“The highest proportion of participants – 68% – reported treatment satisfaction with kiwifruit while similar proportions of those receiving prunes and psyllium – 48% – reported satisfaction”
“The kiwi group had the lowest proportion of participants reporting treatment dissatisfaction at 7%….Participants receiving prunes and psyllium were more likely to report abdominal pain and bloating than those receiving kiwi”
Diagnosis of constipation is primarily based on history and physical exam –not abdominal xray (AXR). In a recent quality improvement study (G Moriel et al. J Pediatr 2020; 225: 109-116. Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department), ED physicians were trying to improve adherence to evidence-based guidelines for diagnosis of constipation in otherwise healthy children. In this article, the authors note evidence “has shown abdominal radiographs to be unreliable in establishing an association between clinical symptoms of constipation and fecal load on abdominal radiographs.”
As part of the study, the researchers provided two 20-minute presentations to the pediatric emergency department providers and sent emails to them and to resident housestaff. The email for ED provider’s included the provider’s baseline abdominal radiograph frequency. After study was initiated, a followup email was sent with similar information with key information on the project along with individualized data.
After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (from 36% at baseline). This 18% decrease was significant ( P < .001) and sustained over a 12-month follow-up period.
The average length of stay was 1.07 hours longer for children who had an abdominal radiograph.
Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit.
While the study focused on healthy children, the authors noted that the overall population (6 mo-18 years) experienced a decline in AXR usage, regardless of exclusion criteria. At baseline the rate of AXR was 39.5% (1550/3926) which decreased to 20.7% (478/2311).
One interesting piece of data was showing that this intervention resulted in a sustained reduction for 12 months after the intervention observation period, which mitigates the potential influence of the Hawthorne effect.
My take: In my view, the keys to this intervention was providing individualized metrics as well as having leadership in establishing this project. The individualized metrics help physicians recognize when they are outliers and to motivate them to address this.
The images below show how much more prevalent problems with regurgitation, colic, functional diarrhea, dyschezia, and functional constipation in the first 3 months of life compared to later in the first year of life.
A recent cross-sectional study (LM Little et al. J Pediatr 2019; 210: 141-5) which examined sensory processing and constipaiton included 66 children and 66 control children.
Children with chronic constipation had significantly higher sensory scores than matched controls. This included sensory avoiding (P<.001) and sensory sensitivity (P<.05).
The authors utilized the Child Sensory Profile-2 and the Toileting Habit Profile Questionnaire.
The finding that sensory problems contribute to chronic constipation. In those with over-responsiveness, which was more frequent in this study, this can lead to avoidance behaviors. In under-responsiveness, children may not realized that they need to defecate which can lead to problems as well.
My take: This study suggests that recognition of how sensory problems contribute to chronic constipation could improve counseling/treatment approaches.
A recent study (LLD Zhong et al. Clin Gastroenterol Hepatol 2019; 17: 1303-10) shows that a Chinese remedy MaZiRenWan (MZRW) which is a combination of 6 herbs is an effective agent for constipation based on a double-blind, double-dummy trial of 291 patients with functional constipation. Thanks to Ben Gold for this reference.
MZRW was dosed at 7.5 mg BID and Senna was dosed at 15 mg per day. Mean age of study participants was 45 years.
Complete response, defined as an increase of stooling by 1 or more BM per week, was similar between MZRW (68%) and Senna (58%) at week 8. Both were superior to placebo which had a 33% complete response.
At week 16, MZRW had better response than senna or placebo, with complete responses of 47%, 21%, and 18% respectively.
No serious adverse effects were reported and there were no significant differences in renal or liver function between the groups.
My take: The authors note that this remedy has been around for 2000 years. Their data show it appears to be a well-tolerated alternative for the management of constipation in adults.
A recent study (Vilanova-Sanchez A, et al. J Pediatr Surg 2018; 53: 722-7) provides reassurance regarding the safety of senna-based laxatives in kids.
The authors performed a literature review and reviewed their personal experience (2014 to 2017) of prescribing Senna in 640 patients. In this cohort, 230 (36%) had functional constipation.
Besides abdominal cramping or diarrhea during the first weeks of administration, there were no other long-term side effects from Senna found in the pediatric literature with long-term treatment
At their institution, 83 (13%) patients presented minor side effects such as abdominal cramping, vomiting or diarrhea, almost half (48%) of which resolved spontaneously within two weeks.
“We did not see any side effects in 540 (84.3%) patients.” The median length of treatment was 338 days and median dose was 17.5 mg. “430 (80%) of them are currently taking Senna.”
17 patients (2.2%) developed blisters during their treatment. Patients who developed blisters had higher doses 60 mg/day; 60 [12–100] vs. 17.5 [1.7–150] (p < 0.001). All of the blistering episodes were related to night-time accidents, with a long period of stool to skin contact.
In their discussion, the authors note that senna and other anthranoid glycosides are not absorbed in the small intestine. They are maintained as prodrugs until they reach the large intestine where they are metabolized to the active form. In addition, “despite an extensive search of both the medical and lay literature we did not find any reference to long term tolerance due to treatment which we find is a frequently mentioned concern by families and clinicians”
“The safety profile of senna is as good as or better than many common medications a person would be on, including over-the-counter medications routinely given to very young children, and tolerance does not appear to be a concern,” says Dr. Levitt, who is also a professor of Surgery at The Ohio State University College of Medicine. “We hope this paper will make physicians more comfortable in using senna-based laxatives, and that they will be more widely used.”
Senna is often more effective than polyethylene glycol. This study shows that it is safe as well. “A physician should consider senna as the first line medication,” says Dr. Levitt.
My take: Many patients who come to pediatric gastroenterologists have not responded to polyethylene glycol. Senna has been effective in many of these patients as part of a bowel regimen which usually includes behavior modification and diet.
The sentiment of wanting to get their kid off laxatives/stool softeners is frequently expressed at GI visits. I certainly understand this. Though, if a child is not stooling adequately when these medicines are withheld, this is usually detrimental for the child.
Given the frequency of this sentiment, it is not surprising that a recent study (IJN Koppen et al. J Pediatr 2018; 199: 132-9) reports low adherence with polyethylene glycol treatment in children with functional constipation.
In this cross-sectional survey using the Medication Adherence Report Scale (MARS-5), with scores of ≥23 indicating better adherence, the authors found that only 43 of 115 (37%) children were adherent. The authors note that one of the determinants of adherence was treatment convenience.
The MARS-5 does not objectively measure the exact intake of medication; thus, the exact rate of adherence is unclear. In addition, there is likely to wide variation in adherence among different populations.
My take: this study shows, at least in some populations, a low adherence with constipation therapy. Sticking with treatment, for constipation and every other condition, usually results in better outcomes.