human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Simple , incentive based behaviour modification , with or without a modest programme of psychotherapy involving outpatient visits every four to six weeks , seems to be associated with a useful cure rate in children with lower bowel function disorders . Appreciable social disadvantage seems to be the most important factor mitigating against a successful outcome , associated with non-compliance with treatment . Failure to respond to treatment was associated with important psychological problems . These were more common in the socially disadvantaged groups . Children from satisfactory social background s who have lower bowl disturbances can be effectively treated by fairly simple programmes . More elaborate and expensive strategies should be reserved for those whose psychosocial circumstances make it possible to predict a less satisfactory outcome BACKGROUND Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal ( STR ) , but whether they are the result of STR or occur before this behavior is not known . OBJECTIVE To determine whether constipation and painful defecation occur as a result of STR or occur before STR . METHODS Three hundred eighty children between 17 and 19 months of age participated in a prospect i ve longitudinal study of toilet training .  Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training . Information obtained in follow-up interviews included parents ' reports on the presence and frequency of hard bowel movements , painful defecation , and child toilet training behaviors .  Children were defined as completing daytime toilet training when they were experiencing < 4 urine accidents per week and < or = 2 episodes of fecal soiling per month . Children were defined as having frequent hard bowel movements if the parents reported a hard bowel movement approximately once per week in > or = 2 follow-up telephone interviews or more than once per week in 1 follow-up telephone interview . RESULTS The mean age at the completion of daytime toilet training was 36.8 + /- 6.1 months ( range : 22 - 54 months ) . Ninety-three children ( 24.4 % ) developed STR . Parents of children who developed STR , in comparison with the rest of the sample , were more likely to report that the child had experienced hard bowel movements ( 67.7 % vs 50.9 % ) , frequent hard bowel movements ( 29.0 % vs 14.3 % ) , and painful defecation ( 41.9 % vs 27.9 % ) . Of the children who experienced both STR and hard bowel movements , 93.4 % demonstrated constipation before the onset of STR . In that group , parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR . Of the children who experienced both STR and painful defecation , 74.4 % experienced the first episode of painful defecation before the onset of STR . Children with frequent hard bowel movements demonstrated a longer duration of STR ( 9.0 + /- 6.5 vs 4.8 + /- 3.0 months ) . CONCLUSIONS When hard bowel movements or painful defecation is associated with STR , the first episode of constipation usually occurs before the STR . The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively . Therefore , hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior . Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR OBJECTIVES To study the prevalence of constipation in young children , and to explore its association with dietary fibre intake . DESIGN Cross-sectional community-based study . SETTING Three kindergartens r and omly selected from the eastern district of Hong Kong . PARTICIPANTS Between October 2003 and January 2004 , parents of children aged 3 to 5 years completed a specially design ed question naire and a 3-day dietary record form , which were used to collect information on bowel function and dietary intake . Children with constipation were identified based on Rome criteria . Children with normal bowel habits served as a comparison group . MAIN OUTCOME MEASURES Dietary intake of energy , protein , and dietary fibre . RESULTS Of 778 children recruited , 561 complete sets of data were successfully obtained from the participating kindergartens . One hundred and sixty-six ( 29.6 % ) children were found to be constipated . The incidence of a family history of constipation was significantly higher in the constipated group ( 14 % ) than in the non-constipated group ( 7 % ) [ P=0.013 ] . Mean dietary fibre consumption was 4.1 g/d ( st and ard deviation , 2.3 g/d ) in all children corresponding to 45.5 % ( st and ard deviation , 24.9 % ) of the daily recommendation . Constipated children ( mean , 40.7 % ; st and ard deviation , 20.5 % ) had a significantly lower  dietary fibre intake of the daily recommendation than the non-constipated group ( mean , 47.5 % ; st and ard deviation , 26.2 % ) [ P=0.017 ] . CONCLUSION Up to 30 % of preschool children in the eastern district had constipation . A family history of constipation was related to its occurrence in the studied children . Dietary fibre intake was insufficient in all children and even lower in those who were constipated BACKGROUND Chronic constipation is one of the most common disorders in Western countries and despite numerous clinical , pathophysiologic , and epidemiologic studies its cause is still unclear . Several hypotheses have been proposed and according to experimental studies and clinical observation , fiber intake could play a role in its pathogenesis . The purpose of this case-control study was to examine the possible correlation of  idiopathic chronic constipation in children and dietary intake , particularly fiber intake . METHODS A r and omized sample of children ( 291 children with constipation and 1602 controls ) aged 2 to 14 years was taken from three of the 52 counties of Greece . Stratification was performed on the basis of urban , rural , or suburban location and socioeconomic status . The nutritional data were obtained from a 3-day dietary record and a dietary history . Statistical analysis was performed with multivariate tests , multivariate analysis of variance , discriminant analysis , and chi-square analysis according to the characteristics of the correlated variables . RESULTS Constipated children had a lower caloric and nutrient intake ( p < 0.001 ) , lower body weight/height ( p < 0.001 ) , and higher prevalence of reported anorexia ( p < 0.001 ) . Discriminant analysis indicated that  dietary fiber alone was independently negatively correlated with chronic constipation , despite the age and the age of onset of constipation . Relative risk also had a negative correlation with  fiber intake ( p < 0.001 ) . Of the main fiber fractions only cellulose and pentose were independently correlated with chronic constipation . CONCLUSIONS Lack of fiber may play an important role in the etiology of chronic idiopathic constipation in children BACKGROUND & AIMS Very little is known about several aspects of bowel habits in the general pediatric population and the aim of this nationwide survey was to assess bowel frequency and modalities of defecation in children . METHODS The survey was conducted by 58 pediatricians who were selected r and omly and distributed evenly throughout Italy . The following items were reported by each pediatrician in a st and ardized question naire : sociodemographic data , frequency and  modalities of bowel evacuation  , and anorectal disorders . RESULTS The response rate of available completed question naires was distributed evenly for the 1-year age group and was 94 % ( number of patients , 2680 ; 1 - 2 years , 442 ; females , 49.8 % ) . Mean bowel frequency did not vary in the first 2 years of life , it decreased ( P = .00001 ) after the second year , and remained stable until the 12th year ; it did not differ between sexes . Mean bowel frequency was reduced significantly in children , both in those younger or older than 2 years , with a positive history of constipation in the parents ( P = .00002 ) . Bowel frequency was inversely correlated with the number of persons living and the number of rooms in the child 's house ( P < .05 , P = .008 , respectively ) . Stool consistency , duration of evacuation , and frequency of episodes of painful defecation showed an inverse relationship ( P < .001 ) with bowel frequency . Bowel frequency was significantly lower ( P < .001 ) in children with anorectal disorders . CONCLUSIONS In Italian children , bowel frequency does not differ between sexes but it differed between the first 2 years of life and age older than 2 . Anorectal disorders increase as bowel frequency decreases PURPOSE We assessed the prevalence of daytime urinary incontinence ( DUI ) and the daytime frequency of voiding by age and sex in neurologically normal children in primary school . We also investigated the association of DUI with background factors . MATERIAL S AND METHODS We performed an anonymous question naire survey of DUI in primary school children . A total of 11 primary schools in Hiroshima City were r and omly selected and 6,917 school children 7 to 12 years old were enrolled . DUI was defined as any involuntary leakage of urine during the daytime occurring more frequently than once monthly in the 6 months before the survey . Slight dampness of the child underwear was also regarded as DUI . RESULTS The overall response rate was 76.4 % of 6,917 school children . The prevalence of DUI was 6.3 % and it was inversely related to age , decreasing from about 9 % at age 7 to 2 % at age 12 years . Children urinated about 5 or 6 times daily and increased daytime frequency occurred in 14.6 % of all children . Daytime frequency of voids , history of cystitis and infrequent bowel habits had a statistically significant positive correlation with DUI . CONCLUSIONS We found that the overall prevalence of DUI in primary school children was 6.3 % , gradually decreasing with age . Increased daytime frequency , history of cystitis and infrequent bowel habits were significantly related to DUI . The link between DUI and daytime frequency , urinary tract infections and constipation deserves more attention BACKGROUND Because abnormal defaecation dynamics , which can be modified by biofeedback , are considered to be the underlying problem in constipation , biofeedback training may be a useful treatment for constipation . This treatment has mainly been studied in uncontrolled trials . We evaluated defaecation dynamics and clinical outcome in chronically constipated children in a r and omised study comparing conventional treatment and conventional treatment with biofeedback training . METHODS Patients , 5 to 16 years old , were referred to the Academic Medical Center in Amsterdam by general practitioners , school doctors , paediatricians , and psychiatrists . They had to fulfil at least two of four criteria for paediatric constipation and were included if they had been treated medically for at least one month before r and omisation . Patients had a medical history , abdominal and rectal examination , and anorectal manometry at the start and end of the 6-week intervention period . The conventional group received laxative treatment with additional dietary advice , toilet training , and maintenance of a diary of bowel habits . The biofeedback group received the same conventional treatment and additionally five biofeedback training sessions . During the first 3 weeks , patients visited the outpatient clinic weekly ; two subsequent visits were twice monthly . FINDINGS 94 patients were r and omised to conventional treatment ( CT ) and 98 to conventional treatment with additional biofeedback training ( CT+BF ) .  Normal defaecation dynamics increased in the CT group from 41 % to 52 % ( not significant ) and in the CT+BF group from 38 % to 86 % ( p = 0.001 ) . At 6 weeks , more patients in the CT+BF group showed normal defaecation dynamics , compared to the CT group ( p < 0.001 ) . This result was unaltered by controlling for baseline status in a logistic regression model . At 1 year , successful treatment ( defaecation frequency > or = 3/week , soiling and /or encopresis < 2/month , and no laxatives ) was accomplished in 59 % of the CT and 50 % of the CT+BF group ( p = 0.24 ) . The results were maintained after 1 1/2 years follow-up . No association was found between achievement of normal defaecation dynamics and clinical outcome . INTERPRETATION Additional biofeedback training compared to conventional therapy did not result in higher success rates in chronically constipated children . Furthermore , achievement of normal defaecation dynamics was not associated with success : abnormal defaecation dynamics seem not to play a crucial role in the pathogenesis of childhood constipation .  Intensive conventional laxative treatment should remain the first choice in chronically constipated children OBJECTIVE To determine the incidence of toileting refusal for bowel movements and its outcome when toilet training children using a child-oriented approach . DESIGN Prospect i ve study . SETTING Private suburban pediatric setting consisting of middle and upper middle class families . METHODS Healthy children between 18 and 30 months with no signs of developmental delay were enrolled in the study . Parents were given questions regarding their child 's toilet training and behavior . Families were followed every 6 months during an office visit or by phone call until the child was successfully day time toilet trained . RESULTS A total of 482 children ( 255 males ) completed the study . There were 106 children ( 54 males ) ( 22 % ) who experienced at least 1 month of stool toileting refusal . There was an association between the presence 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Simple , incentive based behaviour modification , with or without a modest programme of psychotherapy involving outpatient visits every four to six weeks , seems to be associated with a useful cure rate in children with lower bowel function disorders . Appreciable social disadvantage seems to be the most important factor mitigating against a successful outcome , associated with non-compliance with treatment . Failure to respond to treatment was associated with important psychological problems . These were more common in the socially disadvantaged groups . Children from satisfactory social background s who have lower bowl disturbances can be effectively treated by fairly simple programmes . More elaborate and expensive strategies should be reserved for those whose psychosocial circumstances make it possible to predict a less satisfactory outcome BACKGROUND Previous studies demonstrated that constipation and painful defecation are associated with stool toileting refusal ( STR ) , but whether they are the result of STR or occur before this behavior is not known . OBJECTIVE To determine whether constipation and painful defecation occur as a result of STR or occur before STR . METHODS Three hundred eighty children between 17 and 19 months of age participated in a prospect i ve longitudinal study of toilet training .  Children were monitored with telephone interviews every 2 to 3 months until the completion of daytime toilet training . Information obtained in follow-up interviews included parents ' reports on the presence and frequency of hard bowel movements , painful defecation , and child toilet training behaviors .  Children were defined as completing daytime toilet training when they were experiencing < 4 urine accidents per week and < or = 2 episodes of fecal soiling per month . Children were defined as having frequent hard bowel movements if the parents reported a hard bowel movement approximately once per week in > or = 2 follow-up telephone interviews or more than once per week in 1 follow-up telephone interview . RESULTS The mean age at the completion of daytime toilet training was 36.8 + /- 6.1 months ( range : 22 - 54 months ) . Ninety-three children ( 24.4 % ) developed STR . Parents of children who developed STR , in comparison with the rest of the sample , were more likely to report that the child had experienced hard bowel movements ( 67.7 % vs 50.9 % ) , frequent hard bowel movements ( 29.0 % vs 14.3 % ) , and painful defecation ( 41.9 % vs 27.9 % ) . Of the children who experienced both STR and hard bowel movements , 93.4 % demonstrated constipation before the onset of STR . In that group , parents reported hard bowel movements at almost one-half of all follow-up telephone interviews before the onset of STR . Of the children who experienced both STR and painful defecation , 74.4 % experienced the first episode of painful defecation before the onset of STR . Children with frequent hard bowel movements demonstrated a longer duration of STR ( 9.0 + /- 6.5 vs 4.8 + /- 3.0 months ) . CONCLUSIONS When hard bowel movements or painful defecation is associated with STR , the first episode of constipation usually occurs before the STR . The fact that hard bowel movements frequently occur before the onset of STR suggests that for many of these children constipation is a chronic problem that is not being treated effectively . Therefore , hard bowel movements and painful defecation are factors that potentially contribute to the STR and for the majority of children are not caused solely by the STR behavior . Additional studies are needed to determine whether earlier and more effective treatment of constipation could decrease the incidence of STR OBJECTIVES To study the prevalence of constipation in young children , and to explore its association with dietary fibre intake . DESIGN Cross-sectional community-based study . SETTING Three kindergartens r and omly selected from the eastern district of Hong Kong . PARTICIPANTS Between October 2003 and January 2004 , parents of children aged 3 to 5 years completed a specially design ed question naire and a 3-day dietary record form , which were used to collect information on bowel function and dietary intake . Children with constipation were identified based on Rome criteria . Children with normal bowel habits served as a comparison group . MAIN OUTCOME MEASURES Dietary intake of energy , protein , and dietary fibre . RESULTS Of 778 children recruited , 561 complete sets of data were successfully obtained from the participating kindergartens . One hundred and sixty-six ( 29.6 % ) children were found to be constipated . The incidence of a family history of constipation was significantly higher in the constipated group ( 14 % ) than in the non-constipated group ( 7 % ) [ P=0.013 ] . Mean dietary fibre consumption was 4.1 g/d ( st and ard deviation , 2.3 g/d ) in all children corresponding to 45.5 % ( st and ard deviation , 24.9 % ) of the daily recommendation . Constipated children ( mean , 40.7 % ; st and ard deviation , 20.5 % ) had a significantly lower  dietary fibre intake of the daily recommendation than the non-constipated group ( mean , 47.5 % ; st and ard deviation , 26.2 % ) [ P=0.017 ] . CONCLUSION Up to 30 % of preschool children in the eastern district had constipation . A family history of constipation was related to its occurrence in the studied children . Dietary fibre intake was insufficient in all children and even lower in those who were constipated BACKGROUND Chronic constipation is one of the most common disorders in Western countries and despite numerous clinical , pathophysiologic , and epidemiologic studies its cause is still unclear . Several hypotheses have been proposed and according to experimental studies and clinical observation , fiber intake could play a role in its pathogenesis . The purpose of this case-control study was to examine the possible correlation of  idiopathic chronic constipation in children and dietary intake , particularly fiber intake . METHODS A r and omized sample of children ( 291 children with constipation and 1602 controls ) aged 2 to 14 years was taken from three of the 52 counties of Greece . Stratification was performed on the basis of urban , rural , or suburban location and socioeconomic status . The nutritional data were obtained from a 3-day dietary record and a dietary history . Statistical analysis was performed with multivariate tests , multivariate analysis of variance , discriminant analysis , and chi-square analysis according to the characteristics of the correlated variables . RESULTS Constipated children had a lower caloric and nutrient intake ( p < 0.001 ) , lower body weight/height ( p < 0.001 ) , and higher prevalence of reported anorexia ( p < 0.001 ) . Discriminant analysis indicated that  dietary fiber alone was independently negatively correlated with chronic constipation , despite the age and the age of onset of constipation . Relative risk also had a negative correlation with  fiber intake ( p < 0.001 ) . Of the main fiber fractions only cellulose and pentose were independently correlated with chronic constipation . CONCLUSIONS Lack of fiber may play an important role in the etiology of chronic idiopathic constipation in children BACKGROUND & AIMS Very little is known about several aspects of bowel habits in the general pediatric population and the aim of this nationwide survey was to assess bowel frequency and modalities of defecation in children . METHODS The survey was conducted by 58 pediatricians who were selected r and omly and distributed evenly throughout Italy . The following items were reported by each pediatrician in a st and ardized question naire : sociodemographic data , frequency and  modalities of bowel evacuation  , and anorectal disorders . RESULTS The response rate of available completed question naires was distributed evenly for the 1-year age group and was 94 % ( number of patients , 2680 ; 1 - 2 years , 442 ; females , 49.8 % ) . Mean bowel frequency did not vary in the first 2 years of life , it decreased ( P = .00001 ) after the second year , and remained stable until the 12th year ; it did not differ between sexes . Mean bowel frequency was reduced significantly in children , both in those younger or older than 2 years , with a positive history of constipation in the parents ( P = .00002 ) . Bowel frequency was inversely correlated with the number of persons living and the number of rooms in the child 's house ( P < .05 , P = .008 , respectively ) . Stool consistency , duration of evacuation , and frequency of episodes of painful defecation showed an inverse relationship ( P < .001 ) with bowel frequency . Bowel frequency was significantly lower ( P < .001 ) in children with anorectal disorders . CONCLUSIONS In Italian children , bowel frequency does not differ between sexes but it differed between the first 2 years of life and age older than 2 . Anorectal disorders increase as bowel frequency decreases PURPOSE We assessed the prevalence of daytime urinary incontinence ( DUI ) and the daytime frequency of voiding by age and sex in neurologically normal children in primary school . We also investigated the association of DUI with background factors . MATERIAL S AND METHODS We performed an anonymous question naire survey of DUI in primary school children . A total of 11 primary schools in Hiroshima City were r and omly selected and 6,917 school children 7 to 12 years old were enrolled . DUI was defined as any involuntary leakage of urine during the daytime occurring more frequently than once monthly in the 6 months before the survey . Slight dampness of the child underwear was also regarded as DUI . RESULTS The overall response rate was 76.4 % of 6,917 school children . The prevalence of DUI was 6.3 % and it was inversely related to age , decreasing from about 9 % at age 7 to 2 % at age 12 years . Children urinated about 5 or 6 times daily and increased daytime frequency occurred in 14.6 % of all children . Daytime frequency of voids , history of cystitis and infrequent bowel habits had a statistically significant positive correlation with DUI . CONCLUSIONS We found that the overall prevalence of DUI in primary school children was 6.3 % , gradually decreasing with age . Increased daytime frequency , history of cystitis and infrequent bowel habits were significantly related to DUI . The link between DUI and daytime frequency , urinary tract infections and constipation deserves more attention BACKGROUND Because abnormal defaecation dynamics , which can be modified by biofeedback , are considered to be the underlying problem in constipation , biofeedback training may be a useful treatment for constipation . This treatment has mainly been studied in uncontrolled trials . We evaluated defaecation dynamics and clinical outcome in chronically constipated children in a r and omised study comparing conventional treatment and conventional treatment with biofeedback training . METHODS Patients , 5 to 16 years old , were referred to the Academic Medical Center in Amsterdam by general practitioners , school doctors , paediatricians , and psychiatrists . They had to fulfil at least two of four criteria for paediatric constipation and were included if they had been treated medically for at least one month before r and omisation . Patients had a medical history , abdominal and rectal examination , and anorectal manometry at the start and end of the 6-week intervention period . The conventional group received laxative treatment with additional dietary advice , toilet training , and maintenance of a diary of bowel habits . The biofeedback group received the same conventional treatment and additionally five biofeedback training sessions . During the first 3 weeks , patients visited the outpatient clinic weekly ; two subsequent visits were twice monthly . FINDINGS 94 patients were r and omised to conventional treatment ( CT ) and 98 to conventional treatment with additional biofeedback training ( CT+BF ) .  Normal defaecation dynamics increased in the CT group from 41 % to 52 % ( not significant ) and in the CT+BF group from 38 % to 86 % ( p = 0.001 ) . At 6 weeks , more patients in the CT+BF group showed normal defaecation dynamics , compared to the CT group ( p < 0.001 ) . This result was unaltered by controlling for baseline status in a logistic regression model . At 1 year , successful treatment ( defaecation frequency > or = 3/week , soiling and /or encopresis < 2/month , and no laxatives ) was accomplished in 59 % of the CT and 50 % of the CT+BF group ( p = 0.24 ) . The results were maintained after 1 1/2 years follow-up . No association was found between achievement of normal defaecation dynamics and clinical outcome . INTERPRETATION Additional biofeedback training compared to conventional therapy did not result in higher success rates in chronically constipated children . Furthermore , achievement of normal defaecation dynamics was not associated with success : abnormal defaecation dynamics seem not to play a crucial role in the pathogenesis of childhood constipation .  Intensive conventional laxative treatment should remain the first choice in chronically constipated children OBJECTIVE To determine the incidence of toileting refusal for bowel movements and its outcome when toilet training children using a child-oriented approach . DESIGN Prospect i ve study . SETTING Private suburban pediatric setting consisting of middle and upper middle class families . METHODS Healthy children between 18 and 30 months with no signs of developmental delay were enrolled in the study . Parents were given questions regarding their child 's toilet training and behavior . Families were followed every 6 months during an office visit or by phone call until the child was successfully day time toilet trained . RESULTS A total of 482 children ( 255 males ) completed the study . There were 106 children ( 54 males ) ( 22 % ) who experienced at least 1 month of stool toileting refusal . There was an association between the presence 
    Output:
    