles by Kuhl et al.2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9.,2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51. evaluated the effect of a standardized guideline in the increase fluid intake as part of the treatment of retentive encopresis (fecal incontinence caused by retention). Apparently, the authors assumed that increased water intake is a measure that is part of intestinal constipation treatment. The first article showed that the patients had increased fluid intake and the frequency of evacuations at the end of the follow-up; however, since there was no control group, it was not possible to attribute the effect, or part of it, to the fluid intake increase.2626 Kuhl ES, Felt BT, Patton SR. Brief report: adherence to fluid recommendation in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2009;34:1165-9. In the second article,2929 Kuhl ES, Hoodin F, Rice J, Felt BT, Rausch JR, Patton SR. Increasing daily water intake and fluid adherence in children receiving treatment for retentive encopresis. J Pediatr Psychol. 2010;33:1144-51. a group was prospectively treated and compared with data from the medical files of other previously treated patients. It was verified that the intervention resulted in greater fluid intake; however, no improvement in clinical response was observed. These two studies, whose design was not specifically aimed at assessing the efficacy of increasing fluid intake in the treatment of constipation, did not offer evidence on the efficacy of fluids in controlling intestinal constipation associated with retentive encopresis.

Another article on this subject was a randomized clinical trial.3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9. It was performed to compare two types of treatment: (1) standardized diet and (2) personalized dietary intervention. It was observed that the group that received personalized dietary intervention had a higher increase in water intake than the group with a standardized diet. However, both groups showed similar improvement in evacuation frequency and difficulty, as well as in pain to evacuate. Both groups received lactulose during the observation period.3232 Karagiozoglou-Lampoudi T, Daskalou E, Agakidis C, Savvidou A, Apostolou Am, Vlahavas G. Personalized diet management can optimize compliance to a high-fiber, high-water diet in children with refractory functional constipation. J Acad Nutr Diet. 2012;112:725-9. The lactulose dose used in the study was not reported, nor whether it remained the same in both groups during the follow-up period. The most recent article retrieved in the literature search was carried out in Korea.3636 Park M, Bang YG, Cho KY. Risk factors for functional constipation in young children attending daycare centers. J Korean Med Sci. 2016;31:1262-5. The files of patients with constipation who had been stable for at least two months and had recorded fluid intake, stool consistency, and frequency of bowel movements were retrospectively evaluated. The article did not define what was considered higher and lower fluid intake. Moreover, the article did not specify how the consistency and frequency of evacuation scores were calculated based on the information in the medical records. The information on each patient was studied at two different moments. The results showed that there was an association between greater evacuation frequency and lower stool consistency with the use of polyethylene glycol 4000 in periods with higher fluid intake. However, due to its limitations, the clinical relevance of the observed differences may be considered debatable. Therefore, the analysis of these articles to evaluate the role of fluid intake in the treatment of intestinal constipation did not show any consistent results.

Regarding the role of water intake for constipation treatment in adults and the elderly, three studies were retrieved, one in adults1818 Anti M, Pignataro G, Armuzzi A, Valenti A, Lascone E, Marmo R, et al. Water supplementation enhances the effect of high fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. 1998;45:727-32. and two in the elderly.1212 Hope AK, Down EC. Dietary fiber and fluid in the control of constipation in a nursing home population. Med J Aust. 1986;144:306-7.,1616 Rodrigues-Fisher L, Bourguignon C, Good BV. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res. 1993;2:464-77. In the study carried out in adults, it was observed that patients with constipation who consumed two liters of water had a statistically significant increase in the evacuation frequency and a decrease in the use of laxatives. In the elderly, an association was found between higher fluid and dietary fiber intake and intestinal constipation improvement,1212 Hope AK, Down EC. Dietary fiber and fluid in the control of constipation in a nursing home population. Med J Aust. 1986;144:306-7. as well as less need for laxative use.1616 Rodrigues-Fisher L, Bourguignon C, Good BV. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res. 1993;2:464-77. However, in this situation, it is difficult to discriminate whether the positive effect was due to the higher fluid intake or to the higher dietary fiber intake, or even due to the synergistic effect of the two interventions.

Thus, based on the literature analysis, it was observed that few studies have assessed the association between water and/or fluid intake and intestinal constipation. Moreover, these studies are heterogeneous and difficult to compare. The results of studies with a sample of the general population suggest that a lower intake of water and/or fluids is associated with intestinal constipation. Regarding the role of water in the treatment of intestinal constipation, the few existing articles did not show an advantage of a greater fluid intake in the treatment. Conversely, studies with samples from the general population show a favorable effect of increasing water/fluid intake to improve intestinal habits. There is also evidence that normal children and adolescents do not meet daily fluid intake recommendations. In this context, it is considered that the adequate intake of liquids and dietary fiber is part of what are considered healthy eating habits. These may constitute a preventive measure and an initial therapy for cases of mild intestinal constipation. In contrast, more severe patients with fecaloma and fecal incontinence must undergo a treatment program that involves therapeutic measures for disimpaction and medication to ensure that the intestinal rhythm is normalized. For these patients, although there is no evidence, it is important to evaluate fluid intake. If necessary, an increase in fluid intake should be recommended, so that the patient reaches at least what is recommended worldwide.

Therefore, the authors conclude there are few articles that assessed the association between water and fluid intake and intestinal constipation in children and adolescents. The results suggest that a lower water intake is associated with a higher risk of intestinal constipation. Thus, it can be speculated, based on studies carried out with community samples, that a greater water intake may be beneficial for the prevention and treatment of mild intestinal constipation. Further studies are necessary to better understand the role of water and fluids in the etiology and treatment of intestinal constipation in children and adolescents.

  • Please cite this article as: Boilesen SN, Tahan S, Dias FC, Melli LC, Morais MB. Water and fluid intake in the prevention and treatment of functional constipation in children and adolescents: is there evidence? J Pediatr (Rio J). 2017;93:320-7.
  • ☆☆
    This study was carried out at Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Disciplina de Gastroenterologia Pediátrica, São Paulo, SP, Brazil.

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Publication Dates

  • Publication in this collection
    Jul-Aug 2017

History

  • Received
    18 Mar 2016
  • Accepted
    2 Jan 2017
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