Prevalence and Management of Constipation and GI Diagnoses in Children With Solid Tumors

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Stanek, Nicholas D. Yeager, Daniel V. Runco This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-800140/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Despite continued development of targeted therapies for children with cancer, patients continue to experience an array of unwanted side effects. Children with solid tumors may experience constipation as a result many treatment variables. Our objective was to investigate the prevalence and treatment of constipation in hospitalized children with solid tumors treated with chemotherapy. Methods We retrospectively analyzed data from 48 children’s hospitals in the Pediatric Health Information System, extracting patients 0–21 years of age with a solid tumor diagnosis hospitalized from October 2015-December 2019. Primary study outcome investigated which solid tumor subgroups received the diagnosis of constipation or received the most constipation medications while receiving chemotherapy for a cancer diagnosis. Results We identified 13,375 unique patients with a solid tumor diagnosis receiving chemotherapy. Constipation was the most common gastrointestinal complaint with 8,658 (64.7%; 95% Cl: 63.9–65.5%) meeting our defined constipation diagnosis. Bone cancers had the highest percentage (69.9%) of patients with constipation, while Hodgkin’s lymphoma had the lowest, though 52.1% of patients were affected. A total of 44% (n = 35,301) of encounters received an opioid at some point during admission. Of patients receiving constipation medications, the most commonly prescribed was poly-ethyl glycol (n = 25,175, 31.7%), followed by docusate (n = 11,297, 14.2%), senna (n = 10,325, 13.0%), and lactulose (n = 5,501, 6.9%). Conclusions Constipation is the most common gastrointestinal issue that children with solid tumors experience while receiving chemotherapy. Increased attention should be given to constipation prophylaxis and treatment in children with solid tumors undergoing chemotherapy. Critical Care & Emergency Medicine Cancer Biology Oncology Pediatric oncology osteopathic integrative medicine Figures Figure 1 Introduction Childhood cancer remains the second leading cause of death in children aged 5 to 14 years of age[ 1 ]. The most common diagnoses in the United States (US) include leukemias, central nervous system (CNS) tumors, and lymphomas along with a variety of other solid tumors[ 2 ]. Children with cancer undergoing treatment suffer a litany of unwanted side effects during and after their therapy. While survival rates continue to improve with the incorporation of advance immuno- and targeted therapy, many CNS and non-CNS solid tumor treatments continue to rely on traditional cytotoxic and radiotherapy-based treatment agents. Chemotherapy induced constipation (CIC) has been well-studied in the adult oncology literature and is the third most common unwanted side effect in patients receiving cytotoxic chemotherapy, with 50–87% of patients experiencing CIC[ 3 ]. Vinca alkaloids are a common cause of constipation, with 80–90% of adult oncology patients receiving them reporting CIC[ 4 ]. While data exists for constipation in the general pediatric population, no studies have explored constipation burden or sequela in children with solid tumors. In addition, literature has not investigated the use of preemptive constipation management during treatment for children receiving chemotherapy. Constipation accounts for 3% of general pediatric outpatient visits and 25% of pediatric gastrointestinal (GI) specialist visits in the United States[ 5 ]. Children with constipation suffer from an array of physical symptoms including abdominal pain, cramping, fecal incontinence, rectal fissures, enuresis, and urinary tract infections[ 6 ]. In children without cancer, functional constipation has an increased healthcare burden compared to children without constipation. Treatment can be challenging in otherwise healthy children but creates unique challenges for the child undergoing cancer treatment. Constipation management utilizes both pharmacologic and nonpharmacologic interventions to improve symptoms[ 4 ]. Nonpharmacologic interventions, such as increased activity and hydration, may be difficult for children with cancer to adhere to due to nausea, mucositis, anorexia, fatigue, or other treatment effects. Despite ongoing advancements in the pediatric oncology field, there remains a lack of guidance for oncology teams with regard to constipation management. Literature is bereft of studies investigating the incidence and management of constipation in pediatric oncology patients. A prospective questionnaire from 2011 estimated 57–77% of children requiring chemotherapy treatment for an oncology diagnosis experienced constipation, as defined by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition Criteria (NASPGHAN)[ 7 ]. Constipation is the most common GI diagnosis during acute lymphoblastic leukemia (ALL) induction therapy affecting 34% of children, and demonstrating a higher prevalence in females, those with extended hospital stays, and patients receiving opioids. In addition, a wide variety of constipation medications were identified, with 81% of patients receiving at least one laxative during induction[ 8 ]. Most children receiving chemotherapy for a solid tumor diagnosis undergo multiple extended hospital admissions, may require surgical resections impairing mobility, and often receive adjunct radiation therapy. In addition, side effects including mucositis resulting in dehydration and pain control can predispose patients to constipation. Despite ongoing advancements in the pediatric oncology field, there remains a lack of guidance with regard to constipation management. The objective of our study was to utilize a national administrative database to describe the prevalence of constipation, GI diagnoses, variability of inpatient management, and investigate potential risk factors associated with constipation during hospitalizations for pediatric patients with solid tumors in the United States. Methods Data Source Data for this retrospective multicenter cohort study were obtained from the Pediatric Hospital Information System (PHIS) database. Managed by the Children’s Hospital Association (CHA) (Overland Park, Kansas), the PHIS database provides detailed information about hospital-based discharges from 48 of the largest free-standing children’s hospitals across the US. The participating institutions represent all US census geographic regions and the majority of US tertiary care pediatric hospitals. Reliability and validity are continuously assured by data quality assessments from both CHA and participating institutions. Patient data are deidentified and given a unique patient identification number, thus allowing patients to be tracked over time and across multiple admissions. Study Population Our study population included patients aged 0 to 21 years with a solid tumor diagnosis admitted to the hospital between October 2015 and December 2019. To ensure patients were receiving chemotherapy for an active solid tumor malignancy, patients were required to have an ICD-10-CM diagnosis code for a solid tumor and a billing code for a central line supply code, chemotherapy administration procedural code, or a chemotherapy medication code at any point during the study time period. Solid cancers of interest were grouped by organ system and included CNS, bone, liver/biliary, kidney, retinal, nonspecific abdominal/pelvic, nonspecific adrenal tumors, and the remaining diagnoses were classified as other solid tumors. Hodgkin’s and non-Hodgkin’s lymphomas (NHL) were also identified (supplementary 1). Patients with cancer diagnoses in multiple cancer groups were excluded. Study Definitions Previously published methods were utilized for consistency[ 8 ]. ICD-10-CM codes were used to identify diagnoses of constipation (K59.XX) and other GI diagnoses, such as appendicitis, gastritis, and ulcers; and GI symptoms, such as nausea and abdominal pain (supplemental 1). Billing codes were used to identify the receipt of chemotherapy agents, opioids, and constipation medications, as well as operating room (OR) and total parenteral nutrition (TPN) charges. Patients who lacked a diagnosis code of constipation but received at least two unique constipation medications were also defined as a case of constipation. Dates of medication administration were extracted to calculate the start and duration of medication use. To evaluate the possible effect of opioid use on the risk of constipation during the admission, we categorized patients into four groups to best distinguish opioid use between anesthesia and pain: 1) no occurrences of opioid use, 2) patient received fentanyl only, 3) patient received other, non-fentanyl opioids for 1 or 2 days, and 4) patient received ≥ 2 days of other, non-fentanyl opioids. Demographic information, such as patient sex, race, and geographic region, and hospitalization information, including as length of stay, intensive care utilization, and mortality, was also obtained from the PHIS database. Patient age was calculated as the age at their last encounter during the study period. Statistical Analysis: All data were summarized using descriptive statistics. Median and range were used to describe quantitative variables and frequency and percentage were used for qualitative variables. The prevalence of constipation among all solid cancers (as well as in specific cancer groups) was calculated as a percentage. The management of constipation was summarized descriptively. Univariate comparisons between those with and without constipation were performed using chi-square tests for qualitative variables and Wilcoxon rank sum tests for quantitative variables. Statistical significance was determined by p-value < 0.05. Statistical analyses were performed using Statistical Analysis System software 9.4 (SAS Institute, Cary, NC). Results: Demographics We identified 13,375 unique patients (79,530 unique admissions) who were admitted with a solid tumor diagnosis from 48 PHIS hospitals during the four-year period evaluated (Table 1 ). The majority of patients were male (n = 7,465, 55.8%) with a median age of 9.9 years (range: 0.0-20.9 years). CNS cancers were the most commonly identified solid tumor group (24.4%), followed by NHL (14.4%), bone (12.9%), Hodgkin lymphoma (10.2%), kidney (8.3%), abdomen/pelvis (6.8%), adrenal (6.7%), liver/biliary (5.1%), and retinal (2.8%). Solid tumors of other organ systems not specified here accounted for 8.3% of the cohort (Supplemental 1). Table 1 Demographics and clinical characteristics of pediatric patients with solid tumors (Pediatric Hospital Information System, 2015–2019) Characteristic N (%) Unique Patients 13,375 Male sex 7,465 (55.8) Race White 8,550 (63.9) Black 1,757 (13.1) Asian 605 (4.5) Other/Unknown 2,463 (18.4) Age at last encounter (years) 9.9 (infant – 21) Solid cancer diagnosis CNS 3,264 (24.4) Bone 1,730 (12.9) Lymphoma Hodgkin 1,365 (10.2) Non-Hodgkin 1,925 (14.4) Liver/Biliary 686 (5.1) Kidney 1,111 (8.3) Retinal 378 (2.8) Abdominal/pelvic NOS 910 (6.8) Adrenal tumors NOS 896 (6.7) Other solid tumors 1 1,110 (8.3) 1 Includes other solid tumors/masses of other organ systems no listed Abbreviations: CNS= Central Nervous System, NOS= Not Otherwise Specified Prevalence of Constipation and GI Diagnoses Constipation was the most common GI complaint identified in unique solid tumor patients, with 8,658 (64.7%) being diagnosed with constipation or receiving at least two constipation medications during a single admission (Table 2 ). Bone cancers had the highest prevalence (79.7%) of patients with constipation, while retinal tumors had the lowest at 23.3% (Fig. 1 ). Nausea/vomiting (n = 5,439, 48.6%) and abdominal pain (n = 1,044, 9.3%) were the next most commonly observed GI diagnoses. Other GI symptoms commonly reported in solid cancer patients included mucositis (n = 3,017, 26.9%) and gastroesophageal reflux disease (n = 1,419, 12.7%). Mucositis was most common in patients with NHL (42.7%), bone cancers (41.7), and adrenal tumors (38.5%), and least commonly seen in kidney (10.4%) and abdominal/pelvic (10.2%) tumors. GI infections were present in all diagnoses, with adrenal tumors (n = 195, 21.8%) having the most, and Hodgkin lymphoma patients (n = 101, 7.4%) with the fewest reported GI infections. Table 2 Patient prevalence of most commonly identified solid tumor diagnoses with various GI diagnoses (Pediatric Hospital Information System, 2015–2019) Diagnosis All Solid Tumors N (%) CNS Cancers N (%) Bone Cancers N (%) Kidney N (%) Abd/Pelvic N (%) Adrenal tumors N (%) HL N (%) NHL N (%) Total Patients 3,264 1,730 1,111 910 896 1,365 1,925 Defined Constipation 1 8,658 (64.7) 2,281 (69.9) 1,379 (79.7) 734 (66.1) 547 (60.1) 508 (56.7) 711 (52.1) 1,307 (67.9) Constipation (Dx only) 6,477 (48.4) 1,583 (48.5) 1,143 (66.1) 515 (46.4) 419 (46.0) 422 (47.1) 536 (39.3) 984 (51.1) GI Symptoms Abdominal Pain 1,185 (8.9) 255 (7.8) 182 (10.5) 86 (7.7) 86 (9.5) 101 (11.3) 104 (7.6) 230 (12.0) Nausea/Vomiting 6,423 (48.0) 1,440 (44.1) 1,204 (69.6) 367 (33.0) 412 (45.3) 445 (49.7) 646 (47.3) 925 (48.1) Other GI Diagnoses GERD 1,587 (11.9) 415 (12.7) 271 (15.7) 66 (5.9) 90 (9.9) 103 (11.5) 121 (8.9) 254 (13.2) Ulcer 96 (0.7) 29 (0.9) 9 (0.5) 0 (-) 10 (1.1) 4 (0.5) 8 (0.6) 27 (1.4) Gastritis 1,568 (11.7) 302 (9.3) 232 (13.4) 75 (6.8) 86 (9.5) 163 (18.2) 165 (12.1) 319 (16.6) Appendicitis 221 (1.7) 36 (1.1) 32 (1.9) 11 (1.0) 6 (0.7) 22 (2.5) 24 (1.8) 68 (3.5) IBD 62 (0.5) 8 (0.3) 5 (0.3) 4 (0.4) 4 (0.4) 2 (0.2) 8 (0.6) 26 (1.4) IBS 25 (0.2) 6 (0.2) 8 (0.5) 0 (-) 3 (0.3) 0 (-) 1 (< 0.1) 7 (0.4) NEC 6 (< 0.1) 2 (< 0.1) 0 (-) 0 (-) 0 (-) 1 (0.1) 1 (< 0.1) 0 (-) Pancreatic Issues 245 (1.8) 31 (1.0) 12 (0.7) 12 (1.1) 32 (3.5) 12 (1.3) 8 (0.6) 115 (6.0) Gallbladder Issues 237 (1.8) 11 (0.3) 11 (0.6) 9 (0.8) 29 (3.2) 14 (1.6) 11 (0.8) 51 (2.7) Anal/Rectal Issues 751 (5.6) 119 (3.7) 254 (14.7) 25 (2.3) 39 (4.3) 37 (4.1) 56 (4.1) 149 (7.7) Peritonitis 362 (2.7) 30 (0.9) 6 (0.4) 78 (7.0) 64 (7.0) 29 (3.2) 3 (0.2) 55 (2.9) Mucositis 3,436 (25.7) 551 (16.9) 722 (41.7) 116 (10.4) 93 (10.2) 345 (38.5) 369 (27.0) 821 (42.7) GI Infection 1,650 (12.3) 414 (12.7) 210 (12.1) 118 (10.6) 76 (8.4) 195 (21.8) 101 (7.4) 305 (15.8) 1 Administration of constipation medications without the presence of a constipation diagnosis. Abbreviations: CNS = Central Nervous System, Abd = Abdominal, HL = Hodgkin Lymphoma, NHL (Non-Hodgkin Lymphoma), GERD = Gastroesophageal Reflux Disease, IBD = Irritable Bowel Disease, IBS = Irritable Bowel Syndrome Characteristics of Constipation Admissions Inpatient admissions with constipation were more likely to be female (n = 23,420, 57.3%) and/or utilize a narcotic (n = 14,044, 56.8%) (Table 3 ). In addition, admissions with constipation were more likely to have OR charges (56.8% vs 39.9%; p < .0001) and TPN use (10.5% vs 6.7%; p < .0001) compared to admissions without constipation. Table 3 Characteristics of pediatric patients with solid tumor admissions with constipation Constipation admits N = 24,719 No constipation N = 54,811 p-value Median age (IQR) 10.6 (5.0-15.5) 10.1 (4.1–15.1) < .0001 Male sex 13,358 (54.0) 31,391 (57.3) < .0001 Race < .0001 White 15,991 (64.7) 35,070 (64.0) Black 3,180 (12.9) 6,678 (12.2) Asian 1,157 (4.7) 2,635 (4.8) Other 4,391 (17.8) 10,428 (19.0) Ethnicity < .0001 Hispanic/Latino 5,263 (21.3) 11,504 (21.0) Non-Hispanic/Latino 18,284 (74.0) 40,254 (73.4) Other/Unknown 1,172 (4.7) 3,053 (5.6) Median LOS (IQR) 5 (3–10) 3 (2–5) < .0001 Insurance type 0.0002 Public 11,347 (45.9) 25,177 (45.9) Private 11,912 (48.2) 26,165 (47.7) Other 882 (3.6) 2,293 (4.2) Unknown 578 (2.3) 1,176 (2.2) Use of narcotic 14,044 (56.8) 21,859 (39.9) < .0001 OR charges 7,236 (29.3) 10,240 (18.7) < .0001 TPN 2,592 (10.5) 3,661 (6.7) < .0001 Abbreviations: OR = operating room, TPN = total parental nutrition Constipation Management and Opioid Use A constipation medication was administered in 45.8% (n = 36,444) of admissions (Table 4 ). These medications were used in the setting of a constipation diagnosis in 73.1% (n = 11,912) of admissions, while 38.8% (n = 24,532) of admissions utilized a constipation medication without the presence of a constipation diagnosis code. Among admissions with a constipation diagnosis, 21.9% (n = 3,568) required 2 different constipation medications, with 18.2% of admissions requiring 3 or more unique constipation medications. In admissions without the presence of a constipation diagnosis, a single agent was used 24.1% of the time, whereas 13.3% (n = 8,413) received a combination of 2 or more different medications. The most commonly utilized constipation medication, regardless of the presence of a constipation diagnosis, was polyethyl glycol (n = 25,175, 31.7%), followed by docusate (n = 11,297, 14.2%), senna (n = 10,325, 13.0%), and lactulose (n = 5,501, 6.9%). These medications were used for a median of 2 to 3 days. A total of 45% (n = 35,903) of encounters received an opioid at some point during an admission: 4.5% (n = 3,598) received fentanyl only, 15.2% (12,068) received ≤ 2 days of a non-fentanyl opioid, and 25.4% (n = 20,237) received > 2 days of a non-fentanyl opioid. The extended use of non-fentanyl opioids (> 2 days) was more common in admissions with a constipation diagnosis compared to those without a constipation diagnosis (33.1% vs 23.5%; p < .0001). Constipation management and opioid use in specific solid tumor diagnoses are detailed in supplemental 2. Table 4 Constipation medical management and opioid utilization in pediatric patients with solid tumors during inpatient admission (Pediatric Hospital Information System, 2015–2019). Medication All Admissions N = 79,530 Constipation Admissions N = 16,306 No Constipation Admissions 1 N = 63,224 Anti-Constipation 36,444 (45.8) 11,912 (73.1) 24,532 (38.8) Polyethyl Glycol-electrolyte 25,175 (31.7) 8,874 (54.4) 16,301 (25.8) Senna 10,325 (13.0) 4,384 (26.9) 5,941 (9.4) Lactulose 5,501 (6.9) 2,272 (16.7) 2,774 (4.4) Docusate 11,297 (14.2) 4,139 (25.4) 7,158 (11.3) Electrolyte Laxatives 865 (1.1) 559 (3.4) 306 (0.5) Glycerin 1,745 (2.2) 641 (3.9) 1,104 (1.7) Mineral Oil 834 (1.0) 312 (1.9) 522 (0.8) Bisacodyl 2,094 (2.6) 888 (5.4) 1,206 (1.9) Laxative Combination 2 806 (1.0) 400 (2.5) 406 (0.6) Total Different Laxatives Taken 0 44,229 (55.6) 4,679 (28.7) 39,550 (62.6) 1 20,359 (25.6) 5,098 (31.3) 15,261 (24.1) 2 9,433 (11.9) 3,568 (21.9) 5,865 (9.3) 3 or more 5,509 (6.9) 2,961 (18.2) 2,548 (4.0) Opioid Group None 43,627 (54.9) 8,120 (49.8) 35,507 (56.2) Fentanyl Only 3,598 (4.5) 485 (3.0) 3,113 (4.9) ≤ 2 days of Other Opioids 12,068 (15.2) 2,304 (14.1) 9,764 (15.4) > 2 days of Other Opioids 20,237 (25.4) 5,397 (33.1) 14,840 (23.5) Duration of Medication (when used) (IQR) Median Polyethyl Days 2 (1–4) 3 (2–5) 2 (1–4) Median Senna Days 3 (1–5) 3 (2–6) 2 (1–5) Median Docusate Days 3 (2–6) 4 (2–6) 3 (2–5) Median Lactulose Days 2 (1–4) 2 (1–5) 2 (1–4) 1 Administration of > 2 constipation medications without the presence of a constipation diagnosis. 2 Excludes combinations with iron. Percentages may not sum to 100% due to rounding. Discussion: We identified 13,375 unique patients with 79,530 unique admissions in this study of pediatric patients with solid tumors admitted at 48 children’s hospitals. A majority of children received constipation medications regardless of having a billed diagnosis or not. The prevalence of constipation identified in our study (64.7%) is impressively greater than the prevalence reported in the general pediatric population (ranging from 0.7–29%[ 9 , 10 ]). For unclear reasons, pediatric females have been demonstrated to have a higher prevalence of constipation than males in healthy children and the pediatric ALL patient population[ 8 , 11 ]. Similarly, our data demonstrated that females with solid tumors are at higher risk for experiencing constipation during hospitalization. Additionally, our finding that opioids are associated with constipation has been well studied in adult and pediatric cancer literature[ 12 ]. Opioids lead to constipation through their action upon opioid receptors in the GI tract, leading to reduced GI propulsion and increased fluid absorption 13 . Unfortunately, opioids are commonly a necessity for cancer related visceral or bone pain. Additionally, patients with solid tumors can undergo surgical interventions for tumor, staging, or central line placement, involving anesthesia and post-procedure pain control. Certain immunotherapies, such as dinutuximab in neuroblastoma patients, may require continuous intravenous pain medications, leading to prolonged opioid use. Non-Hodgkin lymphoma treatment is notoriously intense and can often result in prolonged mucositis resulting in lengthy opioid use for pain control, which likely correlates with the high rates of constipation we identified. Similarly to patients with ALL in induction, we demonstrated a wide variability in constipation medications prescribed, regardless of a constipation diagnosis, further evidence of the lack of standard practice on how to manage constipation in the pediatric oncology setting[ 8 ]. Previous studies have shown that children with a constipation diagnosis have a significant increase in healthcare utilization compared to children without constipation[ 13 ]. Although constipation in healthy children develops insidiously over time and fortunately is almost always secondary to functional constipation, pediatric oncology patients have psychological stressors as a result of their diagnosis and receive chemotherapy and other interventions which predispose them to constipation. While symptoms of constipation go unnoticed or underreported due to patient embarrassment and/or anxiety with the medical team, symptoms and risks of constipation can worsen. Stool withholding, caused by hard, painful bowel movements, anal fissures, and mucositis, can disrupt brain-colonic signaling leading to increased stretch and stool burden, and progressively worsen stool build up[ 14 ]. The majority of bowel regimens are readily available and affordable for patients to take in the hospital or at home. In addition, there are minimal to no interactions between constipation medications and cancer directed therapy[ 15 ]. Preventative measures and attention to constipation symptoms could eliminate chemotherapy delays and decreases due to severe constipation or chronic constipation habits following chemotherapy. Finally, children with hematologic malignancies and constipation have increased abdominal imaging exposure[ 8 ]. Multiple pediatric subspecialist organizations, including the Children’s Oncology Group, have previously published that increasing ionizing radiation exposure from x-ray and computerized tomography should be avoided as much as possible due to risks of secondary malignant neoplasms[ 16 ]. Although in a general pediatric setting, constipation is a clinical diagnosis that rarely requires imaging, children undergoing chemotherapy can have underlying pathophysiology or life-threatening diagnoses such as typhlitis that may necessitate further work up when presenting with abdominal imaging or nausea. Decreasing the physical symptoms of abdominal pain, nausea, and bloating that accompany many patients with constipation, could result in decreased abdominal radiograph exposure and in turn, decrease unnecessary ionizing radiation exposure. Limitations These findings should be interpreted in light of the strengths and limitations of our study design and data source, as outlined in our previous study[ 8 ]. These limitations acknowledge that PHIS is a large-scale database that provides multi-institutional, geographically diverse representation of a large number of subjects. Relying on accurate coding and diagnoses using ICD-10 codes is an inherent limitation of PHIS. We cannot assess with certainty how often constipation medications were used to prevent, rather than treat constipation, however, we attempted to account for this conservatively by requiring a diagnosis of constipation before considering the intent to be treatment. It is certainly possible that patients receiving constipation medications for “prevention” by our definition could have been experiencing signs or symptoms of constipation, in which case we have under-estimated the true prevalence of constipation in this patient population. Similarly, in patients who received constipation medications, we are unable to comment on whether the number and type of medication prescribed were appropriate for their needs. In those patients receiving an opioid, we are unable to assess if this was used for sedation/anesthesia purposes or pain control. In an attempt to account for this, we placed patients into four opioid groups of presumed increased constipation risk. We are limited to ICD-10-CM coding to define the specific cancer groups based on location of tumor and have no detail regarding the specific tumor classification, stage, histology, or specific treatment regimen. Finally, the PHIS data set does not allow us to assess the extent of constipation or use of medications after discharge. Conclusions In summary, constipation is highly prevalent in children with solid tumors receiving chemotherapy, is likely multifactorial in nature, and most children receive a variety of medications to treat it. Clinical practice guidelines and additional supportive care recommendations for constipation are lacking in pediatric oncology. This report demonstrates the high frequency of constipation in pediatric patients with solid tumors and supports the need for increased attention to prophylaxis and management in this population to prevent patient discomfort, minimize potential impact on cancer treatment, as well as reduce exposure to expensive and potentially harmful radiologic testing for evaluation of gastrointestinal symptoms. Supportive care guidelines are sorely needed in this area, particularly for high-risk populations such as solid tumor patients, and future prospective studies should seek to determine the most effective standardized treatment regimens. Abbreviations CNS Central Nervous System, NOS = Not Otherwise Specified Declarations Funding : The authors did not receive support from any organization for the submitted work. Conflicts of interest/Competing interests : none Availability of data and material : not applicable Code Availability : not applicable Authors’ Contributions : Drs. Belsky and Runco conceptualized and designed the study, drafted the initial manuscript, and revised the manuscript. Mr. Stanek designed the data collection instruments, carried out statistical analyses, reviewed and revised the manuscript. Drs. Yeager and Runco conceptualized the study, reviewed, and revised the manuscript. Ethics approval : This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Indiana University approved this study. Consent to participate : Informed consent was not needed for this retrospective database review Consent for publication : Consent for publication was not needed for this retrospective review References Ward E et al (2014) Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin 64(2):83–103 Siegel RL et al., Cancer Statistics , 2021. CA Cancer J Clin, 2021. 71 (1): p. 7–33 Rhondali W et al (2013) Self-reported constipation in patients with advanced cancer: a preliminary report. J Pain Symptom Manage 45(1):23–32 McQuade RM et al (2016) Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments. Front Pharmacol 7:414 Sood M, Lichtlen P, Perez MC (2018) Unmet Needs in Pediatric Functional Constipation. Clin Pediatr 57(13):1489–1495 Rajindrajith S et al (2016) Childhood constipation as an emerging public health problem. World journal of gastroenterology 22(30):6864–6875 Pashankar FD et al (2011) Acute Constipation in Children Receiving Chemotherapy for Cancer. Journal of Pediatric Hematology/Oncology 33(7):e300–e303 Belsky JA, Stanek JR, O'Brien SH (2020) Prevalence and management of constipation in pediatric acute lymphoblastic leukemia in U.S. children's hospitals. Pediatr Blood Cancer 67(11):e28659 Tabbers MM et al (2014) Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 58(2):258–274 van den Berg MM, Benninga MA, Di Lorenzo C (2006) Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol 101(10):2401–2409 Diaz S, Bittar K, Mendez MD, Constipation , in StatPearls . 2020, StatPearls Publishing StatPearls Publishing LLC: Treasure Island (FL) Drewes AM et al (2016) Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction-Recommendations of the Nordic Working Group. Scand J Pain 11:111–122 Liem O et al (2009) Health utilization and cost impact of childhood constipation in the United States. J Pediatr 154(2):258–262 Medicine JH (2010) Plugged up: Doctors see signs of worsening constipation in children. Science Daily Schmier JK et al (2014) Cost savings of reduced constipation rates attributed to increased dietary fiber intakes: a decision-analytic model. BMC Public Health 14:374 Weiser DA et al (2013) Imaging in childhood cancer: a Society for Pediatric Radiology and Children's Oncology Group Joint Task Force report. Pediatr Blood Cancer 60(8):1253–1260 Supplementary Files Supplementary1and2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-800140","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":51392572,"identity":"18221889-3262-474f-a49b-9c5ad259f065","order_by":0,"name":"Jennifer Belsky","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIie3OsQrCMBCA4SuFuMQ9IthXaHHsy0QculTcHKUQiJtzofVdEgKZirOj3RUyFlxs2he4UTD/cgTuIwcQCv1gUQ2RAgUb4l8UScCTLZ4Am8muQpO4EUoPnSmujEfPt8Qc1lpu6MMcJONxdkORukwNuImQ9RJHjk4PzhSE8cUHSUpQ42F8JCTGkdamhnZFJmkvVu0dQbJG9P1g8yS57LV7nTCkmobwH1aI/bFkHmfcdigUCv1nXxWRPGv/JrGnAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-2260-0395","institution":"Riley Hospital for Children: Riley Hospital for Children at Indiana University Health","correspondingAuthor":true,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Belsky","suffix":""},{"id":51392573,"identity":"4ad6a5ca-5b80-48f4-8296-101b67b05a26","order_by":1,"name":"Joseph R. Stanek","email":"","orcid":"","institution":"Nationwide Children's Hospital Department of Pediatric Hematology Oncology and Bone Marrow Transplants: Nationwide Children's Hospital Hematology Oncology \u0026 Blood and Marrow Transplant","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"R.","lastName":"Stanek","suffix":""},{"id":51392574,"identity":"73a0ab44-6821-419b-aec5-cc64cbac3b8c","order_by":2,"name":"Nicholas D. Yeager","email":"","orcid":"","institution":"Nationwide Children's Hospital Hematology Oncology \u0026 Blood and Marrow Transplant","correspondingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"D.","lastName":"Yeager","suffix":""},{"id":51392575,"identity":"603d09e6-b276-40ed-94cf-5a39261e3965","order_by":3,"name":"Daniel V. Runco","email":"","orcid":"","institution":"Riley Hospital for Children at Indiana University Health","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"V.","lastName":"Runco","suffix":""}],"badges":[],"createdAt":"2021-08-11 00:31:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-800140/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-800140/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13315578,"identity":"18a0d75e-0353-41e5-8944-5c09f369db49","added_by":"auto","created_at":"2021-09-13 14:42:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61835,"visible":true,"origin":"","legend":"Prevalence of constipation among hospitalized patients with solid cancers (Pediatric Hospital Information System, 2015-2019)\nAbbreviations: CNS= Central Nervous System, Abd= Abdominal, HL= Hodgkin Lymphoma, NHL= Non-Hodgkin Lymphoma","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-800140/v1/a29d9fc77809a03797001228.jpg"},{"id":15916813,"identity":"c3dfa769-e2ce-411b-bf0b-43dd8dd0704e","added_by":"auto","created_at":"2021-11-26 13:41:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":558190,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-800140/v1/e890a101-6492-4f4a-b3e7-3efe603eb0ad.pdf"},{"id":13315579,"identity":"087dbffb-6054-40fd-9885-bad2c2a7065a","added_by":"auto","created_at":"2021-09-13 14:42:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":38022,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1and2.docx","url":"https://assets-eu.researchsquare.com/files/rs-800140/v1/1b54261994379838d1375a5e.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003ePrevalence and Management of Constipation and GI Diagnoses in Children With Solid Tumors\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildhood cancer remains the second leading cause of death in children aged 5 to 14 years of age[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The most common diagnoses in the United States (US) include leukemias, central nervous system (CNS) tumors, and lymphomas along with a variety of other solid tumors[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Children with cancer undergoing treatment suffer a litany of unwanted side effects during and after their therapy. While survival rates continue to improve with the incorporation of advance immuno- and targeted therapy, many CNS and non-CNS solid tumor treatments continue to rely on traditional cytotoxic and radiotherapy-based treatment agents. Chemotherapy induced constipation (CIC) has been well-studied in the adult oncology literature and is the third most common unwanted side effect in patients receiving cytotoxic chemotherapy, with 50\u0026ndash;87% of patients experiencing CIC[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Vinca alkaloids are a common cause of constipation, with 80\u0026ndash;90% of adult oncology patients receiving them reporting CIC[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While data exists for constipation in the general pediatric population, no studies have explored constipation burden or sequela in children with solid tumors. In addition, literature has not investigated the use of preemptive constipation management during treatment for children receiving chemotherapy.\u003c/p\u003e \u003cp\u003eConstipation accounts for 3% of general pediatric outpatient visits and 25% of pediatric gastrointestinal (GI) specialist visits in the United States[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Children with constipation suffer from an array of physical symptoms including abdominal pain, cramping, fecal incontinence, rectal fissures, enuresis, and urinary tract infections[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In children without cancer, functional constipation has an increased healthcare burden compared to children without constipation. Treatment can be challenging in otherwise healthy children but creates unique challenges for the child undergoing cancer treatment. Constipation management utilizes both pharmacologic and nonpharmacologic interventions to improve symptoms[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Nonpharmacologic interventions, such as increased activity and hydration, may be difficult for children with cancer to adhere to due to nausea, mucositis, anorexia, fatigue, or other treatment effects. Despite ongoing advancements in the pediatric oncology field, there remains a lack of guidance for oncology teams with regard to constipation management.\u003c/p\u003e \u003cp\u003eLiterature is bereft of studies investigating the incidence and management of constipation in pediatric oncology patients. A prospective questionnaire from 2011 estimated 57\u0026ndash;77% of children requiring chemotherapy treatment for an oncology diagnosis experienced constipation, as defined by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition Criteria (NASPGHAN)[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Constipation is the most common GI diagnosis during acute lymphoblastic leukemia (ALL) induction therapy affecting 34% of children, and demonstrating a higher prevalence in females, those with extended hospital stays, and patients receiving opioids. In addition, a wide variety of constipation medications were identified, with 81% of patients receiving at least one laxative during induction[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Most children receiving chemotherapy for a solid tumor diagnosis undergo multiple extended hospital admissions, may require surgical resections impairing mobility, and often receive adjunct radiation therapy. In addition, side effects including mucositis resulting in dehydration and pain control can predispose patients to constipation.\u003c/p\u003e \u003cp\u003eDespite ongoing advancements in the pediatric oncology field, there remains a lack of guidance with regard to constipation management. The objective of our study was to utilize a national administrative database to describe the prevalence of constipation, GI diagnoses, variability of inpatient management, and investigate potential risk factors associated with constipation during hospitalizations for pediatric patients with solid tumors in the United States.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cp\u003eData for this retrospective multicenter cohort study were obtained from the Pediatric Hospital Information System (PHIS) database. Managed by the Children\u0026rsquo;s Hospital Association (CHA) (Overland Park, Kansas), the PHIS database provides detailed information about hospital-based discharges from 48 of the largest free-standing children\u0026rsquo;s hospitals across the US. The participating institutions represent all US census geographic regions and the majority of US tertiary care pediatric hospitals. Reliability and validity are continuously assured by data quality assessments from both CHA and participating institutions. Patient data are deidentified and given a unique patient identification number, thus allowing patients to be tracked over time and across multiple admissions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eOur study population included patients aged 0 to 21 years with a solid tumor diagnosis admitted to the hospital between October 2015 and December 2019. To ensure patients were receiving chemotherapy for an active solid tumor malignancy, patients were required to have an ICD-10-CM diagnosis code for a solid tumor and a billing code for a central line supply code, chemotherapy administration procedural code, or a chemotherapy medication code at any point during the study time period. Solid cancers of interest were grouped by organ system and included CNS, bone, liver/biliary, kidney, retinal, nonspecific abdominal/pelvic, nonspecific adrenal tumors, and the remaining diagnoses were classified as other solid tumors. Hodgkin\u0026rsquo;s and non-Hodgkin\u0026rsquo;s lymphomas (NHL) were also identified (supplementary 1). Patients with cancer diagnoses in multiple cancer groups were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Definitions\u003c/h2\u003e \u003cp\u003ePreviously published methods were utilized for consistency[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. ICD-10-CM codes were used to identify diagnoses of constipation (K59.XX) and other GI diagnoses, such as appendicitis, gastritis, and ulcers; and GI symptoms, such as nausea and abdominal pain (supplemental 1). Billing codes were used to identify the receipt of chemotherapy agents, opioids, and constipation medications, as well as operating room (OR) and total parenteral nutrition (TPN) charges. Patients who lacked a diagnosis code of constipation but received at least two unique constipation medications were also defined as a case of constipation. Dates of medication administration were extracted to calculate the start and duration of medication use. To evaluate the possible effect of opioid use on the risk of constipation during the admission, we categorized patients into four groups to best distinguish opioid use between anesthesia and pain: 1) no occurrences of opioid use, 2) patient received fentanyl only, 3) patient received other, non-fentanyl opioids for 1 or 2 days, and 4) patient received\u0026thinsp;\u0026ge;\u0026thinsp;2 days of other, non-fentanyl opioids.\u003c/p\u003e \u003cp\u003eDemographic information, such as patient sex, race, and geographic region, and hospitalization information, including as length of stay, intensive care utilization, and mortality, was also obtained from the PHIS database. Patient age was calculated as the age at their last encounter during the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eAll data were summarized using descriptive statistics. Median and range were used to describe quantitative variables and frequency and percentage were used for qualitative variables. The prevalence of constipation among all solid cancers (as well as in specific cancer groups) was calculated as a percentage. The management of constipation was summarized descriptively. Univariate comparisons between those with and without constipation were performed using chi-square tests for qualitative variables and Wilcoxon rank sum tests for quantitative variables. Statistical significance was determined by p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistical analyses were performed using Statistical Analysis System software 9.4 (SAS Institute, Cary, NC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results:","content":"\u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eWe identified 13,375 unique patients (79,530 unique admissions) who were admitted with a solid tumor diagnosis from 48 PHIS hospitals during the four-year period evaluated (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The majority of patients were male (n\u0026thinsp;=\u0026thinsp;7,465, 55.8%) with a median age of 9.9 years (range: 0.0-20.9 years). CNS cancers were the most commonly identified solid tumor group (24.4%), followed by NHL (14.4%), bone (12.9%), Hodgkin lymphoma (10.2%), kidney (8.3%), abdomen/pelvis (6.8%), adrenal (6.7%), liver/biliary (5.1%), and retinal (2.8%). Solid tumors of other organ systems not specified here accounted for 8.3% of the cohort (Supplemental 1).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographics and clinical characteristics of pediatric patients with solid tumors (Pediatric Hospital Information System, 2015\u0026ndash;2019)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnique Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,465 (55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,550 (63.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,757 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e605 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,463 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at last encounter (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.9 (infant \u0026ndash; 21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSolid cancer diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,264 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,730 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLymphoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHodgkin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,365 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-Hodgkin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,925 (14.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiver/Biliary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e686 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKidney\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,111 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e378 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdominal/pelvic NOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e910 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdrenal tumors NOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e896 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther solid tumors\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,110 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003csup\u003e1\u003c/sup\u003eIncludes other solid tumors/masses of other organ systems no listed\u003cbr\u003eAbbreviations: CNS= Central Nervous System, NOS= Not Otherwise Specified\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003e\u003cstrong\u003ePrevalence of Constipation and GI Diagnoses\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eConstipation was the most common GI complaint identified in unique solid tumor patients, with 8,658 (64.7%) being diagnosed with constipation or receiving at least two constipation medications during a single admission (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Bone cancers had the highest prevalence (79.7%) of patients with constipation, while retinal tumors had the lowest at 23.3% (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Nausea/vomiting (n\u0026thinsp;=\u0026thinsp;5,439, 48.6%) and abdominal pain (n\u0026thinsp;=\u0026thinsp;1,044, 9.3%) were the next most commonly observed GI diagnoses. Other GI symptoms commonly reported in solid cancer patients included mucositis (n\u0026thinsp;=\u0026thinsp;3,017, 26.9%) and gastroesophageal reflux disease (n\u0026thinsp;=\u0026thinsp;1,419, 12.7%). Mucositis was most common in patients with NHL (42.7%), bone cancers (41.7), and adrenal tumors (38.5%), and least commonly seen in kidney (10.4%) and abdominal/pelvic (10.2%) tumors. GI infections were present in all diagnoses, with adrenal tumors (n\u0026thinsp;=\u0026thinsp;195, 21.8%) having the most, and Hodgkin lymphoma patients (n\u0026thinsp;=\u0026thinsp;101, 7.4%) with the fewest reported GI infections.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatient prevalence of most commonly identified solid tumor diagnoses with various GI diagnoses (Pediatric Hospital Information System, 2015\u0026ndash;2019)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"9\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll Solid Tumors\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCNS Cancers\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBone Cancers\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKidney\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAbd/Pelvic\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdrenal tumors\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHL\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNHL\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,730\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,925\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefined Constipation\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8,658 (64.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,281 (69.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,379 (79.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e734 (66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e547 (60.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e508 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e711 (52.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,307 (67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstipation (Dx only)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6,477 (48.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,583 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,143 (66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e515 (46.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e419 (46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e422 (47.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e536 (39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e984 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGI Symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdominal Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,185 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e255 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e182 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e230 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNausea/Vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6,423 (48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,440 (44.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,204 (69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e412 (45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e445 (49.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e646 (47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e925 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther GI Diagnoses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGERD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,587 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e415 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e271 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e254 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUlcer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e96 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,568 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e302 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e232 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e163 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e165 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e319 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAppendicitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e221 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIBD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (\u0026lt;\u0026thinsp;0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6 (\u0026lt;\u0026thinsp;0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (\u0026lt;\u0026thinsp;0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (\u0026lt;\u0026thinsp;0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (-)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePancreatic Issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e245 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGallbladder Issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e237 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnal/Rectal Issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e751 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e254 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeritonitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e362 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMucositis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3,436 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e551 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e722 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e345 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e369 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e821 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGI Infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,650 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e414 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e210 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e195 (21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e305 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e\u003csup\u003e1\u003c/sup\u003eAdministration of constipation medications without the presence of a constipation diagnosis.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eAbbreviations: CNS\u0026thinsp;=\u0026thinsp;Central Nervous System, Abd\u0026thinsp;=\u0026thinsp;Abdominal, HL\u0026thinsp;=\u0026thinsp;Hodgkin Lymphoma, NHL (Non-Hodgkin Lymphoma), GERD\u0026thinsp;=\u0026thinsp;Gastroesophageal Reflux Disease, IBD\u0026thinsp;=\u0026thinsp;Irritable Bowel Disease, IBS\u0026thinsp;=\u0026thinsp;Irritable Bowel Syndrome\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003e\u003cstrong\u003eCharacteristics of Constipation Admissions\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eInpatient admissions with constipation were more likely to be female (n\u0026thinsp;=\u0026thinsp;23,420, 57.3%) and/or utilize a narcotic (n\u0026thinsp;=\u0026thinsp;14,044, 56.8%) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). In addition, admissions with constipation were more likely to have OR charges (56.8% vs 39.9%; p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) and TPN use (10.5% vs 6.7%; p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) compared to admissions without constipation.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of pediatric patients with solid tumor admissions with constipation\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eConstipation admits\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;24,719\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo constipation\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;54,811\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian age (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.6 (5.0-15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.1 (4.1\u0026ndash;15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,358 (54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31,391 (57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15,991 (64.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35,070 (64.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,180 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,678 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,157 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,635 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,391 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,428 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,263 (21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,504 (21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18,284 (74.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40,254 (73.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,172 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,053 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian LOS (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,347 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25,177 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,912 (48.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26,165 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e882 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,293 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e578 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,176 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of narcotic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,044 (56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,859 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR charges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,236 (29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,240 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTPN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,592 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,661 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eAbbreviations: OR\u0026thinsp;=\u0026thinsp;operating room, TPN\u0026thinsp;=\u0026thinsp;total parental nutrition\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003e\u003cstrong\u003eConstipation Management and Opioid Use\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eA constipation medication was administered in 45.8% (n\u0026thinsp;=\u0026thinsp;36,444) of admissions (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). These medications were used in the setting of a constipation diagnosis in 73.1% (n\u0026thinsp;=\u0026thinsp;11,912) of admissions, while 38.8% (n\u0026thinsp;=\u0026thinsp;24,532) of admissions utilized a constipation medication without the presence of a constipation diagnosis code. Among admissions with a constipation diagnosis, 21.9% (n\u0026thinsp;=\u0026thinsp;3,568) required 2 different constipation medications, with 18.2% of admissions requiring 3 or more unique constipation medications. In admissions without the presence of a constipation diagnosis, a single agent was used 24.1% of the time, whereas 13.3% (n\u0026thinsp;=\u0026thinsp;8,413) received a combination of 2 or more different medications. The most commonly utilized constipation medication, regardless of the presence of a constipation diagnosis, was polyethyl glycol (n\u0026thinsp;=\u0026thinsp;25,175, 31.7%), followed by docusate (n\u0026thinsp;=\u0026thinsp;11,297, 14.2%), senna (n\u0026thinsp;=\u0026thinsp;10,325, 13.0%), and lactulose (n\u0026thinsp;=\u0026thinsp;5,501, 6.9%). These medications were used for a median of 2 to 3 days. A total of 45% (n\u0026thinsp;=\u0026thinsp;35,903) of encounters received an opioid at some point during an admission: 4.5% (n\u0026thinsp;=\u0026thinsp;3,598) received fentanyl only, 15.2% (12,068) received\u0026thinsp;\u0026le;\u0026thinsp;2 days of a non-fentanyl opioid, and 25.4% (n\u0026thinsp;=\u0026thinsp;20,237) received\u0026thinsp;\u0026gt;\u0026thinsp;2 days of a non-fentanyl opioid. The extended use of non-fentanyl opioids (\u0026gt;\u0026thinsp;2 days) was more common in admissions with a constipation diagnosis compared to those without a constipation diagnosis (33.1% vs 23.5%; p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). Constipation management and opioid use in specific solid tumor diagnoses are detailed in supplemental 2.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eConstipation medical management and opioid utilization in pediatric patients with solid tumors during inpatient admission (Pediatric Hospital Information System, 2015\u0026ndash;2019).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll Admissions\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;79,530\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eConstipation Admissions\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;16,306\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo Constipation Admissions\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;63,224\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnti-Constipation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36,444 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,912 (73.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24,532 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePolyethyl Glycol-electrolyte\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25,175 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,874 (54.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,301 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSenna\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,325 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,384 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,941 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLactulose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,501 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,272 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,774 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDocusate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,297 (14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,139 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,158 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElectrolyte Laxatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e865 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e559 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e306 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGlycerin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,745 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e641 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,104 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMineral Oil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e834 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e312 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e522 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBisacodyl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,094 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e888 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,206 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaxative Combination\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e806 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e400 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e406 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Different Laxatives Taken\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44,229 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,679 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39,550 (62.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,359 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,098 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15,261 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,433 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,568 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,865 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,509 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,961 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,548 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpioid Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43,627 (54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,120 (49.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35,507 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFentanyl Only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,598 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e485 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,113 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;2 days of Other Opioids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,068 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,304 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,764 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;2 days of Other Opioids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,237 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,397 (33.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,840 (23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Medication (when used) (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian Polyethyl Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian Senna Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian Docusate Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian Lactulose Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1\u0026ndash;4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003eAdministration of \u0026gt;\u0026thinsp;2 constipation medications without the presence of a constipation diagnosis. \u003csup\u003e2\u003c/sup\u003eExcludes combinations with iron.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ePercentages may not sum to 100% due to rounding.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion:","content":"\u003cp\u003eWe identified 13,375 unique patients with 79,530 unique admissions in this study of pediatric patients with solid tumors admitted at 48 children\u0026rsquo;s hospitals. A majority of children received constipation medications regardless of having a billed diagnosis or not. The prevalence of constipation identified in our study (64.7%) is impressively greater than the prevalence reported in the general pediatric population (ranging from 0.7\u0026ndash;29%[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]).\u003c/p\u003e \u003cp\u003eFor unclear reasons, pediatric females have been demonstrated to have a higher prevalence of constipation than males in healthy children and the pediatric ALL patient population[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Similarly, our data demonstrated that females with solid tumors are at higher risk for experiencing constipation during hospitalization. Additionally, our finding that opioids are associated with constipation has been well studied in adult and pediatric cancer literature[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Opioids lead to constipation through their action upon opioid receptors in the GI tract, leading to reduced GI propulsion and increased fluid absorption\u003csup\u003e13\u003c/sup\u003e. Unfortunately, opioids are commonly a necessity for cancer related visceral or bone pain. Additionally, patients with solid tumors can undergo surgical interventions for tumor, staging, or central line placement, involving anesthesia and post-procedure pain control. Certain immunotherapies, such as dinutuximab in neuroblastoma patients, may require continuous intravenous pain medications, leading to prolonged opioid use. Non-Hodgkin lymphoma treatment is notoriously intense and can often result in prolonged mucositis resulting in lengthy opioid use for pain control, which likely correlates with the high rates of constipation we identified. Similarly to patients with ALL in induction, we demonstrated a wide variability in constipation medications prescribed, regardless of a constipation diagnosis, further evidence of the lack of standard practice on how to manage constipation in the pediatric oncology setting[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have shown that children with a constipation diagnosis have a significant increase in healthcare utilization compared to children without constipation[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Although constipation in healthy children develops insidiously over time and fortunately is almost always secondary to functional constipation, pediatric oncology patients have psychological stressors as a result of their diagnosis and receive chemotherapy and other interventions which predispose them to constipation. While symptoms of constipation go unnoticed or underreported due to patient embarrassment and/or anxiety with the medical team, symptoms and risks of constipation can worsen. Stool withholding, caused by hard, painful bowel movements, anal fissures, and mucositis, can disrupt brain-colonic signaling leading to increased stretch and stool burden, and progressively worsen stool build up[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The majority of bowel regimens are readily available and affordable for patients to take in the hospital or at home. In addition, there are minimal to no interactions between constipation medications and cancer directed therapy[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Preventative measures and attention to constipation symptoms could eliminate chemotherapy delays and decreases due to severe constipation or chronic constipation habits following chemotherapy. Finally, children with hematologic malignancies and constipation have increased abdominal imaging exposure[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Multiple pediatric subspecialist organizations, including the Children\u0026rsquo;s Oncology Group, have previously published that increasing ionizing radiation exposure from x-ray and computerized tomography should be avoided as much as possible due to risks of secondary malignant neoplasms[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although in a general pediatric setting, constipation is a clinical diagnosis that rarely requires imaging, children undergoing chemotherapy can have underlying pathophysiology or life-threatening diagnoses such as typhlitis that may necessitate further work up when presenting with abdominal imaging or nausea. Decreasing the physical symptoms of abdominal pain, nausea, and bloating that accompany many patients with constipation, could result in decreased abdominal radiograph exposure and in turn, decrease unnecessary ionizing radiation exposure.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThese findings should be interpreted in light of the strengths and limitations of our study design and data source, as outlined in our previous study[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These limitations acknowledge that PHIS is a large-scale database that provides multi-institutional, geographically diverse representation of a large number of subjects. Relying on accurate coding and diagnoses using ICD-10 codes is an inherent limitation of PHIS. We cannot assess with certainty how often constipation medications were used to prevent, rather than treat constipation, however, we attempted to account for this conservatively by requiring a diagnosis of constipation before considering the intent to be treatment. It is certainly possible that patients receiving constipation medications for \u0026ldquo;prevention\u0026rdquo; by our definition could have been experiencing signs or symptoms of constipation, in which case we have under-estimated the true prevalence of constipation in this patient population. Similarly, in patients who received constipation medications, we are unable to comment on whether the number and type of medication prescribed were appropriate for their needs. In those patients receiving an opioid, we are unable to assess if this was used for sedation/anesthesia purposes or pain control. In an attempt to account for this, we placed patients into four opioid groups of presumed increased constipation risk. We are limited to ICD-10-CM coding to define the specific cancer groups based on location of tumor and have no detail regarding the specific tumor classification, stage, histology, or specific treatment regimen. Finally, the PHIS data set does not allow us to assess the extent of constipation or use of medications after discharge.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, constipation is highly prevalent in children with solid tumors receiving chemotherapy, is likely multifactorial in nature, and most children receive a variety of medications to treat it. Clinical practice guidelines and additional supportive care recommendations for constipation are lacking in pediatric oncology. This report demonstrates the high frequency of constipation in pediatric patients with solid tumors and supports the need for increased attention to prophylaxis and management in this population to prevent patient discomfort, minimize potential impact on cancer treatment, as well as reduce exposure to expensive and potentially harmful radiologic testing for evaluation of gastrointestinal symptoms. Supportive care guidelines are sorely needed in this area, particularly for high-risk populations such as solid tumor patients, and future prospective studies should seek to determine the most effective standardized treatment regimens.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral Nervous System, NOS\u0026thinsp;=\u0026thinsp;Not Otherwise Specified\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e:\u003c/u\u003e none\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e:\u0026nbsp;\u003c/u\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eCode Availability\u003c/strong\u003e\u003c/u\u003e: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e:\u003c/u\u003e Drs. Belsky and Runco conceptualized and designed the study, drafted the initial manuscript, and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eMr. Stanek designed the data collection instruments, carried out statistical analyses, reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eDrs. Yeager and Runco conceptualized the study, reviewed, and revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e:\u003c/u\u003e This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Indiana University approved this study.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/u\u003e: Informed consent was not needed for this retrospective database review\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u003c/u\u003e Consent for publication was not needed for this retrospective review\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eWard E et al (2014) Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin 64(2):83\u0026ndash;103\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSiegel RL et al., \u003cem\u003eCancer Statistics\u003c/em\u003e, 2021. CA Cancer J Clin, 2021. \u003cstrong\u003e71\u003c/strong\u003e(1): p.\u0026nbsp;7\u0026ndash;33\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRhondali W et al (2013) Self-reported constipation in patients with advanced cancer: a preliminary report. J Pain Symptom Manage 45(1):23\u0026ndash;32\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMcQuade RM et al (2016) Chemotherapy-Induced Constipation and Diarrhea: Pathophysiology, Current and Emerging Treatments. Front Pharmacol 7:414\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSood M, Lichtlen P, Perez MC (2018) Unmet Needs in Pediatric Functional Constipation. Clin Pediatr 57(13):1489\u0026ndash;1495\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRajindrajith S et al (2016) Childhood constipation as an emerging public health problem. World journal of gastroenterology 22(30):6864\u0026ndash;6875\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePashankar FD et al (2011) Acute Constipation in Children Receiving Chemotherapy for Cancer. Journal of Pediatric Hematology/Oncology 33(7):e300\u0026ndash;e303\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBelsky JA, Stanek JR, O\u0026apos;Brien SH (2020) Prevalence and management of constipation in pediatric acute lymphoblastic leukemia in U.S. children\u0026apos;s hospitals. Pediatr Blood Cancer 67(11):e28659\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTabbers MM et al (2014) Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 58(2):258\u0026ndash;274\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003evan den Berg MM, Benninga MA, Di Lorenzo C (2006) Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol 101(10):2401\u0026ndash;2409\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDiaz S, Bittar K, Mendez MD, \u003cem\u003eConstipation\u003c/em\u003e, in \u003cem\u003eStatPearls\u003c/em\u003e. 2020, StatPearls Publishing\u0026nbsp;\u003c/span\u003e\u003cspan\u003eStatPearls Publishing LLC: Treasure Island (FL)\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDrewes AM et al (2016) Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction-Recommendations of the Nordic Working Group. Scand J Pain 11:111\u0026ndash;122\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLiem O et al (2009) Health utilization and cost impact of childhood constipation in the United States. J Pediatr 154(2):258\u0026ndash;262\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMedicine JH (2010) Plugged up: Doctors see signs of worsening constipation in children. Science Daily\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSchmier JK et al (2014) Cost savings of reduced constipation rates attributed to increased dietary fiber intakes: a decision-analytic model. BMC Public Health 14:374\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWeiser DA et al (2013) Imaging in childhood cancer: a Society for Pediatric Radiology and Children\u0026apos;s Oncology Group Joint Task Force report. Pediatr Blood Cancer 60(8):1253\u0026ndash;1260\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric, oncology, osteopathic, integrative medicine","lastPublishedDoi":"10.21203/rs.3.rs-800140/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-800140/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eDespite continued development of targeted therapies for children with cancer, patients continue to experience an array of unwanted side effects. Children with solid tumors may experience constipation as a result many treatment variables. Our objective was to investigate the prevalence and treatment of constipation in hospitalized children with solid tumors treated with chemotherapy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed data from 48 children\u0026rsquo;s hospitals in the Pediatric Health Information System, extracting patients 0\u0026ndash;21 years of age with a solid tumor diagnosis hospitalized from October 2015-December 2019. Primary study outcome investigated which solid tumor subgroups received the diagnosis of constipation or received the most constipation medications while receiving chemotherapy for a cancer diagnosis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified 13,375 unique patients with a solid tumor diagnosis receiving chemotherapy. Constipation was the most common gastrointestinal complaint with 8,658 (64.7%; 95% Cl: 63.9\u0026ndash;65.5%) meeting our defined constipation diagnosis. Bone cancers had the highest percentage (69.9%) of patients with constipation, while Hodgkin\u0026rsquo;s lymphoma had the lowest, though 52.1% of patients were affected. A total of 44% (n\u0026thinsp;=\u0026thinsp;35,301) of encounters received an opioid at some point during admission. Of patients receiving constipation medications, the most commonly prescribed was poly-ethyl glycol (n\u0026thinsp;=\u0026thinsp;25,175, 31.7%), followed by docusate (n\u0026thinsp;=\u0026thinsp;11,297, 14.2%), senna (n\u0026thinsp;=\u0026thinsp;10,325, 13.0%), and lactulose (n\u0026thinsp;=\u0026thinsp;5,501, 6.9%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eConstipation is the most common gastrointestinal issue that children with solid tumors experience while receiving chemotherapy. Increased attention should be given to constipation prophylaxis and treatment in children with solid tumors undergoing chemotherapy.\u003c/p\u003e","manuscriptTitle":"Prevalence and Management of Constipation and GI Diagnoses in Children With Solid Tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-13 14:42:17","doi":"10.21203/rs.3.rs-800140/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"18ebdccc-a340-45cc-88c7-c71f1e4bf11a","owner":[],"postedDate":"September 13th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":7144404,"name":"Critical Care \u0026 Emergency Medicine"},{"id":7144405,"name":"Cancer Biology"},{"id":7144406,"name":"Oncology"}],"tags":[],"updatedAt":"2021-11-26T13:41:26+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-13 14:42:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-800140","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-800140","identity":"rs-800140","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}