Updated Pediatric Expert Constipation Guidelines

Posted on January 1, 2014 by gutsandgrowth

Updated guidelines for the diagnosis and treatment of constipation by NASPGHAN and ESPGHAN have undergone formal peer review are likely to be published soon (available online with the following link: bit.ly/1geLxrk). “Evidence-Based Recommendations from ESPGHAN and NASPGHAN for Evaluation and Treatment of Functional Constipation in Infants and Children” by Merti Tabbers, Carlo DiLorenzo et al. The following are some of their recommendations.

Diagnostic recommendations:

The ROME III criteria are recommended for the definition of functional constipation for all age groups.
Diagnosis of functional constipation is based on history and physical examination.
There is no role for the routine use of an abdominal X-ray to diagnose functional constipation.
A plain abdominal radiography may be used in a child in whom fecal impaction is suspected but in whom physical examination is unreliable/not possible.
Based on expert opinion, a 2-4 weeks trial of avoidance of cow’s milk protein may be indicated in the child with intractable constipation.
Routine laboratory testing to screen for hypothyroidism, celiac disease and hypercalcemia is not recommended in children with constipation in the absence of alarm symptoms.

Treatment Recommendations:

We do not recommend the use of biofeedback as additional treatment in childhood constipation.
Polyethylene glycol (PEG) with or without electrolytes orally 1-1.5 gr/kg/day for 3-6 days is recommended as first-line treatment for children presenting with fecal impaction
An enema once a day for 3-6 days is recommended for children with fecal impaction if PEG is not available.
PEG with or without electrolytes is recommended as first-line maintenance treatment. A starting dose of 0.4 gr/kg/day is recommended and the dose should be adjusted according to the clinical response.
Addition of enemas to the chronic use of PEG is not recommended.
Based on expert opinion, use of milk of magnesia, mineral oil and stimulant laxatives may be considered as additional or second line treatment.
Antegrade enemas are recommended in the treatment of selected children with intractable constipation.

Related blog posts:

“Poo in You” Video

Posted on November 4, 2013 by gutsandgrowth

From NASPGHAN ‏twitter feed:

New “Poo in You” education video for constipation / encopresis available through YouTube channel: http://www.youtube.com/NASPGHANencopresis

I took a look at this 5 minute video and it explains why kids soil and the basics of treatment; in addition, there is a “wah-wah-wah” sound effect at 2:29 in video when soiling occurs. Probably worth including this link on an after visit summary:

Related blog posts:

Constipation Guidelines:

Data Supporting Miralax

Posted on August 14, 2013 by gutsandgrowth

A summary of the effectiveness of polyethylene glycol for chronic constipation, fecal disimpaction, and as a bowel preparation are presented in a recent article (JPGN 2013; 57: 134-40).

The article provides information on the biochemistry and mechanism of action along with a good number of references –49.

From the summary:

“PEG is an osmotic laxative used in children in the last few years. It is more effective than lactulose for the treatment of chronic constipation. It is equally effective compared with milk of magnesia and mineral oil for the long-term treatment of constipation but has a much better acceptance rate…It is a safe medication without any significant adverse effects. Because PEG can be mixed in a beverage of the patient’s choice, it has excellent long-term patient acceptance.”

Related blog posts:

Newsflash: constipation frequently causes abdominal pain

Posted on May 25, 2013 by gutsandgrowth

From the following link (forwarded to me by Mike Hart) http://www.dailyrx.com/abdominal-pain-children-emergency-room-was-most-commonly-constipation:

A recent study found that constipation is the most common reason for abdominal pain among children going to one emergency room.

Appendicitis was diagnosed in only about 4 percent of children who went to the ER.

In addition, the researchers did not find any major differences in the treatment or outcomes of children based on their race.

“Call the pediatrician if your child has severe abdominal pain.”

The study, led by Kerry Caperell, MD, of the Department of Pediatrics at the University of Louisville in Kentucky, looked at the outcomes of children who went to the emergency room for abdominal pain.

The researchers investigated the medical records of 9,424 children, aged 1 to 18, who went to the Children’s Hospital of Pittsburgh emergency department for abdominal pain during a two-year period.

More than half of these children, a total of 5,493, ended up receiving multiple diagnoses for their complaints.

The researchers found that 1.9 percent of the African American children and 5.1 percent of the white children who visited the ER were diagnosed with appendicitis. Overall, 4.3 percent of the children had appendicitis.

Appendicitis was less common among younger children, but constipation was commonly diagnosed for all ages.

Almost 20 percent of the children were diagnosed with constipation, and more than 25 percent of the children aged 5 to 12 had constipation.

Constipation, gastroenteritis and urinary tract infections were more common among the African American patients than the white patients.

“Diagnosing causes of abdominal pain in children can often be difficult, especially the younger they are,” said Chris Galloway, MD, a dailyRx expert who specializes in emergency medicine.

“Fortunately common causes are still common and constipation is a frequent diagnosis we make in the ER, and can be quite distressing for your child,” Dr. Galloway said. “Consult your pediatrician if your child has abdominal pain.”

Older children were more likely to remain in the hospital and have an operation related to the reason they went to the ER.

The researchers did not find any differences in children’s outcomes related to their race. This finding means that all the children who went to the ER received similar evaluation and treatment and had similar outcomes regardless of their ethnicity.

The study was published May 20 in the journal Pediatrics. The research did not receive external funding, and the authors declared no conflicts of interest.

Comment: While constipation is a common entity, many of these children have underlying functional problems that are not addressed in the ER setting.

Related blog links:

Three PEG Pediatric Cleanouts

Posted on February 13, 2013 by gutsandgrowth

Several articles highlight the use of polyethylene glycol (Miralax) as a bowel prep for children:

JPGN 2013; 56: 215-19
JPGN 2013; 56: 220-24
JPGN 2013; 56: 225-28

These studies and the accompanying editorial (pg 115) show fairly good results with PEG cleanout regimens.

The first study compared PEG versus senna in a blinded, prospective randomized trial. After enrolling 30 children (6-21 years of age) at a planned interim analysis, the study showed superiority of PEG (1.5 g/kg/day) when used for 2 days prior to colonoscopy. In addition to laxatives, patients were instructed to consume full liquid diet for 2 days prior to procedure & clear liquid on day prior (up to 3 hours before procedure). In the PEG group, good or excellent cleanout scores were noted in 88% compared with only 29% in the senna group. There were no significant adverse effects or electrolyte changes which are well-detailed in this study (Table 2).

The second study evaluated a 1-day regimen with 46 children in a prospective open-label study. 238 g of PEG was mixed with 1.9 L of gatorade and administered over several hours. Patients (8-18 years) were instructed to take only clears after noon the day prior to procedure Only 37 (82%) were able to take the full preparation. 43 (93%) took at least 75% of the preparation. Despite issues with tolerance and nausea/vomiting (noted in 60%), 77% were rated as having an effective cleanout.

The third study enrolled 45 children (5-21 years) in a prospective study of a 1-day bowel preparation. Patients <45 kg received 136 g of PEG solution with 32 ounces of Gatorade; patients >45 kg received 255 g in 64 ounces. 44 children completed study. Patients were told to take PEG over 3 hours the evening prior to procedure and allowed clears until 3 hours prior to procedure. In this group, nausea was noted in 34% and vomiting in 16%. However, patients reported that preparation was easy in 61% and tolerable in 39%. The quality of the preparation was considered excellent in 23%, good in 52%, fair in 23% and poor in 2%. There were no significant electrolyte changes.

Take Home Message:

Numerous small studies show that PEG solutions can be used as a safe, effective bowel preparation in children. Shorter duration preparations are more convenient and may result in nausea or vomiting.

In our institution, we frequently use PEG cleanouts. However, typically our doses of PEG are lower (eg. 136-168 g) and often combined with an enema to complete cleanout process. Unlike adult preparations, we have not instructed families in split-dose regimens mainly due to concerns about the ability of pediatric patients to adhere to these regimens.

Related blog entry:

Colonoscopy, Split–dosing bowel preps, and Ottawa scores …

Miralax Safety

Posted on February 12, 2013 by gutsandgrowth

Periodically questions about the safety of Miralax arise. Recently, several colleagues have received some questions about the use of Miralax due to information on the internet. You may want to familiarize yourself with this link due to the misinformation which is provided:

http://www.gutsense.org/gutsense/the-role-of-miralax-laxative-in-autism-dementia-alzheimer.html

Some of the misleading statements:

Miralax has never been tested for safety in children
Miralax makes one cancer-prone by leaving the colon unprotected
Miralax may result in severe malnutrition ..leading to Autism
Miralax can cause memory loss and neurologic side effects

It is true that there is not enough adequate long-term data on the use of Miralax, though there are studies showing its effectiveness/safety (see below). However, according to the FDA, there are no neuropsychiatric warnings needed for Miralax:

http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/ucm295585.htm

As with all medications, one has to weigh the risks and the benefits. Clearly, the risk and consequences of untreated defecation problems can be severe in some children and may have terrible adverse effects on daily living. The known safety profile of Miralax is very good and its usage has been recommended by the American Gastroenterological Association (AGA) and by the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) in position statements on the treatment of constipation:

An article from NY Times on this subject:

Miralax, a Drug for Adults, Is Popular as a Children’s Remedy …

AGA Constipation Guidelines

Posted on February 11, 2013 by gutsandgrowth

Constipation is a ubiquitous problem. Updated guidelines and a technical review for adults with constipation have been published (Gastroenterol 2013; 144: 211-17, Gastroenterol 2013; 144: 218-38). AGA Institute Policy and Position Statements – Gastroenterology …

For pediatric gastroenterologists, the 2006 NASPGHAN guidelines (Evaluation and Treatment of Constipation – North American Soci) are more useful. Nevertheless, these AGA guidelines offer some helpful insights.

Definition: “physicians often regard constipation to be synonymous with infrequent bowel movements, typically fewer than 3 per week, patients have a broader set of symptoms” that are considered constipation including hard stools, abdominal discomfort, incomplete evacuation, and excessive straining. Rome III criteria: “symptoms for ≥ 6 months and ≥ 2 of the following symptoms for more than one-fourth of defecations during the past 3 months: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual maneuvers to facilitate defecations; ❤ defecations/wk, loose stools are not present and there are insufficient criteria for IBS”

In adults, medical testing:

“In the absence of other symptoms and signs, only a complete blood count is necessary.” Not needed unless other features: TSH, calcium, colonoscopy
Anorectal manometry and rectal balloon expulsion should be performed in patients who fail to respond to laxatives. Defocography should be considered subsequently. Colonic transit should be evaluated if anorectal test results do not show a defecatory disorder.

Recommended Treatment:

Start with increased fiber and laxatives (e.g. PEG, milk of magnesia, bisacodyl). Newer pharmaceutical agents (e.g. lubiprostone and linaclotide) can be considered if no improvement.
Both “normal transit constipation and slow transit constipation can be safely managed with long-term use of laxatives.” (strong recommendation, moderate-quality evidence). “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system. Neurologic damage might just as readily be the cause, not the result.”
Pelvic floor retraining by biofeedback rather than laxatives is recommended for defecatory disorders
Additional workup in those who do not respond. Surgical treatment of slow transit constipation (subtotal colectomy or colectomy with ileorectal anastomosis) only when well-documented failure of aggressive prolonged laxatives/prokinetics

The technical review has a table that lists medications associated with constipation, describes pathophysiology in detail, lists the conditions associated with constipation, and explains the testing/medical management in-depth.

Related blog entries:

PEG vs. Fiber for constipation | gutsandgrowth
Stimulants for constipation | gutsandgrowth
It’s worth the cost | gutsandgrowth
ACE report -10 year effectiveness | gutsandgrowth
Linaclotide –not for kids | gutsandgrowth
Clues about constipation and more than 2.5 million … – gutsandgrowth

Feeling the urge and stopping the shame

Posted on January 29, 2013 by gutsandgrowth

So many parents misinterpret withholding behavior in children. Many indicate that their child is trying to go but cannot and others indicate that their child does not feel an urge to defecate. Now more insight into this common issue has emerged (JPGN 2013; 56: 19-22).

The authors reviewed their experience with colonic manometry (n=410). 150 patients were identifed as having functional constipation. Among this group, 56 patients volunteered that they had no urge to defecate.

Yet, during colonic manometry, when the first high-amplitude propagating colonic contraction (HAPC) occurred, this was associated with retentive posturing, grimacing or denial of sensation. When the HAPC occurred, the examiner would explain that it was causing pain that would improve if the child defecated. Ultimately, “every patient acknowledged an urge to defecate and successfully defecated.”

One other interesting part of this publication is the discussion of psychological aspects. Do you remember Erikson’s stages (Erik Erikson – Wikipedia, the free encyclopedia)? The authors note, “if toilet training is not achieved or the process involves negative experiences including being shamed into the process, shame and doubt will persist. Shame, according to Erikson, is an infantile emotion and leads to secretive behavior. Therefore, children who failed toilet learning may deny sensations of the urge to defecate…all the while having shame and embarrassment.”

These psychological issues are important in the propagation of constipation. The authors note that, even in children with rectal distention due to chronic constipation which could result in decreased sensation, studies have shown rectal compliance was not associated with treatment failure. Therefore, constipation and soiling are not simply due to a mechanical issue of not knowing when to go.

Related posts:

Linaclotide –not for kids

Posted on January 6, 2013 by gutsandgrowth

Linaclotide has been approved for adults (≥18 years) with chronic constipation and constipation-predominat irritable bowel syndrome (IBS-C) (Gastroenterol & Hepatol 2012; 8: 653-60).

Linaclotide is a 14-amino acid peptide that stimulates guanylyl cyclase C (GCC) receptors. It mimics the endogenous peptides guanylin (15 amino acids) and uroguanylin (16 amino acids) which activate GCC through a cascade which activates CFTR to increase luminal levels of bicarbonate, chloride and water. This in turn improves gastrointestinal transit.

There were several trials undertaken to assess the efficacy of linaclotide in IBS-C:

47 patients (36 women) with IBS-C were treated with linaclotide (100 μg or 1000 μg) or placebo –5 day study. The 1000 μg dose significantly decreased colonic transit time compared with placebo. No serious adverse events were reported.
420 patients were enrolled in a 12-week, randomized, double-blind, placebo-controlled, dose-ranging study. The population was 92% female, 80% caucasian with a mean age of 44 years. 337 patients completed the study. There were improvements in the number of complete spontaneous bowel movements (CSBMs) per week and in abdominal pain. Additional results:

With 300 μg dose, there were 3.93 CSBMs/week, with150 μg dose 2.79 CSBMs/week compared with 1.47 for placebo.
With 300 μg dose, there was -0.90 in pain score, with 150 μg dose -0.71 compared with -0.49 for placebo. Overall, abdominal pain improved in 31.1-38.7% of linaclotide-treated patients compared with 22.7% of placebo-treated patients.

For chronic constipation, four trials (n=42, n=310, n=630, and n=642) have shown increased CSBMs/week. On average, a dose of 290-300 μg dose resulted in 1.8-2.7 CSBMs/week, a dose of 145-150 μg dose resulted in 1.6-2.0 CSBMs/week compared with 0.5-0.6 CSBMs/week for placebo. Changes in stool frequency were also reflected in quality of life scores. When linaclotide was stopped, patients reverted to similar stooling rates as placebo-treated patients but no rebound effects were noted.

Prior to approval of linaclotide, lubiprostone (Amitiza) had been the only FDA-approved medication for IBS-C. For chronic constipation, polyethylene glycol is another approved treatment.

Related blog entries:

PEG vs. Fiber for constipation

Posted on October 24, 2012 by gutsandgrowth

Which is better for childhood constipation, polyethylene glycol 3350 (PEG) or fiber? A recent study weighs in (J Pediatr 2012; 161: 710-15).

This randomized, prospective, open-label study compared PEG (with electrolytes) to a fiber supplement (acacia fiber, psyllium fiber, and fructose [AFPFF]) in 100 children with chronic functional constipation (Rome III criteria). Mean age was 6.5 years. Study design allowed for dosage adjustment. Initial PEG dosing was 0.5 g/kg but could be increased to 1 g/kg. AFPFF was dosed at 16.8 g daily but could be increased to 22.4 g. Primary outcome was ≥3 bowel movements per week and improved stool consistency (≥2 on Bristol stool scale).

Key findings:

Compliance was better with PEG than AFPFF: 96% for 72%.
After 8 weeks, improvement noted in 83% of PEG patients compared to 78% of AFPFF (P=0.788). At this time point, PEG were having ~5.8 stools/week vs. 5.6 for AFPFF. Mean Bristol scores were 3.7 and 3.5 respectively.
Conclusion: similar efficacy but PEG had better acceptance. No mention of relative costs of these agents is noted.

Additional references:

Diagnosis and management of idiopathic childhood constipation – BMJ NICE (Nat’L institute for Health and Clinical Excellence) recommendations 2010

Also, a recent previous post (ACE report -10 year effectiveness | gutsandgrowth) has links to multiple related blog entries.

gutsandgrowth

Pediatric Gastroenterology

Tag Archives: constipation