Constipation%20in%20children Treatment

• Treatment goals in general include evacuation, pain-free bowel movement, and formation of regular bowel habits

Disimpaction

• If fecal impaction is present, initial therapy is to evacuate the colon
  
  • Fecal impaction is identified through a physical exam finding of palpable stool on abdominal and rectal exam and excessive stool on abdominal X-ray
• Disimpaction may be done with oral or rectal medications or a combination of these 2 and in uncontrolled clinical trials, these had been effective
  •  It is important to discuss options with the family regarding treatment choice

Oral Disimpaction

• Eg high-dose Mineral oil, Polyethylene glycol (PEG) electrolyte solutions, high-dose Magnesium citrate, Magnesium hydroxide, Sorbitol, Lactulose, Senna, or Bisacodyl
• Preferred due to its non-invasiveness but adherence may be difficult
• PEG is the recommended 1st-line therapy for children presenting with fecal impaction

Rectal Disimpaction

• Considered only when oral medications have failed and only with the child or family’s consent
• May be done with saline or phosphate soda enemas or a mineral oil enema followed by a phosphate enema
  
  • Glycerin suppositories in infants is recommended but enema to be avoided
  • Bisacodyl suppositories in older children are used
  • Soap suds, tap water and magnesium are potentially toxic and are not recommended
• Digital disimpaction is not recommended or discouraged
•  Follow-up is needed within 1 week for children undergoing disimpaction

Maintenance Therapy

• Following disimpaction, maintenance therapy is then started and may be needed for several months
• Monitoring is essential during this time to ensure the child does not become reimpacted and to address issues such as adherence and toileting
• Frequency of clinic visits is individualized based on the child’s needs and of the family’s
• It is recommended that the same person or team perform the reassessment
• Laxatives are advantageous in children until they are able to maintain regular toilet habits
• Clear evidence is lacking as to which laxative is superior
• Discontinuation of maintenance therapy may be considered if the child has developed regular bowel habits

Bulk-forming Laxatives

• Eg Ispaghula (Psyllium), Methylcellulose
• Used for treatment and prolonged prophylaxis of patients with constipation without outlet obstruction
• Often used as 1st-line treatment and only used if increased dietary fiber is ineffective
• Water-absorbing organic polymers that increase fecal mass and make it softer and easier to pass, adequate intake of fluid is important

Enemas

• Eg Glycerol, Sodium chloride, Sodium phosphate, Phosphate enemas
• Not recommended for infants
  
  • Increases risk for mechanical trauma to rectal wall, abdominal distention, vomiting
• Disimpaction with enemas is a recommended option for children
•  Phosphate enemas are used after disimpaction with the use of other enema

Lubricants

• Eg Mineral oil
• Not recommended in infants
• Used for managing acute or subacute constipation
• Soften stool and ease its passage by decreasing water absorption from the gastrointestinal (GI) tract

Osmotic Laxatives

• Eg poorly absorbed electrolytes Magnesium hydroxide, Magnesium citrate, Magnesium sulfate, and poorly absorbed disaccharides Lactulose and Sorbitol, and PEG 3350/4000
• For long-term treatment of constipation that is difficult to manage, low-dose Polyethylene glycol (PEG) electrolyte solution may be used
• PEG with or without electrolytes is recommended as 1st-line maintenance therapy and Lactulose should be considered if PEG solutions are not available
• Lactulose and Sorbitol are used in infants as stool softeners
• Produces an osmotic effect in the colon resulting in distention and peristalsis promoting bowel emptying
• Changes water distribution in the stool causing fluid retention in the colon through osmosis, good fluid intake is essential

Stimulant Laxatives

• Eg Anthraquinones (Senna, Cascara, Danthron), diphenylmethanes (Bisacodyl), Castor oil, Glycerol, Sodium picosulfate
• In the maintenance period, it is not recommended to use stimulant laxatives for a prolonged time
  
  • It is also not recommended in infants
• Used as a “rescue therapy” when taken intermittently or for short periods
•  Directly stimulates colonic nerves, increase peristalsis in the GI tract, induce water and salt secretion in the colon

Stool Softeners

• Eg Docusate sodium, Liquid paraffin
• Stool softeners may be combined with a stimulant
  
  • While softening stool, the stimulant increases peristaltic activity in the GI tract
• Used for prophylaxis in acute and subacute settings
•  Surface-active agents that allow absorption of fat and water into the stool making it softer and easier to pass