Expert 2017 Opinion: Miralax is (Still) First Choice Laxative for Children

Posted on October 23, 2017 by gutsandgrowth

IJN Koppen et al. Journal of Pediatric Gastroenterology & Nutrition: October 2017 – Volume 65 – Issue 4 – p 361–363

Abstract:

According to international guidelines, polyethylene glycol (PEG) is the laxative of first choice in the treatment of functional constipation in children, both for disimpaction and for maintenance treatment. PEG acts as an osmotic laxative and its efficacy is dose dependent. PEG is highly effective, has a good safety profile, and is well tolerated by children. Only minor adverse events have been reported. Overall the use of PEG in children has been reported to be safe, although in patients predisposed to water and electrolyte imbalances monitoring of serum electrolytes should be considered.

Because this topic is of great importance to the families that are seen by pediatric gastroenterologists (and pediatricians), I wanted to review this brief article which describes the efficacy and safety of polyethylene glycol (aka miralax).

Key Points:

Polyethylene glycol (PEG) is the most widely used laxative in children and adults
It works by interacting “with water molecules by forming hydrogen bonds, in a ratio of 100 water molecules per 1 PEG molecule, which leads to an additional increase in colonic water content.” It is minimally absorbed.
Studies have demonstrated that PEG is better or noninferior to all of the following: lactulose, milk of magnesia, mineral oil, and flixweed (a medicinal herb)

Safety:

Only minor adverse events have been reported in studies. In randomized, placebo-controlled trials, adverse events “did not occur more frequently in patients receiving PEG compared to patients receiving placebo.”
The main safety issue has been when it has been administered via nasogastric administration; improper placement can lead to severe pulmonary complications. In addition, PEG should be used “cautiously in children with swallowing problems…because of risk of aspiration.”

Combatting Myths:

The authors assert that there has never been reports of physical or psychological dependence. Weaning from PEG is to prevent relapse of constipation.
There is no evidence to support loss of efficacy.
The phenomenon of “lazy bowel syndrome” in which there is worsened colonic function has not been described due to PEG; though, patients with underlying motility problems have had these problems misattributed to PEG use.
Despite anecdotal reports of tremors, tics, and obsessive-compulsive behavior in children taking PEG, there has been no evidence of a causal relationship. “These events …are still under investigation, but the FDA has decided that no action is necessary.” The authors note that the co-occurrence of neuro-behavioral problems and constipation is well-recognized in children with and without laxative use.

Clinical Pearl: Stimulant Laxatives After Repaired Anorectal Malformations:

“In children with constipation after repaired anorectal malformations, …stimulant laxatives (eg. senna) should be the laxative of choice.” (J Pediatr Surg 2017; 52: 84-8)

My take (borrowed from the authors): “PEG has rapidly become the treatment of first choice for children with functional constipation.”

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“Not Up For Debate: The Science Behind Vaccination”

Posted on September 18, 2015 by gutsandgrowth

Wednesday’s well publicized debate unfortunately discussed vaccination. Perhaps it is not surprising that a businessman/entertainer, Donald Trump, reiterated misinformation. Yet, the two former physicians (Ben Carson and Rand Paul) on the stage also provided misleading information. A good write-up of this issue from the NY Times: Not Up for Debate: The Science Behind Vaccination

Here’s an excerpt:

Here are the facts:

Vaccines aren’t linked to autism.
The number of vaccines children receive is not more concerning than it used to be.
Delaying their administration provides no benefit, while leaving children at risk.
All the childhood vaccines are important.

There is no evidence that links vaccines to autism. Many, many, many studies have confirmed this. The most recent Cochrane systematic review of research on the MMR vaccine included six self-controlled case series studies, two ecological studies, one case crossover trial, five time series trials, 17 case-control studies, 27 cohort studies and five randomized controlled trials. More than 15 million children took part in this research. No one could find evidence that vaccines are associated with autism….

It’s also not correct to call autism an “epidemic,” as Mr. Trump often seems to do. Autism is more prevalent as a diagnosis than it used to be. But much of that in recent years is because we’ve changed the definition of what it means to have “autism spectrum disorder.” For instance, 10 years ago, two-thirds of children diagnosed with autism had below-average intelligence. But today only about a third of those diagnosed with A.S.D. do. The fastest-growing group of children with autism have average or above average intelligence. We’re being more inclusive in the diagnosis…

Mr. Carson, though observing there was no evidence linking vaccines to autism, also said that many pediatricians were recognizing that “we are probably giving way too many in too short a period of time.” I know of no data that supports this assertion. Pediatricians, as a group, overwhelmingly support vaccines and the current vaccine schedule…

Spacing out vaccines provides no benefit, and leaves children susceptible to illnesses for a longer time…

Today, the number of antigens contained in all the vaccines given to a child by age 2 is less than 315. In contrast, it’s thought a child most likely fights off 2,000 to 6,000 antigens every day from the environment.

Here’s a link to an official AAP statement on this issue. AAP reiterates safety and importance of vaccines

From USA Today: Health group calls Trump statements on vaccine ‘dangerous’

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Safety initiatives -the first 10 items

Posted on September 22, 2013 by gutsandgrowth

A recent review (Ann Intern Med 2013; 158: 365-8) notes that “over the past 12 years, since the publication of the Institute of Medicine’s report, ‘To Err is Human: Building a Safer Health System, ‘ improving patient safety has been the focus of considerable public and professional interest.” The following is a summary of this report (Epocrates docalert summary):

Patient-safety experts in North America and the U.K. systematically reviewed the growing evidence base for 158 patient-safety topics, including 41 strategies designated as most important to practitioners and patients. All reviews are published in the Agency for Healthcare Research and Quality (AHRQ) evidence report entitled “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices” to update the original 2001 publication. After carefully analyzing each patient-safety problem and its related safety strategy, the authors strongly recommend immediate adoption of the following 10 strategies:

Preoperative and anesthesia checklists to prevent operative and postoperative events
Bundles (with checklists) to prevent central line–associated bloodstream infections
Interventions to reduce urinary catheter use
Bundles to prevent ventilator-associated pneumonia
Hand hygiene
Do-not-use list for hazardous abbreviations
Multicomponent interventions to prevent pressure ulcers
Barrier precautions to prevent healthcare-associated infections
Real-time ultrasonography for central line placement
Interventions to improve prophylaxis for venous thromboembolism

The authors also provide a list of 12 “encouraged” (rather than “strongly encouraged”) patient-safety practices, these are listed in Table 2 of the paper.