Epidemiology of Paediatric constipation in Indonesia and its association with exposure to stressful life events

Childhood constipation is considered to be an emerging global public health problem [1]. The prevalence varies among countries from 0.7 to 29.6% [2, 3]. It is estimated that approximately one third of children with constipation suffer from psychological maladjustment [4]. In addition, childhood constipation leads to significant healthcare costs and poor health-related quality of life [5–8]. The aetiology of constipation in children and young adults is not clear. Studies suggest that psychological stress, childhood maltreatment and abnormal childhood personality traits such as hostility, aggression, and negative self-esteem, are associated with functional constipation in children [4, 9, 10]. Some studies have evaluated potential socio-demographic factors, including social class and living area (urban/rural), that may play a role in the development of constipation in children [10–12].

A few studies in Asia have shown that the prevalence of childhood constipation vary between 0.3% in Japan to 32.2% in Taiwan [11–13]. However, there is still a dearth of studies and information to fully understand the clinical epidemiology of this important health problem in Asia [11]. Indonesia has a multi-cultural, multi-lingual and multi-ethnic society. Population of Indonesia is estimated to be over 261 million people. It is the world’s 4th most populous country and the most populous country in the Austronesian region. About 53% of the population live in urban areas. Indonesia has 17,504 islands with over 300 different native languages [14].

We hypothesized that studying the socio-demographic factors, stressful events and bowel habits of the Indonesian children and adolescents would contribute towards the provision of a novel insight into the epidemiology and precipitating factors of constipation in children and adolescents. Therefore, we aimed to study epidemiology, and risk factors, including exposure to emotional stress, for constipation in Indonesian children and adolescents of the 10–17 year age group.

Three thousand five hundred and seventy-two (3572) questionnaires were distributed in total through the first and second methods listed in the Methods. In the first round (July to August 2016), 2718 questionnaires were distributed and only 1196 (44%), were returned. Then out of that, 1007 (37.1%) questionnaires had all the necessary data to be included into the analysis. In the second round (November–December 2016), 854 questionnaires were distributed, and children were asked to fill the questionnaires at school in the presence of a research assistant. From that, 811 (95%) questionnaires were collected, and 789(92.4%) questionnaires had complete data to be included into the analysis. Therefore, 2007 questionnaires were collected, of which 1796 (89.5%) were included in the analysis; males 732 (40.8%), mean age 13.58 years, SD 0.992 years. Two hundred and eleven (211) questionnaires were excluded due to incomplete socio-demographic details and bowel habit descriptions that would affect the result. In the context that participants recruited by the second method had higher proportion of the return rate compared to the first method, it is possible that this might have resulted in some bias. Therefore, sensitivity analysis was carried out and that showed that there was no difference in the results for the two methods.

This large epidemiological survey describes the prevalence and risk factors for constipation of children and adolescents in Jakarta, Indonesia [17]. Nearly one fifth (18.3%) of Indonesian school children and adolescents aged 10–17 years fulfil the Rome III criteria for constipation. Constipation was more common in girls and adolescents who were exposed to both home and school related stressful life events had higher odds of developing constipation.

The prevalence rate of constipation in Indonesia (18.3%) is slightly higher than most of the studies from the Western world, [US (12.9%) [18], Greece (13.9%) [19]], South-East Asia, [Sri Lanka (15.3%) [11]] and South America, [Mexico (12.6%) [20], and Panama (15.9%) [21]]. In contrast, the prevalence rate of constipation in Taiwan (32.2%) [12] was nearly twice as high as in the current study. However, the prevalence of constipation in Indonesia was markedly higher than China where the prevalence rates range from 3.1 to 12.2% [22–25]. The reason for these differences are not entirely clear. It may have been due to many reasons such as differences in sample selection (community samples vs. school samples), differences in methods of data collection (parental vs. child questionnaires), differences in data collection instruments including subtle alterations in translations, differences in cultural and regional interpretation of bowel habits and other GI symptoms together with differences in diet and behavioural patterns. In addition, there could be a true difference in genetic potential in developing constipation in these populations.

Predominance of a gender in constipation is still far from conclusive. Studies from Panama and Sri Lanka reported no difference between males and females [11, 21]. Whereas Lewis et al. found constipation more prevalent in males than females in the US [18]. In contrast to the latter study we found a higher prevalence in females. Similar to our findings, Wu et al noted a significantly higher prevalence of constipation in females in Taiwan [12]. Adult studies have also shown that constipation was more common in females than males [26]. When we looked further into our data, the predominance of constipation in females might be related to more stressful events in females than males in our study (data not shown). Socio-demographic factors did not show any significant difference between children with constipation and controls in our study.

Only a few studies describe bowel habits of children with constipation. Compared to children with constipation in Sri Lanka and Iran, children and adolescents included in this study had higher occurrence of infrequent stools (< 3/ per week), and hard stools [11, 27]. They were also noted to have higher frequency of posturing and having more faecal incontinence. The frequency of faecal incontinence was higher than that of Brazilian children with constipation [28]. However, pain while passing stools and large diameter stools were less frequent in Indonesian children with constipation compared to Sri Lankan and Iranian children [11, 27]. Of the other symptoms studied, abdominal pain was the only symptom that was independently associated with constipation. A similar observation was noted in the study conducted among Sri Lankan adolescents [11].

Many factors could contribute to the development of constipation in children, such as abnormal personality traits [4], stressful life events [9], child maltreatment [10], dietary habits [29] and obesity [30]. Pressure at home and school could transform into stressful events that lead to constipation. In our study, father’s alcoholism, severe illness in a close family member, hospitalization of the child for another illness, being bullied at school and loss of a parent’s job were clearly associated with constipation. Similarly, another study reported the association between stress and constipation [9]. In that study, separation from the best friend, failure in exam, severe illness among family members, and frequent punishments by parents were associated with constipation. Although there are subtle variations in the findings of that study and the current study, it is evident that home and school related stressful events predispose children to develop constipation. In contrast, a study from Nigeria, using the same list of stressful events, did not find a significant association between constipation and stressful life events. A smaller sample size could have contributed to this lack of difference in the Nigerian study. It had been shown that poor quality of interactions due to marital disharmony, verbal/emotional abuse of children etc., between the child and the caregiver before the age of 18 years could lead to the development of functional gastrointestinal disorders [31].

There are several strengths of this study. We included a large number of children in the study which conferred adequate power to our findings. We also used standard Rome III criteria for the diagnosis of constipation and therefore were able to compare our findings with other studies to draw meaningful conclusions. However, as many of the other epidemiological surveys across the world on this topic, we did not conduct a physical examination on these children nor did we investigate them to rule out the possibility of organic disorders. However, most of the studies have failed to find significant organic disorders in children who have fulfilled Rome criteria for functional gastrointestinal disorders [32, 33] and current guidelines also do not recommend investigating children who fulfil standard criteria for constipation [34].

As an observational study, data were obtained using questionnaires which may be subject to information bias, including recall bias. As this study was conducted using two different methods for data collection (questionnaires filled at home and questionnaires filled in the school), sensitivity analysis was performed between the two methods. In sociodemographic factor, gender was found to be not significant in the second method (p = 0.378) while the first method showed the same result with the total participants (p = 0.027). This could have occurred because of differences in gender proportion (60.7% subjects are girls). We did not find any other significant differences in the sensitivity analysis.

Our findings have noteworthy implications both at national and global levels for clinical and research practices. According to Unicef estimates, Indonesia has around 85 million children, which represents one-third of the national population [17]. Therefore, allocation of healthcare resources for this growing problem of constipation would be an uphill task for policymakers. Our data also provide the understanding of epidemiological distribution of constipation in children at the global level and provide an insight towards predisposing factors. We believe that these findings could contribute to the development of preventive strategies for constipation in children.

The present study shows that almost 20% of children and adolescents in Indonesia suffer from constipation. This functional gastrointestinal disorder is more common in girls. Some common school and home related stressful live events predispose children to develop constipation and therefore, national, regional and global policymakers need to pay attention to the growing problem of constipation in Indonesian children.