ORIGINAL ARTICLE: GASTROENTEROLOGY

Dietary Fiber Mixture in Pediatric Patients With

Controlled Chronic Constipation


Thabata K. Weber, yMauro S. Toporovski,
Soraia Tahan,
y
Clarice B. Neufeld, and
Mauro B. de Morais

ABSTRACT
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fecal impaction is treated with disimpaction therapy, and mainten-

Objectives: The aim of the study was to test the clinical efficacy and effect
ance therapy is initiated to avoid recurrences (2,3). The mainten-
on colonic transit time (CTT) of a dietary fiber mixture given to children
ance therapy involves the continued use of stool softeners,
with controlled chronic constipation (CC) after the withdrawal of stool
correcting eating habits and adopting a fiber-rich diet (3).
softeners and enemas.
The modulation of a number of intestinal functions is a
Methods: This randomized, placebo-controlled, double-blind clinical
physiological effect attributed to dietary fiber (4). Diets that
trial involved 54 patients aged 4 to 12 years and had CC that was
contain sufficient fiber can increase the number and volume of
controlled by the use of low-dose stool softeners. The use of these
bowel movements, soften stool texture, and decrease intestinal
softeners was discontinued when the patients were admitted to the
transit time (5). The preferential consumption of foods with
clinical trial. The patients were randomized into 2 groups for the
higher fiber content is not always sufficient to attain an adequate
4-week study period. One group received a dietary fiber mixture and
dietary fiber intake (6). Therefore, individuals can increase their
the other group received a placebo (maltodextrin). The primary outcome
fiber consumption using dietary fiber supplements. Despite
was therapeutic failure (oral stool softeners or enemas was required to
indications that increased fiber consumption aids in the treatment
prescribe during the trial). Secondary outcomes included defecation
of constipation (2,3,7), few clinical trials (8–12) have evaluated
frequency, stool consistency (measured using the Bristol Stool Form
the efficacy of increased fiber intake. These trials have demon-
Scale), and CTT.
strated little evidence that fiber supplements are more effective
Results: Therapeutic failure was observed in 34.6% (9/26) of the patients in
than placebo, and in the majority of cases, the effect of only a
the dietary fiber mixture group and in 35.7% (10/28) in the control group
single type of fiber was evaluated. Each type of dietary fiber
(P ¼ 0.933). The mean increase in daily bowel movements was 0.53 in the
presents particular characteristics that determine its action, mech-
dietary fiber mixture group and 0.23 in the control group (P ¼ 0.014). The
anism, and performance in different parts of the colon (13).
patients in the dietary fiber mixture group (60.0%) passed nonhardened
Therefore, the combination of different types of fibers into a
stools more frequently than did those in the control group (16.7%,
single product for fiber supplementation may result in greater
P ¼ 0.003). The CTT was similar for both groups.
effectiveness.
Conclusions: The fiber mixture did not prevent the suspension of stool
Owing to the lack of well-designed, randomized clinical
softeners or lead to reduced CTT; however, the mixture promoted an
trials targeting nonpharmacological treatment for constipated
increased frequency of defecation and an improvement in the stool
children (14), we designed a clinical trial to evaluate the clinical
consistency.
efficacy and effect of a dietary fiber mixture on colonic transit time
Key Words: child, constipation, fiber, randomized controlled trial (CTT) in pediatric patients with controlled CC.

(JPGN 2014;58: 297–302)

METHODS
Children between the ages of 4 and 12 years were included

C hronic constipation (CC) is a common symptom in pediatric

populations (1). Treatment involves various educational
measures concerning appropriate intestinal habits; when necessary,
Received August 8, 2013; accepted October 17, 2013.
From the
Division of Pediatric Gastroenterology, Federal University of
São Paulo, São Paulo, Brazil, and the yDepartment of Pediatrics, School
of Medicine, Santa Casa de São Paulo, São Paulo, Brazil.
Address correspondence and reprint requests to Mauro S. Toporovski, PhD,
Department of Pediatrics, School of Medicine, Santa Casa de São
Paulo, Avenida Pacaembú, 1083, CEP-01234-001 São Paulo, Brazil
(e-mail: toporovski@uol.com.br).
www.clinicaltrials.gov registration number: 01333787.
This research was supported by the National Counsel of Technological and
Scientific Development (CNPq).
The authors report no conflicts of interest.
Copyright # 2014 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000000224
in the study. The initial diagnosis of functional CC was based on
the Rome III criteria (1). The children were treated at the Pediatric
Gastroenterology Outpatient Clinics of the Santa Casa de
Misericórdia Hospital and the Federal University of São Paulo,
Brazil, which are located in the city of São Paulo. All of the patients
had controlled CC and had received maintenance therapy with low
doses of stool softeners (<1.0 mL/kg of magnesium sulfate, mineral
oil or lactulose or <0.5 g/kg of polyethylene glycol 3350). The
controlled CC was defined by at least 1 evacuation every 2 days and
the absence of fecal incontinence or fecal impaction for >1 month.
In addition to this, the patients were in the gradual removal phase of
the softener and working toward the goal of complete suspension of
the medication.
The exclusion criteria included the following: organic causes
of constipation, metabolic illnesses, regular use of fiber and pro-
biotic supplements in the 4 weeks before admission to the study, use
of medications that could cause constipation, a family that was
unable to record the protocol information, and absence of a fixed or
mobile telephone.

JPGN  Volume 58, Number 3, March 2014 297

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 Weber et al
Study Design and Intervention
This study was a randomized, parallel, double-blind,
placebo-controlled trial that followed the standards proposed by
the Consolidated Standards of Reporting Trials (15). The random-
ization was generated using a random number table produced by a
clinical research company (Invitare, São Paulo, Brazil). Blocks of
6 patients were allocated at a 1:1 ratio into the study and control
groups.
For the clinical evaluation, we assessed the patients’ prior
and present history of constipation. We paid special attention to the
abdominal and rectal evaluations to verify the absence of fecal
impaction. Upon admission to the study, the child’s parents were
instructed to suspend the use of stool softeners and to administer the
supplied supplement or placebo. They were informed about main-
taining daily toilet training and regular water ingestion. A daily diet
inquiry and 24-hour recording methods were used to determine the
child’s dietary consumption. Energy, fat, carbohydrate, and protein
levels were measured using the Nutritional Decision Support
System (version 2.5) software (São Paulo, Brazil) (16). The
Brazilian food composition table was used to quantify the intake
of dietary fiber from food sources (17).
The patients were evaluated once weekly during the 4-week
study period. The first (day 7) and third (day 21) evaluations were
performed over the telephone, and the second (day 14) and fourth
(day 28) evaluations were conducted at the ambulatory outpatient
clinic. At home, the individual responsible for administering treat-
ment completed 2 specific questionnaires: first, a daily defecation
frequency and type of feces eliminated questionnaire based on the
Bristol Stool Form Scale (18) (stools were rated based on water
content; a score of 1 represented hard stools and a score of
7 represented liquid stools), and, second, a questionnaire addressing
symptoms related to constipation and the use of the supplement
provided.
Dietary Fiber Mixture
During the 4-week study period, the patients received the
fiber mixture or the maltodextrin placebo. The fiber mixture used in
this study (Stimulance; Milupa, Friedrichsdorf, Germany; imported
and distributed by Support Produtos Nutricionais, São Paulo,
Brazil) was selected because it had been successfully used in
hospitalized adults who required enteral nutrition (19). Addition-
ally, its various components are digested in different portions of the
colon (proximal and distal); therefore, the combined use of these
fiber types was expected to be more effective than the use of single-
fiber products. It should be emphasized that several of the com-
ponents (10.5% fructooligosaccharides, 12.5% inulin, 24% gum
arabic, 9% resistant starch, 33% soy polysaccharide, and 12%
cellulose) are considered prebiotics.
Dietary fiber and fiber supplements are often recom-
mended for both the treatment and prevention of constipation;
however, there is no specific therapeutic dose (14,20), according
to the North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition guideline (3). The product manufac-
turer suggests a variable dose for both children (1/2–3, 3.8-g/day)
and adults (1–3 g/day). In this context, we decided to use a
lower dose for children <18 kg of weight and a higher dose for
children weighing >18 g. The dose was defined according to
body weight: 3.8 g of fiber or placebo (1 tablespoon) diluted in
200 mL of a chocolate milk drink was given twice a day to
children weighing up to 18 kg, and 7.6 g of fiber or placebo
(2 tablespoons) was given in the same form to children weighing
>18 kg.
298
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JPGN  Volume 58, Number 3, March 2014
The parents were instructed on how to adequately prepare
the fiber mixture or the placebo with the chocolate milk drink.
Therapeutic compliance with the prescription was based on the
weight of the product tins, which were delivered unopened to the
researchers. The labeling was standardized, and the products
resembled each other and were administered in an identical
manner.
Outcome Parameters
The primary outcome was defined as therapeutic failure.
Therapeutic failure was defined as a patient who experienced
hardened stools, defecation with pain or difficulty, a greater interval
between evacuations compared with the previous day, the appear-
ance of fecal incontinence and fecal impaction, or when the patient
required a stool softener during the study period. Therapeutic
success was defined as a patient maintaining normal bowel habits
without the use of stool softeners or enemas.
Secondary outcomes were defined as the defecation frequency
(as stated in the bowel movement records); the form and consistency
of the stool, for which hardened stools included types 1, 2, and 3 and
nonhardened stools included types 4, 5, 6, and 7, according to the
Bristol Stool Form Scale (18); the CTT; the palatability level, based
on palatability scores (1 ¼ good, 2 ¼ reasonable, and 3 ¼ poor); and
the occurrence of adverse effects.
CTT
The total and segmental CTTs were evaluated during the last
week of the study using the method proposed by Bouchoucha et al
(21), although with several modifications (22). Radiopaque markers
(Sitzmarks; Konsyl Pharmaceuticals, Easton, MD) were reencap-
sulated to contain 12 markers in each capsule. A capsule containing
12 radiopaque markers was ingested on 6 consecutive mornings
(at 9:00 AM). An abdominal radiograph was obtained on day 7. To
determine the segmental transit time (right, left, and rectosigmoid),
the topographic regions proposed by Gutierrez et al (22) were used.
Based on the number of markers counted in each region, the CTTs
were calculated using the following formula: CTT ¼ (sum of the
markers  [time between administrations/number of markers per
capsule]).
Ethics
We obtained written informed consent for each patient before
the patients were admitted into the clinical trial. The ethics com-
mittees from both research centers approved the study.
Statistical Analysis
The sample size was calculated based on the primary out-
come (therapeutic failure). We assumed a 30% failure rate for the
intervention group and a 70% failure rate for the control group. With
a ¼ 0.05 and b ¼ 0.20 (power ¼ 0.80), each group would ideally
comprise 28 patients.
To compare the mean and median values of the 2 study
groups, we used a parametric (the Student t test) or a nonparametric
test (the Mann-Whitney U test) in accordance with the variable
distribution. The paired t test was performed to compare intragroup
averages. To determine proportions, we used the x2 test or the Fisher
exact test. We performed the calculations using SigmaStat 3.1
(Jandel Corporation, Richmond, CA) (23) and EpiInfo (24) soft-
ware. To calculate the risk ratio (RR) and 95% confidence intervals
(CIs), we used the EpiInfo program. To calculate the number needed
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 JPGN  Volume 58, Number 3, March 2014 Dietary Fiber Mixture in Controlled Chronic Constipation

to treat, we used the inverse of the absolute risk reduction. The
difference between the study groups was considered significant
when P < 0.05 or when the 95% CI for the risk ratio did not exceed
1.0 (equivalent to P < 0.05).
RESULTS
Patients
Between February 2008 and January 2009, 60 children were
eligible for the study, and 57 patients were randomized into
2 groups. The experimental group (n ¼ 27) received the dietary
fiber mixture, and the control group (n ¼ 30) received the placebo.
No statistically significant differences were found between the
groups at the time of their admission to the trial (Table 1). During
the treatment period, 2 patients from the control group were
excluded from the analysis; 1 patient was excluded for consuming
products containing probiotics, and the other patient was excluded
for not attending the consultations. One patient in the dietary fiber
mixture group discontinued intervention because he did not want to
drink the chocolate milk and was therefore not consuming the fiber
treatment. In total, 54 patients were evaluated, 26 from the dietary
fiber mixture group and 28 from the control group. Six patients in
the dietary fiber mixture group (6/26) and 4 patients in the control
group (4/28) interrupted their treatment (because of the need for
stool softeners or enemas to manage fecal impaction) during the
intervention period (P ¼ 0.254). Twenty patients from the dietary
fiber mixture group (20/26) and 24 patients from the control group
(24/28) completed the entire 4-week protocol (Fig. 1). Three
patients in the intervention group and 6 patients in the control
group were, however, designated as therapeutic failures during the
last evaluation.
The analysis of the primary outcome followed the intention-
to-treat principle. Therefore, all 54 of the patients included in the
study were considered. The evaluation of the secondary outcomes
(defecation frequency, stool consistency, and CTT) was based on
the data from the 44 patients who completed the 4-week study
period.
Therapeutic Failure
Therapeutic failure was similar between the 2 groups. In
total, 9 (9/26, 34.6%) patients from the dietary fiber mixture group
and 10 (10/28, 35.7%) patients from the control group were
considered to present therapeutic failure (Table 2).
Defecation Frequency and Stool Consistency
Taking into account the secondary outcomes, a greater
increase in defecation frequency per day (final  basal value)
was observed for patients in the dietary fiber mixture group
(0.529  0.423) compared with those in the control group
(0.232  0.350, P ¼ 0.014; Table 3). The recording of the form
and consistency of the stool according to the Bristol Stool Form
Scale permitted the identification of the predominant type of stool
passed. Hardened stools included types 1, 2, and 3, and nonhardened
stools included types 4, 5, 6, and 7 based on the Bristol Stool Form
Scale. Hardened stools predominated among the control group
patients, whereas nonhardened stools predominated among the
patients in the dietary fiber mixture group. This association was
statistically significant (Table 4).
Consumption of Fiber, Energy, and
Macronutrients
The median dietary fiber intake was similar for both groups
before the start of the clinical trial (13.8 g/day in the dietary fiber
mixture group and 14.10 g/day in the control group, P ¼ 0.993). In
addition to this, the median energy and consumption of macronu-
trients were similar between the groups. During the study period,
the children maintained their normal and expected body mass index
values (data not shown).
CTT
We did not perform an abdominal radiograph on 1 patient in
the dietary fiber mixture group. Table 5 presents the total and
segmental CTTs during the fourth week of the clinical trial. These
times were similar for the 2 groups.
The median (25th and 75th percentiles) palatability scores
for the dietary fiber mixture and the placebo (maltodextrin) were
1.25 (1.00–1.67) and 1.00 (1.00–1.25), respectively (P ¼ 0.007).
Nevertheless, the compliance of the dietary fiber mixture group
with the prescribed dosage was satisfactory.
Adverse Events
A total of 81% of the children in the fiber mixture group
consumed >80% of the prescribed dosage. No child failed to take
the supplements on consecutive days throughout the study. Serious

TABLE 1. Baseline demographic and clinical characteristics

Dietary fiber mixture group, n ¼ 26 Control group, n ¼ 28 P

Age, y 8.5  1.8 7.7  2.4 NS
Sex (male/female) 14/12 12/16 NSy
Body mass index, kg/m2 16.2 (14.8–17.4) 16.4 (14.7–19.5) NSz
Appearance of constipation symptoms during first year of life (%) 8 (30.8) 9 (32.1) NSy
Prior occurrence of fecal incontinence per retention (%) 11 (42.3) 13 (46.4) NSy


Defecation frequency (bowel movements/day) 0.59  0.31 0.69  0.30 NS
Stool consistency (%)§
Hardened 18 (69.2) 22 (78.6) NSy
Nonhardened 8 (30.8) 6 (21.4)

NS ¼ not significant; SD ¼ standard deviation.

Student t test, mean  SD.
y 2
x test, number and percentage.
z
Mann-Whitney U test, median (25 – 75 percentiles).
§
Stool consistency ¼ predominant type of feces according to the Bristol Stool Form Scale: hardened stools (types 1, 2, and/or 3); nonhardened stools (types 4,
5, 6, and/or 7).

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 Weber et al JPGN  Volume 58, Number 3, March 2014

Diagram of the study:

60 patients eligible

1 refused to participate
2 refused the chocolate milk
drink

57 randomized

27 Dietary fiber mixture group 30 Control group

Discontinued intervention (n = 2):

Discontinued intervention (n = 1): 1 lost during the intervention period
1 lost during the intervention period 1 exclusion due to the consumption
of a probiotic

26 dietary fiber mixture group 28 control group

Evaluation during the protocol: Evaluation during the protocol:

6 therapeutic failures 4 therapeutic failures

20 children completed the study, but 3 24 children completed the study, but 6
had therapeutic failure. had therapeutic failure.
Thus, the total therapeutic failure = 9 Thus, the total therapeutic failure = 10

FIGURE 1. Diagram for the trial according to the Consolidated Standards of Reporting Trials statement (15).

adverse events were not observed for either group, and the products
were well tolerated.
DISCUSSION
This clinical trial demonstrated that the ingestion of a dietary
fiber mixture can contribute to increased defecation frequency and
increased stool softness in pediatric patients with controlled CC and
those who have been withdrawn from stool softener therapies. The
dietary fiber mixture was the sole therapeutic intervention used in
this study.
The admission data demonstrated that the children in both
treatment groups defecated at least once every 2 days. Despite this
frequency of defecation, the consumption of dietary fiber increased
the daily defecation rate. This increase was more evident in the
patients who completed the 4-week study. The mean rate of
defecation was approximately once per day in the group treated
with the fiber mixture, which is similar to the normal defecation rate
for children >3 years of age (3,25).
Previous clinical trials evaluated stool consistency using
different methods, including subjective evaluations from the child’s
parents (11), 5 different scores (8,10), and the Bristol Stool Form
Scale (12). We used the Bristol Stool Form Scale to verify that the
individuals in the dietary fiber mixture group produced softened
stools and that those in the control group predominantly produced
hardened stools. Furthermore, stools in the form of round balls
(sausage-shaped but lumpy, type 2) were more frequent among
patients who had received the placebo. Smooth, thin stools (type 4)
were more frequent among individuals in the dietary fiber mixture
group (P < 0.05; data not shown).
In adults with a polymeric enteral diet, increased production
of short-chain fatty acids and an increase in the total number of
bacteria have been observed (19). In addition to this, these patients
demonstrated decreased CTTs (26). Fatty acid production is known
to favor bacterial proliferation (13). This increase in bacteria and the
resulting high percentage of water create a moist stool with a soft
consistency (5) that is more easily excreted (27). Although they do
not directly address the research subject being presented, these
results support the hypothesis that this fiber mixture can benefit the
intestinal function of constipated children and can promote better
stool consistency and increased defecation frequency, despite the
fact that our patients ate a regular diet and not a special polymeric
enteral diet.
No statistically significant difference was found in terms of
the proportion of therapeutic failure and success between the
2 groups. It is worth noting that patients with hard stools and those

TABLE 2. Primary outcome measures

Variable Dietary fiber mixture group, n ¼ 26, n (%) Control group, n ¼ 28, n (%) RR (95% CI) NNT

Therapeutic failures 9 (34.6) 10 (35.7)

0.98 (0.54–1.75) 100
Therapeutic successes 17(65.4) 18 (64.3)

x2 test (P ¼ 0.933). CI ¼ confidence interval; NNT ¼ number needed to treat; RR ¼ risk ratio.

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 JPGN  Volume 58, Number 3, March 2014 Dietary Fiber Mixture in Controlled Chronic Constipation

TABLE 3. Secondary outcome measures: defecation frequency

Dietary fiber mixture group, n ¼ 20 Control group, n ¼ 24 P

Defecation frequency


Basal 0.564  0.299y 0.675  0.304z 0.230


Final 1.093  0.452y 0.907  0.310z 0.114


D (final  basal) 0.529  0.423 0.232  0.350 0.014

SD ¼ standard deviation.


Student t test, mean  SD. Paired t test.
y
P < 0.001.
z
P ¼ 0.004.

TABLE 4. Secondary outcome measures: stool consistency according to the Bristol Stool Form Scale

Stool consistency Dietary fiber mixture group, n ¼ 20, n (%) Control group, n ¼ 24, n (%) RR (95% CI) NNT

Hardened 8 (40.0) 20 (83.3)

0.38 (0.20–0.73) 3
Nonhardened 12 (60.0) 4 (16.7)

x2 test (P ¼ 0.003). Stool consistency ¼ predominant type of feces according to the Bristol Stool Form Scale. Hardened stools: types 1, 2, and/or 3;
nonhardened stools: types 4, 5, 6, and/or 7. CI ¼ confidence interval; NNT ¼ number needed to treat; RR ¼ risk ratio.

with pain during defecation, fecal inconsistency, or the need
for stool softeners and enemas were, however, considered
therapeutic failures in this study. These failure criteria were
rigorously compared with those reported in the published litera-
ture. Loening-Baucke et al (10) observed a 68% therapeutic
success rate for constipated patients without encopresis using
glucomannan and a 13% success rate for patients using a placebo.
The definition of therapeutic success from the study permitted the
occurrence of up to 1 episode of fecal incontinence in 3 weeks
and the use of stool softeners (10), a definition used in other
studies (8,12). The present study, however, used a stricter defi-
nition of therapeutic success. Nevertheless, the dietary fiber
group achieved a therapeutic success rate (65.4%) that approxi-
mated the expected value for this sample size (70.0%). The
placebo effect (64.3%) was higher in this study than the expected
level of 30.0% observed in other clinical trials (9,10). It should be
noted that the high success rate of the placebo has been shown in
clinical trials involving children and adults with functional
gastrointestinal disorders (28).
The patients’ total and segmental CTTs were similar for both
groups. The median total CTT (50 hours in both groups) was shorter
than the normal upper limit of 62 hours recommended in the
literature (29). This value (45.7 hours) was longer than the mean
time and 2 standard deviations measured for 30 Spanish children
without constipation (29.1  8.3 hours). Thus, in the last week of
our clinical trial, the total CTTs of both the dietary fiber mixture
TABLE 5. Secondary outcome measures: total and segmental CCT
Dietary fiber mixture group, Control group,
CCT, h n ¼ 19 n ¼ 24
Total 50.0 (40.0–61.0) 50.0 (37.0–59.0)
Right colon 10.0 (4.5–21.5) 8.0 (5.0–14.0)
Left colon 10.0 (6.0–15.5) 8.0 (2.0–18.0)
Rectosigmoid 28.0 (11.0–38.5) 25.0 (18.0–32.0)
CCT ¼ colonic transit time; NS ¼ not significant.

population included only patients who used low-dose stool softener
Mann-Whitney U test, median, and 25th and 75th percentiles in par-
entheses.
group and the control group were longer than the reference values
observed in normal children. The median transit time of 50 hours
was also longer than the values observed during the sixth week of
mineral oil treatment for 33 patients with severe constipation
(median, 37 hours) (30). Thus, the exclusive use of the dietary
fiber mixture did not result in the same transit times that were
demonstrated for the mineral oil treatment.
The short duration of our study (4 weeks) may have been
insufficient to show a greater difference between the groups,
given that CC is a condition marked by frequent improvements
and then relapses. Another limitation relates to a greater increase
in defecation frequency per day. Although we found significant
differences between the 2 groups regarding this variable, it is
important to consider that constipated patients can often have
daily bowel movements without fully emptying their rectums,
which may lead to increased stool accumulation. This factor could
explain why we found no difference in intestinal transit times
between the patients who received placebo and those who con-
sumed fiber. The results may have been better understood if the
transit time had been evaluated upon admission to the trial.
Measures such as an outlet dysfunction evaluation (31) would
have highlighted the presence of disorders that would not have
been expected to improve with the addition of fiber alone. Thus,
the failure to rule out complicating disorders before patients were
enrolled could be considered another limitation of the study. The
relation between the effects of administered dietary fiber, its
ingestion time, and the CCT of constipated children should be
explored in future studies.
In conclusion, the use of a mixture containing 6 different
types of dietary fiber did not prevent the need for stool softeners or
enemas during the dietary fiber intervention nor did it reduce CTT


P in constipated patients who were in the suspension phase of
treatment with stool softeners. The increase in defecation frequency
NS
and the improvement in stool consistencies observed in the children
NS
who finished the study without using stool softeners were, however,
NS
important findings concerning the prevention of recurring consti-
NS
pation symptoms. These findings cannot be extrapolated to those
children who present with severe constipation because our study
therapies and had controlled CC.

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 Weber et al
Acknowledgments: The authors are thankful for the support
from Support Produtos Nutricionais and for the collaboration of
residents in pediatric gastroenterology, namely Cristina Marino,
Fernanda Miyamoto Barreto (Santa Casa de Misericórdia, de São
Paulo), Sabrina Bortolin Nery, and Juliana Okamoto (Federal
University of São Paulo).
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