What treatments work best for constipation in children?

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Clinical Inquiries

What treatments work best for constipation in children?

J Fam Pract. 2009 June;58(6):329-331

By

Zia Rahman, MD

Fereshteh Gerayli, MD

Nakia Joye Carter, MS

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References

1. Loening-Baucke V, Miele E, Staiano A. Fiber (glucomannan) is beneficial in the treatment of childhood constipation. Pediatrics. 2004;113:e259-e264.

2. Thomson MA, Jenkins HR, Bisset WM, et al. Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double-blind, placebo-controlled, crossover study. Arch Dis Child. 2007;92:996-1000.

3. Voskuijl W, De Lorijn F, Verwijs W, et al. PEG 3350 (Transipeg) versus lactulose in the treatment of childhood functional constipation: a double-blind randomised, controlled, multicentre trial. Gut. 2004;53:1590-1594.

4. Candy DC, Edwards D, Geraint M. Treatment of faecal impaction with polyethylene glycol plus electrolytes (PEG + E) followed by a double-blind comparison of PEG+E versus lactulose as maintenance therapy. J Pediatr Gastroenterol Nutr. 2006;43:65-70.

5. Tolia V, Lin CH, Elitsur Y. A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children. Aliment Pharmacol Ther. 1993;7:523-529.

6. Sondheimer JM, Gervaise EP. Lubricant versus laxative in the treatment of chronic functional constipation of children: a comparative study. J Pediatr Gastroenterol Nutr. 1982;1:223-226.

7. Perkin JM. Constipation in childhood: a controlled comparison between lactulose and standardized senna. Curr Med Res Opin. 1977;4:540-543.

8. Price KJ, Elliott TM. What is the role of stimulant laxatives for constipation and soiling in children? Cochrane Database Syst Rev. 2001;(3):CD002040.-

9. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2006;(2):CD002240.-

10. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43:e1-e13.

11. University of Michigan Health System. Functional constipation and soiling in children. Ann Arbor, MI: University of Michigan Health System; February 2003. Available at: http://cme.med.umich.edu/ pdf/guideline/peds08.pdf. Accessed January 27, 2008.

EVIDENCE-BASED ANSWER

Osmotic laxatives produce the best results. Fiber and behavior modification may have a role. Increased fiber and behavior modification are the most often recommended first steps in managing chronic functional constipation (CFC) in children, but only limited evidence supports this approach (strength of recommendation [SOR]: B for fiber, 1 randomized controlled trial [RCT]; C for behavior modification, 1 small trial).

For pharmacologic management, the best evidence supports osmotic laxatives (SOR: A, 6 fair- to good-quality RCTs).

Evidence summary

CFC with or without encopresis is a common pediatric problem that’s distressing to both the child and family. High-quality RCTs on managing CFC are lacking. Our search located 7 relevant RCTs^1-7 and 2 relevant systematic reviews.^8,9 The TABLE summarizes the RCTs.

TABLE
How laxatives for childhood constipation compare

INTERVENTION VS COMPARISON	NNT	EFFECTIVE DOSE	AVERAGE COST/MONTH
Glucomannan vs placebo¹	3	100 mg/kg/d	$10-$30*
PEG + E vs placebo²	2	7-42 g/d	$14-$60*
PEG + E vs lactulose³	4	3-6 g/d vs 6-12 g/d	$20 vs $20
PEG + E vs mineral oil for disimpaction over 2 days ⁵	5	20 mL/kg/h×4 h/d 30-120 mL BID	$20 vs $20
Mineral oil vs senna⁶	3	3 mL/kg/d vs 1-4 tab/d	$8 vs $5
Lactulose vs senna⁷	4	15 mL/d vs 20 mL/d	$20 vs $10
*Retail price varies by manufacturer.
NNT, number needed to treat; PEG + E, polyethylene glycol 3350 plus electrolytes.

Fiber may help—and doesn’t hurt

A fair-quality crossover RCT (31 children, mean age 7 years, with CFC) compared fiber (glucomannan) with placebo for 4 weeks.¹ More children were successfully treated with fiber than placebo (45% vs 13%; number needed to treat [NNT]=3.125; P<.05). Parents rated children as doing better on fiber (68% vs 13%), and abdominal pain occurred less often (10% vs 42%; P<.05). No adverse effects were associated with fiber.

Osmotic laxatives, especially PEG, get results

A recent high-quality RCT compared the osmotic laxative polyethylene glycol 3350 plus electrolytes (PEG + E) with placebo in 51 children with CFC, 2 to 11 years of age.² The mean number of defecations per week was higher for children on PEG + E (3.12 vs 1.45; P<.001); straining or pain and stool consistency improved.

FAST TRACK

Polyethylene glycol plus electrolytes works well, but bad taste can be a problem.

One good-quality RCT (100 children, 6 months to 15 years old with CFC) compared PEG + E with lactulose.³ Both significantly increased stool frequency and decreased encopresis. However, PEG + E had a markedly higher success rate (56% vs 29%; NNT=3.7; P=.02). The 8-week trial found significantly more complaints about bad taste in the PEG + E group; the lactulose group reported higher rates of abdominal pain, straining, and pain at defecation. The only dropout because of adverse events (bad taste) occurred in the PEG + E group.

Evidence-based answers from the Family Physicians Inquiries Network

What treatments work best for constipation in children?

References

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