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Nichols KR, Streetman DD, Gordon NA, Knoderer CA. Measurement of Polyethylene Glycol 3350 With Standard Household Measuring Devices. J Pediatr Pharmacol Ther 2024; 29:286-291. [PMID: 38863850 PMCID: PMC11163905 DOI: 10.5863/1551-6776-29.3.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/10/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE Though standard household measuring devices (e.g., teaspoons, tablespoons) are often used in clinical practice to measure pediatric doses of polyethylene glycol 3350 (PEG-3350), no published -literature documents the accuracy of these measurements. Standard dosing for adults is 17 grams, which is 1 capful according to the manufacturer. The objective of this study was to determine the weight of household teaspoons and tablespoons of PEG-3350. METHODS PEG-3350 measurements were performed using 5 different household measuring teaspoons and tablespoons and the cap that accompanies the bottle for 3 different brands of PEG-3350. Using an electronic balance to determine weights, 3 investigators completed 5 measurements for each of the 5 measurement devices and PEG-3350 bottle caps as follows: leveled teaspoons and tablespoons, unleveled teaspoons and tablespoons, "heaping" tablespoons, half-capfuls, and capfuls. RESULTS A leveled teaspoonful of PEG-3350 weighed ∼3.3 grams and an unleveled teaspoonful weighed ∼3.7 grams. A leveled, unleveled, and heaping tablespoon of PEG-3350 weighed about 10, 11, and 15 grams, respectively. Heaping tablespoons, half-capfuls, and capfuls resulted in the most measurement variability. CONCLUSIONS Use of a kitchen scale may be the most precise method of measurement, however not all patients have kitchen scales. Standard household measuring devices (teaspoons and tablespoons) may be used to conveniently measure PEG-3350 doses. Using 1 dedicated measurement device and leveling the dose may improve consistency, which could be beneficial for patients who are sensitive to dose variability.
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Affiliation(s)
- Kristen R Nichols
- Health Sciences Department (KN), Butler University College of Pharmacy and Health Sciences, Indianapolis, IN
| | - Darcie D Streetman
- Health Sciences Department (KN), Butler University College of Pharmacy and Health Sciences, Indianapolis, IN
- Pharmacy Practice Department (CA), Butler University College of Pharmacy and Health Sciences, Indianapolis, IN
- PharmD Candidate, anticipated graduation May 2024, Butler University College of Pharmacy and Health Sciences (NG), Indianapolis, IN
| | - Nicolette A Gordon
- PharmD Candidate, anticipated graduation May 2024, Butler University College of Pharmacy and Health Sciences (NG), Indianapolis, IN
| | - Chad A Knoderer
- Pharmacy Practice Department (CA), Butler University College of Pharmacy and Health Sciences, Indianapolis, IN
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Sayre CL, Yellepeddi VK, Job KM, Krepkova LV, Sherwin CMT, Enioutina EY. Current use of complementary and conventional medicine for treatment of pediatric patients with gastrointestinal disorders. Front Pharmacol 2023; 14:1051442. [PMID: 36778015 PMCID: PMC9911676 DOI: 10.3389/fphar.2023.1051442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
Infants, children, and adolescents are at risk of experiencing a multitude of gastrointestinal disorders (GID). These disorders can adversely affect the quality of life or be life-threatening. Various interventions that span the conventional and complementary therapeutic categories have been developed. Nowadays, parents increasingly seek complementary options for their children to use concurrently with conventional therapies. Due to the high prevalence and morbidity of diarrhea, constipation, and irritable bowel syndrome (IBS) in children, in this review, we decided to focus on the current state of the evidence for conventional and complementary therapies used for the treatment of these diseases in children. Diarrhea treatment focuses on the identification of the cause and fluid management. Oral rehydration with supplementation of deficient micronutrients, especially zinc, is well established and recommended. Some probiotic strains have shown promise in reducing the duration of diarrhea. For the management of constipation, available clinical trials are insufficient for conclusive recommendations of dietary modifications, including increased use of fruit juice, fiber, and fluid. However, the role of laxatives as conventional treatment is becoming more established. Polyethylene glycol is the most studied, with lactulose, milk of magnesia, mineral oil, bisacodyl, and senna presenting as viable alternatives. Conventional treatments of the abdominal pain associated with IBS are poorly studied in children. Available studies investigating the effectiveness of antidepressants on abdominal pain in children with IBS were inconclusive. At the same time, probiotics and peppermint oil have a fair record of benefits and safety. The overall body of evidence indicates that a careful balance of conventional and complementary treatment strategies may be required to manage gastrointestinal conditions in children.
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Affiliation(s)
- Casey L. Sayre
- Division of Clinical Pharmacology, Pediatrics, School of Medicine, Salt Lake City, UT, United States,College of Pharmacy, Roseman University of Health Sciences, South Jordan, UT, United States
| | | | - Kathleen M. Job
- Division of Clinical Pharmacology, Pediatrics, School of Medicine, Salt Lake City, UT, United States
| | - Lubov V. Krepkova
- Center of Medicine, All-Russian Research Institute of Medicinal and Aromatic Plants (VILAR), Moscow, Russia
| | - Catherine M. T. Sherwin
- Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH, United States
| | - Elena Y. Enioutina
- Division of Clinical Pharmacology, Pediatrics, School of Medicine, Salt Lake City, UT, United States,*Correspondence: Elena Y. Enioutina,
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Efficacy, safety, and acceptability of polyethylene glycol 3350 without electrolytes vs magnesium hydroxide in functional constipation in children from six months to eighteen years of age: A controlled clinical trial. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021; 88:107-117. [PMID: 34961695 DOI: 10.1016/j.rgmxen.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION AND AIMS There are few studies that compare polyethylene glycol (PEG) 3350 and magnesium hydroxide (MH), as long-term treatment of functional constipation (FC) in children, and they do not include infants as young as 6 months of age. Our aim was to determine the efficacy, safety, and acceptability of PEG vs MH in FC, in the long term, in pediatric patients. METHODS An open-label, parallel, controlled clinical trial was conducted on patients from 6 months to 18 years of age, diagnosed with FC, that were randomly assigned to receive PEG 3350 or MH for 12 months. Success was defined as: ≥ 3 bowel movements/week, with no fecal incontinence, fecal impaction, abdominal pain, or the need for another laxative. We compared adverse events and acceptability, measured as rejected doses of the laxative during the study, in each group and subgroup. RESULTS Eighty-three patients with FC were included. There were no differences in success between groups (40/41 PEG vs 40/42 MH, p = 0.616). There were no differences in acceptability between groups, but a statistically significant higher number of patients rejected MH in the subgroups > 4 to 12 years and > 12 to 18 years of age (P = .037 and P = .020, respectively). There were no differences regarding adverse events between the two groups and no severe clinical or biochemical adverse events were registered. CONCLUSIONS The two laxatives were equally effective and safe for treating FC in children from 0.5 to 18 years of age. Acceptance was better for PEG 3350 than for MH in patients above 4 years of age. MH can be considered first-line treatment for FC in children under 4 years of age.
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What is the Evidence for Over the Counter Laxatives to Treat Childhood Constipation? Curr Gastroenterol Rep 2021; 23:19. [PMID: 34637057 DOI: 10.1007/s11894-021-00818-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Functional constipation is a common pediatric GI disorder that is responsible for a significant portion of pediatric office visits each year. It presents a significant stressor for patients, their families, and providers alike. There are a variety of over the counter agents available for treatment of pediatric constipation. RECENT FINDINGS Osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, remain the most effective and safe therapy for both long and short term treatment of pediatric functional constipation. Stimulant laxatives, like Senna and Bisacodyl, probiotics, fiber preparations, enemas, and suppositories make excellent choices for adjunct therapies in specific clinical scenarios. There are multiple over the counter pharmacologic agents with various mechanisms of action that have demonstrated efficacy in pediatric functional constipation. These therapies are generally safe and well tolerated by patients.
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Utilisation and Safety of Polyethylene Glycol 3350 With Electrolytes in Children Under 2 Years: A Retrospective Cohort. J Pediatr Gastroenterol Nutr 2021; 72:683-689. [PMID: 33587408 PMCID: PMC8549461 DOI: 10.1097/mpg.0000000000003074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES In the UK, Movicol paediatric plain (polyethylene glycol 3350 with electrolytes [PEG 3350+E], Norgine, UK), is licensed for chronic constipation in children 2 -11 years of age and faecal impaction (FI) from 5 years. This study aimed to investigate usage and characterise the risk profile in children under 2 years of age using PEG 3350+E in the UK. METHODS Retrospective, single exposure cohort study, with patients identified from Clinical Practice Research Datalink (CPRD) GOLD. Patients first prescribed PEG 3350+E under 2 years of age for the treatment of constipation or FI, between September 2003 and July 2019, were included. RESULTS There were 13,235 patients with a constipation indication and 40 patients with FI. For the constipation cohort: median age of PEG 3350+E first prescription was 1.2 years [interquartile range (IQR) 0.9, 1.6] and 68.4% had one treatment episode (TE). The mean duration of exposure, in the first TE, was 88.9 days. The most common total daily dose was one sachet (6.9 g).In terms of incident events on treatment, 0.5% of patients had abdominal pain, 3.0% had diarrhoea (may be attributed to treatment) and 4.1% had vomiting. 2.0% had signs/symptoms which could (in extreme cases) be associated with electrolyte disturbance, however, none had abnormal electrolyte values. DISCUSSION The safety aspect of this study did not identify any signals of concern in the constipation cohort. The number of patients in the FI cohort were too small for robust conclusions. If information were available, then a safety study would ideally assess treatment intake per kilogram, including electrolyte intake, before reaching safety conclusions. Nevertheless, these data contribute to real-world evidence on the use of PEG 3350+E in this population.
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Dheivamani N, Thomas W, Bannerjii R, Mukherjee M, Mitra M. Efficacy of polyethylene glycol 3350 as compared to lactulose in treatment of ROME IV criteria-defined pediatric functional constipation: A randomized controlled trial. Indian J Gastroenterol 2021; 40:227-233. [PMID: 33830440 DOI: 10.1007/s12664-021-01148-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Functional constipation is a common childhood problem, with a prevalence of approximately 3% worldwide. The aim of the study was to compare the efficacy of polyethylene glycol (PEG) 3350 and lactulose in the treatment of pediatric functional constipation. METHODS A total of 100 subjects with functional constipation were enrolled and centrally randomized to receive PEG 3350 (0.7-1.5 mg/kg/day) or lactulose (0.7-2.0 g/kg/day). RESULTS There was a significant increase in median (min, max) stool frequency within 1 week in the PEG 3350 group as compared to the lactulose group (1 [0, 3] to 8 [3, 39] vs. 1 [0, 3] to 7 [1, 17]) (p-value < 0.01). The trend was maintained at week 2, week 3 (p-value < 0.01), and week 4 (p-value = 0.05) with the PEG 3350 group reporting higher weekly median stool frequency than the lactulose group. The PEG group reported significant reduction in painful bowel movements from 68.8% subjects at baseline to 43.8% at the end of first week, whereas the lactulose group reported an increase from 48.9% to 73.3% (p-value = 0.05). Other parameters of constipation, i.e. straining, large diameter stool, and large fecal mass as reported subjectively by parents, significantly decreased from baseline to the end of the study in the PEG 3350 arm compared to those in the lactulose arm. At the end of week 4, there was a statistically significant reduction in all the ROME IV-defined criteria between the two groups. CONCLUSION This study proved that the PEG 3350 treatment group had early symptom relief and significant improvement compared to the lactulose group in pediatric functional constipation. TRIAL REGISTRATION Clinical Trials Registry India (CTRI/2018/01/011061).
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Affiliation(s)
| | - Winston Thomas
- Institute of Child Health, Halls Road, Egmore, Chennai, 600 008, India
| | - Rohit Bannerjii
- Department of Pediatrics, Institute of Child Health, 11, Biresh Guha Street, Kolkata, 100 017, India
| | - Mallar Mukherjee
- Department of Pediatrics, Institute of Child Health, 11, Biresh Guha Street, Kolkata, 100 017, India
| | - Monjori Mitra
- Department of Pediatrics, Institute of Child Health, 11, Biresh Guha Street, Kolkata, 100 017, India.
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Abstract
PURPOSE OF REVIEW Chronic constipation is a common problem that substantially impacts the quality of life of patients and families, healthcare professionals, and resources. The purpose of this review is to discuss the medications that are available for management of chronic constipation, including medications that have been approved by the FDA for adults, other been studied in pediatrics now, and might become available within the upcoming years. RECENT FINDINGS Recent developments in the evaluation of childhood constipation are providing a better understanding into defecation disorders in children and not only new therapies are becoming available, including medications, but also other therapies, such as biofeedback for treatment of functional defecation disorders, electrical stimulation, and surgeries. The aim of this article is to provide an update on the medications that are available for management of chronic constipation, especially with the development and study of newer medications, such as Linaclotide and Lubiprostone with promising results in both adult and pediatric patients. SUMMARY This review will help us identify and have a better understanding regarding what medications are available for use and the indications, so that we can better manage patients with chronic constipation. VIDEO ABSTRACT.
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Comparison of effectiveness between polyethylene glycol 4000 and lactulose in the treatment of pediatric functional constipation. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.742937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Diarrhoeal events can trigger long-term Clostridium difficile colonization with recurrent blooms. Nat Microbiol 2020; 5:642-650. [PMID: 32042128 DOI: 10.1038/s41564-020-0668-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/07/2020] [Indexed: 11/08/2022]
Abstract
Although Clostridium difficile is widely considered an antibiotic- and hospital-associated pathogen, recent evidence indicates that this is an insufficient depiction of the risks and reservoirs. A common thread that links all major risk factors of infection is their association with gastrointestinal disturbances, but this relationship to C. difficile colonization has never been tested directly. Here, we show that disturbances caused by diarrhoeal events trigger susceptibility to C. difficile colonization. Using survey data of the human gut microbiome, we detected C. difficile colonization and blooms in people recovering from food poisoning and Vibrio cholerae infections. Carriers remained colonized for year-long time scales and experienced highly variable patterns of C. difficile abundance, where increased shedding over short periods of 1-2 d interrupted week-long periods in which C. difficile was undetectable. Given that short shedding events were often linked to gastrointestinal disturbances, our results help explain why C. difficile is frequently detected as a co-infecting pathogen in patients with diarrhoea. To directly test the impact of diarrhoea on susceptibility to colonization, we developed a mouse model of variable disturbance intensity, which allowed us to monitor colonization in the absence of disease. As mice exposed to avirulent C. difficile spores ingested increasing quantities of laxatives, more individuals experienced C. difficile blooms. Our results indicate that the likelihood of colonization is highest in the days immediately following acute disturbances, suggesting that this could be an important window during which transmission could be interrupted and the incidence of infection lowered.
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Abstract
PURPOSE To describe the implementation and effectiveness of a multimodal therapeutic approach used to successfully treat a child with encopresis. SUMMARY OF KEY POINTS The child demonstrated chronic constipation, poor pelvic floor muscle awareness, weakness, and incoordination during voiding. He participated in 8 sessions of physical therapy intervention including pelvic floor muscle awareness, strengthening and coordination exercises, behavioral adaptations, diet modification, and use of media, art, and interactive visualization activities. CONCLUSIONS The child improved pelvic floor muscle strength and coordination and became fully continent of bowel in home and community settings. WHAT THIS CASE ADDS TO EVIDENCE-BASED PRACTICE This case report demonstrates that pediatric age-appropriate educational and motivational tools (media, art, and interactive visualization activities) are readily available, economical, and effective when used in conjunction with current practice to decrease impairments and improve active participation and compliance during treatment of retentive encopresis in the pediatric population.
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Hussain SZ, Belkind‐Gerson J, Chogle A, Bhuiyan MAN, Hicks T, Misra S. Probable neuropsychiatric toxicity of polyethylene glycol: roles of media, internet and the caregivers. ACTA ACUST UNITED AC 2019. [DOI: 10.1002/ygh2.336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sunny Z. Hussain
- Willis‐Knighton Pediatric Gastroenterology and Research Shreveport Louisiana
| | | | - Ashish Chogle
- Pediatrics Children's Hospital of Orange County Orange California
| | | | - Timothy Hicks
- Pediatrics Children's Hospital of Orange County Orange California
| | - Sudipta Misra
- Pediatrics Summerville Medical Center Summerville South Carolina
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Matoori S, Roveri M, Tiefenboeck P, Romagna A, Wuerthinger O, Kolokythas O, Froehlich JM. An MRI-guided HIFU-triggered wax-coated capsule for supertargeted drug release: a proof-of-concept study. Eur Radiol Exp 2019; 3:11. [PMID: 30838465 PMCID: PMC6401064 DOI: 10.1186/s41747-019-0090-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/05/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Externally controlling and monitoring drug release at a desired time and location is currently lacking in the gastrointestinal tract. The aim of the study was to develop a thermoresponsive wax-coated capsule and to trigger its release upon applying a magnetic resonance imaging (MRI)-guided high-intensity focused ultrasound (HIFU) pulse. METHODS Capsules containing a lyophilised gadolinium-based contrast agent (GBCA) were coated with a 1:1 (mass/mass) mixture of lanolin and cetyl alcohol (melting point ≈43 °C) and exposed to simulated gastric and intestinal fluids (United States Pharmacopoeia) at 37 °C for 2 and 24 h, respectively. In a HIFU gel phantom, wax-coated capsules (n = 3) were tracked based on their T1- and T2-hypointensity by 1.5-T T1- and T2-weighted MRI pre- and post-exposure to an MRI-guided HIFU pulse. RESULTS Lanolin/cetyl alcohol-coated capsules showed high resistance to simulated gastrointestinal fluids. In a gel phantom, an MRI-guided HIFU pulse punctured the wax coating, resulting in the hydration and release of the encapsulated lyophilised GBCA and yielding a T1-hyperintense signal close to the wax-coated capsule. CONCLUSION We provide the proof-of-concept of applying a non-invasive MRI-guided HIFU pulse to actively induce the disintegration of the wax-coated capsule, and a method to monitor the release of the cargo via T1-weighted MRI based on the hydration of an encapsulated lyophilised GBCA. The wax-coated capsule platform enables temporally and spatially supertargeted drug release via the oral route and promises to address a currently unmet clinical need for personalised local therapy in gastrointestinal diseases such as inflammatory bowel diseases and cancer.
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Affiliation(s)
- Simon Matoori
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 1-5/10, 8093, Zurich, Switzerland.
| | - Maurizio Roveri
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 1-5/10, 8093, Zurich, Switzerland
| | - Peter Tiefenboeck
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 1-5/10, 8093, Zurich, Switzerland
| | - Annatina Romagna
- Clinical Research Group, Klus Apotheke Zurich, Zurich, Switzerland
| | - Olha Wuerthinger
- Clinical Research Group, Klus Apotheke Zurich, Zurich, Switzerland
| | - Orpheus Kolokythas
- Department of Radiology, Kantonsspital Winterthur, Winterthur, Switzerland
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Johannes M Froehlich
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Vladimir-Prelog-Weg 1-5/10, 8093, Zurich, Switzerland
- Clinical Research Group, Klus Apotheke Zurich, Zurich, Switzerland
- Department of Radiology, Kantonsspital Winterthur, Winterthur, Switzerland
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Trivić I, Hojsak I. Evaluation and Treatment of Malnutrition and Associated Gastrointestinal Complications in Children with Cerebral Palsy. Pediatr Gastroenterol Hepatol Nutr 2019; 22:122-131. [PMID: 30899688 PMCID: PMC6416384 DOI: 10.5223/pghn.2019.22.2.122] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/31/2018] [Indexed: 01/25/2023] Open
Abstract
The majority of children with cerebral palsy (CP) have feeding difficulties and are especially prone to malnutrition. The early involvement of a multidisciplinary team should aim to prevent malnutrition and provide adequate nutritional support. Thorough nutritional assessment, including body composition, should be a prerequisite for the nutritional intervention. As in typically-developed children nutritional support should start with dietary advice and the modification of oral feeding, if safe and acceptable. However, for prolonged feeding, in the presence of unsafe swallowing and inadequate oral intake, enteral nutrition should be promptly initiated and early gastrostomy placement should be evaluated and discussed with parents/caregivers. Gastrointestinal problems (oropharyngeal dysfunction, gastroesophageal disease, and constipation) in children with CP are frequent and should be actively detected and adequately treated as they can further worsen the feeding process and nutritional status.
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Affiliation(s)
- Ivana Trivić
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia.,University of Zagreb, School of Medicine, Zagreb, Croatia.,Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia
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Yield and Examiner Dependence of Digital Rectal Examination in Detecting Impaction in Pediatric Functional Constipation. J Pediatr Gastroenterol Nutr 2018; 67:570-575. [PMID: 29601443 DOI: 10.1097/mpg.0000000000001969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Guidelines on functional constipation recommend digital rectal examination (DRE) when constipation is doubtful or with a suspicion of organic etiology. The guidelines do not clarify if DRE is mandatory to diagnose impaction. This study aims to determine the frequency of impaction detectable only on DRE among children satisfying Rome III criteria without requiring DRE and also the inter-observer influences on impaction detection by DRE. METHODS Children between 6 months to 13 years of age, presenting with history suggestive of constipation were assessed. After excluding those with suspicion of organic etiology, those who needed DRE for diagnosis of constipation and those who do not satisfy Rome III criteria without DRE, the rest who satisfied Rome III criteria were assessed for impaction by palpable fecoliths or constipation-associated fecal incontinence. Those without such impaction were randomized to 2 examiners for DRE to diagnose impaction, in the absence of contraindications. RESULTS Two hundred and thirty-three children were assessed. One hundred and sixty-nine satisfied Rome III without needing DRE. Forty-eight (28.4%) had impaction detectable without DRE. Among the rest, 28 (30.1%) had impaction by DRE. There was no difference between the frequency of impaction detected by the 2 examiners. Clinical characteristics were similar (P > 0.05) between those with impaction detectable by DRE and those without. CONCLUSIONS DRE does detect cases of impaction not discernible by other means. Such a finding may be comparable between examiners. These children may be identified by other clinical characteristics. The clinical significance of such a finding needs more understanding from the standpoint of therapeutic choices.
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Mínguez M, López Higueras A, Júdez J. Use of polyethylene glycol in functional constipation and fecal impaction. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:790-806. [PMID: 27871178 DOI: 10.17235/reed.2016.4571/2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate in an analytical and descriptive manner the evidence published so far on the use of polyethylene glycol (PEG), with or without electrolytes, in the management of functional constipation and the treatment of fecal impaction. METHODOLOGY Search on MEDLINE, EMBASE and Cochrane databases until May 2016 of all publications adjusted to the following terms: constipation AND/OR fecal impaction AND (PEG OR polyethylene glycol OR macrogol OR movicol OR idralax OR miralax OR transipeg OR forlax OR golytely OR isocolan OR mulytely) NOT colonoscopy. Critical reading of selected articles (English or Spanish), sorting their description according to group age (adult/pediatric age) and within those, in accordance with study features (efficacy evaluation versus placebo, doses query, safety, comparison with other laxatives, observational studies and monographic review articles of polyethylene glycol or meta-analysis). RESULTS Fifty-eight publications have been chosen for descriptive analysis; of them, 41 are clinical trials, eight are observational studies and nine are systematic reviews or meta-analysis. Twelve clinical trials evaluate PEG efficacy versus placebo, eight versus lactulose, six are dose studies, five compare polyethylene glycol with and without electrolytes, two compare its efficacy with respect to milk of magnesia, and the rest of the trials evaluate polyethylene glycol with enemas (two), psyllium (one), tegaserod (one), prucalopride (one), paraffin oil (one), fiber combinations (one) and Descurainia sophia (one). CONCLUSIONS Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability. These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term. They are as efficacious as enemas in fecal impaction, avoid the need for hospital admission and are well tolerated by patients (mainly when administered without electrolytes).
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Affiliation(s)
- Miguel Mínguez
- Servicio de Medicina Digestiva, Hospital Clínico de Valencia
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European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment. J Pediatr Gastroenterol Nutr 2017; 65:242-264. [PMID: 28737572 DOI: 10.1097/mpg.0000000000001646] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment. METHODS Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.
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Miquel I, Arancibia ME, Alliende F, Ríos G, Rodríguez L, Lucero Y, Saelzer E. [Intestinal cleaning for colonoscopy in children: effectiveness, adherence and adverse effects of schemes differentiated by age]. ACTA ACUST UNITED AC 2016; 88:216-222. [PMID: 27425772 DOI: 10.1016/j.rchipe.2016.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 06/13/2016] [Indexed: 10/21/2022]
Abstract
Adequate intestinal cleanliness is crucial to achieve optimal colonoscopy performance. Several bowel preparation (BP) schemes have been proposed, but there is still no consensus as regards which is the most suitable in paediatric patients. OBJECTIVE To describe the effectiveness, adherence, and adverse effects of BP protocols differentiated by age group in paediatric patients subjected to colonoscopy. PATIENTS AND METHOD Prospective, study that included patients < 18 years subjected to colonoscopy. BP protocols differentiated by age group were indicated as follows: < 6 m (glycerine suppository); 6 m-3y 11 m (poly-ethylene-glycol (PEG 3350 without electrolytes); 4y-9y 11 m (PEG 3350 without electrolytes + bisacodyl); 10 y-18 y (PEG 3350 with electrolytes). Demographic, clinical information, adherence and adverse effects were registered. Effectiveness was determined using a validated scale (Boston modified) during colonoscopy. RESULTS A total of 159 patients were included, of which 87 (55%) were males, and with a median age of 4 years (range 1 m-17 years). Seventy eight percent of patients achieved successful BP. The higher effectiveness was observed in the groups of < 6 m (96%) and 10-18 y (91%). Constipation was significantly more frequent (29%) in the 4 yo-9 yo 11 m in which lower effectiveness was observed (69%). Good adherence was observed in 87% of patients. Adverse effects were observed in a third of patients, although they were mild and did not lead to the suspension of the BP. CONCLUSIONS Satisfactory results were achieved with the BP schemes used, with a successful BP being obtained in 4 out of 5 patients. Results were different between groups, which is probably related to previous bowel transit and indicated medication.
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Affiliation(s)
- Isabel Miquel
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | | | | | - Gloria Ríos
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Lorena Rodríguez
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Yalda Lucero
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Eric Saelzer
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
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Abstract
OBJECTIVES Electrolyte-free polyethylene glycol powder (PEG-3350) has been widely used for colonoscopy preparation (prep); however, limited safety data on electrolyte changes exists with 1-day prep regimens. The primary aim of this study was to determine the proportion of patients with significant serum chemistry abnormalities before and at the time of colonoscopy. Secondary aims included evaluation of prep tolerance and bowel cleansing efficacy. METHODS We performed a prospective descriptive observational study of pediatric patients scheduled for outpatient colonoscopy who received our standard 1-day, weight-based 4 g/kg PEG-3350 prep with a single stimulant laxative dose and had serum chemistry testing within 60 days before and at the time of colonoscopy. A standardized bowel cleanliness tool (Aronchick scale) was completed by the endoscopist. RESULTS One hundred fifty-five patients had serum electrolytes data pre- and postprep. Comparison of each patient's chemistries demonstrated statistical equivalence with the 1 exception of blood urea nitrogen levels (P = 0.56). Hypokalemia was detected postprep in 37 subjects (24%), but none had a serum level <3.3 mmol/L, which was deemed to be of no clinical significance. Five patients were hypoglycemic post prep; 3 were 7 years or younger (P = 0.02). The colon cleanliness rating was excellent or good in 77% and suboptimal in 23% of patients. CONCLUSIONS A 1-day, weight-based PEG-3350 bowel prep in children appears safe. Changes in electrolyte levels and renal function were not clinically significant. Children of 7 years or younger seem to be at a higher risk of hypoglycemia compared with older children.
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Practice patterns of pediatricians and trainees for the management of functional constipation compared with 2006 NASPGHAN guidelines. J Pediatr Gastroenterol Nutr 2015; 60:308-11. [PMID: 25714574 DOI: 10.1097/mpg.0000000000000591] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition has formulated guidelines for managing functional constipation. There have been no studies that have investigated how pediatricians apply the constipation guideline since it was revised in 2006. The purpose of this study was to examine how pediatricians approach functional constipation and how closely their approaches adhere to the guidelines. METHODS An anonymous multiple-choice questionnaire was developed by general pediatricians and pediatric gastroenterologists. This was distributed to pediatricians and pediatric residents at 7 academic institutions, and to the American Academy of Pediatrics section on medical students, residents, and fellowship trainees mailing list. RESULTS A total of 1202 responses were received (952 trainees, 250 attendings). Of these, 84.3% reported being unfamiliar/slightly familiar with the guidelines. The most common initial interventions for constipation without fecal incontinence included fluids (92.1%), fiber (89.5%), juice (77.7%), behavioral interventions (71.2%), follow-up (53.4%), and reducing constipating foods (50.1%). The most common initial interventions for constipation with fecal incontinence included bowel cleanout (73.4%), maintenance medication (70.0%), fluids (67.9%), behavioral interventions (67.6%), fiber (66.1%), and follow-up (57.8%). Osmotics were the most commonly prescribed as needed (83.0%) and maintenance medications (96.8%), with stimulants prescribed PRN by 35.6% and as maintenance by 16.8%. Some individuals (39.7%) reported concern that osmotics could result in dependence, addiction, or electrolyte imbalances, compared with 73.0% for stimulants. CONCLUSIONS Our results show that more education regarding medication in functional constipation is necessary, including the use of medication reducing time to remission, the necessity of disimpaction, and misconceptions regarding adverse effects.
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Abstract
Constipation is a common and chronic problem in children worldwide. Long-term use of laxatives is necessary for successful treatment of chronic constipation. Commonly used laxatives in children include milk of magnesia, lactulose, mineral oil, and polyethylene glycol (PEG). Recent studies report the efficacy and safety of PEG for the long-term treatment of constipation in children. Because of its excellent patient acceptance, PEG is being used widely in children for constipation. In this commentary, we review the recently published pediatric literature on the efficacy, safety, and patient acceptance of PEG. We also assess the role of PEG in childhood constipation by comparing it with other laxatives in terms of efficacy, safety, patient acceptance, and cost.
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Bush NC, Shah A, Barber T, Yang M, Bernstein I, Snodgrass W. Randomized, double-blind, placebo-controlled trial of polyethylene glycol (MiraLAX®) for urinary urge symptoms. J Pediatr Urol 2013; 9:597-604. [PMID: 23127806 PMCID: PMC3641652 DOI: 10.1016/j.jpurol.2012.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 10/09/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children. PATIENTS AND METHODS Patients aged >3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parent's perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB. RESULTS Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p < 0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms. CONCLUSIONS Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.
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Affiliation(s)
- Nicol Corbin Bush
- Department of Pediatric Urology, University of Texas Southwestern Medical Center, Dallas, TX 75207, USA.
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22
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Abstract
Constipation is a common problem in children worldwide. It can also be a chronic problem persisting for many months to years. Successful treatment of constipation requires long-term use of laxatives. Commonly used laxatives in children include milk of magnesia, lactulose, mineral oil, and polyethylene glycol. Compared with other laxatives, polyethylene glycol (with and without electrolytes) is a relatively new laxative used during the last decade. Recent studies report excellent efficacy and safety of polyethylene glycol for the long-term treatment of constipation in children. Because of excellent patient acceptance, polyethylene glycol has become a preferred choice of laxative for many practitioners. This article reviews the recently published pediatric literature on biochemistry, efficacy, safety, patient acceptance, and pharmacoeconomics of polyethylene glycol.
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Infante Pina D, Segarra Cantón O, Vilalta Casas R, Carnicer de la Pardina J, López Liñán MJ, Molera Busoms C. [Efficacy, tolerance and safety of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children]. An Pediatr (Barc) 2013; 80:278-84. [PMID: 23856223 DOI: 10.1016/j.anpedi.2013.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To assess the renal safety of treatment with polyethylene glycol 3350 with electrolytes at 1, 3 and 6 months, its gastrointestinal tolerance and dose effectiveness. PATIENTS AND METHODS Three groups of 30 healthy patient aged 2-10 years (mean 6.2 years) who suffered functional constipation (Rome III criteria) with 1, 3 and 6 months of treatment were evaluated. Efficacy was evaluated by the change in the number of stools per week and stool consistency (Bristol scale). Urine screens, sodium and osmolality, were performed at the beginning and after 1, 3 and 6 months of treatment. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed on the one-month treatment group. RESULTS The mean dose was 0.37g/kg/day (range 0.18 to 0.8) titrated according to age, weight and response. The number of stools per week during treatment (2.4±0.64) showed a significant difference (P<.001) vs (6.21±1.5) after treatment. There was also a significant difference in the Bristol scale score (1.9±0.75 vs 4.9±1.1 [P<.001]). The mean sodium intake was 112mg (5mg/kg/day [range 4-12mg/kg/day]). The values of sodium and urine osmolality were normal in all groups with no statistical difference compared to normal control values (90 healthy children without treatment). NIRA values were normal in all patients. The hydrogen breath test was normal with a median of 7ppm. CONCLUSION There were no adverse renal biochemical parameters or gastrointestinal disorders. Tolerance and efficacy was shown to be optimal. Polyethylene glycol 3350 with electrolytes can be safely recommended for the treatment of functional constipation in children in the short and long term.
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Affiliation(s)
- D Infante Pina
- Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica, Hospital Universitario Materno-Infantil Vall d'Hebron, Barcelona, España.
| | - O Segarra Cantón
- Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica, Hospital Universitario Materno-Infantil Vall d'Hebron, Barcelona, España
| | - R Vilalta Casas
- Servicio de Nefrología Pediátrica, Hospital Universitario Materno-Infantil Vall d'Hebron, Barcelona, España
| | - J Carnicer de la Pardina
- Unidad de Gastroenterología, Servicio de Pediatría, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, España
| | - M J López Liñán
- Unidad de Gastroenterología, Servicio de Pediatría, Hospital de Terrassa, Terrassa, Barcelona, España
| | - C Molera Busoms
- Unidad de Gastroenterología, Servicio de Pediatría, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, España
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Elitsur R, Butcher L, Vicki L, Elitsur Y. Polyethylene glycol 3350 based colon cleaning protocol: 2 d vs 4 d head to head comparison. World J Gastrointest Endosc 2013; 5:165-168. [PMID: 23596539 PMCID: PMC3627839 DOI: 10.4253/wjge.v5.i4.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 01/06/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare between 2 and 4 d colon cleansing protocols.
METHODS: Children who were scheduled for colonoscopy procedure (2010-2012) for various medical reasons, were recruited from the pediatric gastroenterology clinic at Marshall University School of Medicine, Huntington, WV. Exclusion criteria were patients who were allergic to the medication used in the protocols [polyethylene glycol (PEG) 3350, Bisacodyl], or children with metabolic or renal diseases. Two PEG 3350 protocols for 4 d (A) and 2 d (B) were prescribed as previously described. A questionnaire describing the volume of PEG consumed, clinical data, and side effects were recorded. Colon preparation was graded by two observers according to previously described method. Main outcome measurements: Rate of adequate colon preparation.
RESULTS: A total of 78 patients were considered for final calculation (group A: 40, group B: 38). Age and stool consistency at the last day was comparable in both groups, but the number of stools/day was significantly higher in group B (P = 0.001). Adequate colon preparation was reached in 57.5% (A) and 73.6% (B), respectively (P = 0.206). Side effects were minimal and comparable in both groups. There was no difference in children’s age, stool characteristics, or side effects between the children with adequate or inadequate colon preparation. Correlation and agreement between observers was excellent (Pearson correlation = 0.972, kappa = 1.0).
CONCLUSION: No difference between protocols was observed, but the 2 d protocol was superior for its shorter time. Direct comparison between different colon cleansing protocols is crucial in order to establish the “gold standard” protocol for children.
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Prospective evaluation of 1-day polyethylene glycol-3350 bowel preparation regimen in children. J Pediatr Gastroenterol Nutr 2013; 56:220-4. [PMID: 22744195 DOI: 10.1097/mpg.0b013e31826630fc] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of the present study was to evaluate efficacy, safety, and tolerability of a pediatric colonoscopy bowel preparation regimen composed of polyethylene glycol-3350 (PEG-3350) and a sports drink completed in a few hours. METHODS A prospective, open-label trial of a colonoscopy bowel preparation in children ages 8 to 18 years that included 238 g of PEG-3350 mixed with 1.9 L of Gatorade completed in a few hours. Efficacy was determined using the Boston Bowel Preparation Scale. Basic metabolic profiles and questionnaires were obtained that assessed for safety, adverse effects, tolerability, and patient acceptability. RESULTS Forty-six patients completed the study. Patients were predominately boys (56.5%) with a mean age of 14.50 years (SD ± 2.9 years). Forty-three (93.5%) were able to complete the regimen. All of the colonoscopies were completed to the cecum and 84% had terminal ileum visualization. Seventy-seven percent were found to be effective preparations. Nausea/vomiting were the most common reported adverse effect (60%) followed by abdominal pain/cramping (44%) and fatigue/weakness (40%). Overall, the regimen was acceptable with 1 exception being the large volume to drink. There were no clinically significant changes in basic metabolic profiles, although there was a statistically significant decrease in the mean potassium (0.16 mEq/L; P = 0.016), blood urea nitrogen (2.68 mg/dL; P < 0.0001), and carbon dioxide (1.89 mmol/L; P < 0.0001). CONCLUSIONS This study demonstrated that PEG-3350 + Gatorade administered in a few hours is an effective, safe, and moderately tolerable bowel preparation regimen for colonoscopy in children.
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Rajindrajith S, Devanarayana NM, Benninga MA. Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management. Aliment Pharmacol Ther 2013; 37:37-48. [PMID: 23106105 DOI: 10.1111/apt.12103] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 05/23/2012] [Accepted: 10/02/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Faecal incontinence (FI) in children is a significant gastrointestinal problem, with great personal and social impacts. It is characterised by recurrent loss of faecal matter into the underwear. Both functional and organic causes contribute to its aetiology with the former predominating. AIM To review the epidemiology, pathophysiology, clinical evaluation and management of functional faecal incontinence in children. METHODS A PubMed search was conducted using search terms f(a)ecal incontinence, and encopresis. Articles on epidemiology, pathophysiology, clinical evaluation, investigation and management of functional FI in children were retrieved and assessed. RESULTS Community prevalence of this distressing problem ranges from 0.8% to 7.8% globally. Male: female ratio varies from 3:1 to 6:1. The diagnosis of FI is often based on established clinical criteria. The majority (82%) have constipation associated functional FI. Biopsychosocial factors play a crucial role in the pathogenesis. Limited physiological testing of anorectal function is recommended in the diagnostic procedures, particularly in children with atypical symptoms and possible organic disorders. Management of FI needs a multidisciplinary approach which includes establishment of an effective doctor-patient partnership, understanding the underlying mechanisms, pharmacotherapy and behavioural treatment. Approximately 15% of children with functional nonretentive faecal incontinence (FNRFI) had the same symptoms at the age of 18 years. CONCLUSION Significant therapeutic advances have been made for retentive faecal incontinence, but treatment options for functional nonretentive faecal incontinence are limited. Limited long-term outcome data show that the majority outgrow faecal incontinence. A substantial proportion of children progress to adulthood with faecal incontinence.
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Affiliation(s)
- S Rajindrajith
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
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Savino F, Viola S, Erasmo M, Di Nardo G, Oliva S, Cucchiara S. Efficacy and tolerability of peg-only laxative on faecal impaction and chronic constipation in children. A controlled double blind randomized study vs a standard peg-electrolyte laxative. BMC Pediatr 2012; 12:178. [PMID: 23152962 PMCID: PMC3511173 DOI: 10.1186/1471-2431-12-178] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 11/08/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND PEG-based laxatives are considered today the gold standard for the treatment of constipation in children. PEG formulations differ in terms of composition of inactive ingredients which may have an impact on acceptance, compliance and adherence to treatment. We therefore compared the efficacy, tolerability, acceptance and compliance of a new PEG-only formulation compared to a reference PEG-electrolyte (PEG-EL) formulation in resolving faecal impaction and in the treatment of chronic constipation. METHODS Children aged 2-16 years with functional chronic constipation for at least 2 months were randomized to receive PEG-only 0.7 g/kg/day in 2 divided doses or 6.9 g PEG-EL 1-4 sachets according to age for 4 weeks. Children with faecal impaction were randomized to receive PEG-only 1.5/g/kg in 2 divided doses until resolution or for 6 days or PEG-EL with an initial dose of 4 sachets and increasing 2 sachets a day until resolution or for 7 days. RESULTS Ninety-six children were randomized into the study. Five patients withdrew consent before starting treatment. Three children discontinued treatment for refusal due to bad taste of the product (1 PEG-only, 2 PEG-EL); 1 (PEG-EL) for an adverse effect (abdominal pain). Intent-to-treat analysis was carried out in 49 children in the PEG-only group and 42 in the PEG-EL group.No significant differences were observed between the two treatment groups at baseline.Adequate relief of constipation in terms of normalized frequency and painless defecation of soft stools was achieved in all patients in both groups. The number of stools/week was 9.2 ± 3.2 (mean ± SD) in the PEG-only group and 7.8 ± 2.4 in the PEG-EL group (p = 0.025); the number of days with stool was 22.4 ± 5.1 in the PEG-only group and 19.6 ± 7.2 in the PEG-EL group (p = 0.034).In the PEG-only group faecaloma resolution was observed in 5 children on the second day and in 2 children on the third day, while in the PEG-EL group it was observed in 2 children on the second day, in 3 children on the third day and in 1 child on the fifth day.Only 2 patients reported mild treatment-related adverse events: 1 child in the PEG-only group had diarrhoea and vomiting and 1 child in the PEG-EL group had abdominal pain requiring treatment discontinuation. The PEG-only preparation was better tolerated as shown by the lower frequency of nausea than in the PEG-EL group.In the PEG-only group, 96% of patients did not demonstrate any difficulties associated with treatment, as compared with 52% of patients in the PEG-EL group (p < 0.001). Also, the PEG-only formulation taste was better than that of PEG-EL (p < 0.001). The difference between the percentage of subjects who took > 80% of the prescribed dose was in favour of the PEG-only group (98% vs. 88%), though it did not reach a conventional statistical level (p = 0.062). CONCLUSION PEG-only was better tolerated and accepted than PEG-EL in children with chronic constipation. At the higher PEG doses recommended by the manufactures children in the PEG-only group had higher and more regular soft stool frequency than PEG-EL.
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Affiliation(s)
- Francesco Savino
- Department of Pediatrics 1, "Regina Margherita" Children's Hospital, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza della Città di Torino, Turin, Italy.
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Quitadamo P, Coccorullo P, Giannetti E, Romano C, Chiaro A, Campanozzi A, Poli E, Cucchiara S, Di Nardo G, Staiano A. A randomized, prospective, comparison study of a mixture of acacia fiber, psyllium fiber, and fructose vs polyethylene glycol 3350 with electrolytes for the treatment of chronic functional constipation in childhood. J Pediatr 2012; 161:710-5.e1. [PMID: 22677568 DOI: 10.1016/j.jpeds.2012.04.043] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 03/14/2012] [Accepted: 04/23/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To compare the effectiveness of a mixture of acacia fiber, psyllium fiber, and fructose (AFPFF) with polyethylene glycol 3350 combined with electrolytes (PEG+E) in the treatment of children with chronic functional constipation (CFC); and to evaluate the safety and effectiveness of AFPFF in the treatment of children with CFC. STUDY DESIGN This was a randomized, open label, prospective, controlled, parallel-group study involving 100 children (M/F: 38/62; mean age ± SD: 6.5 ± 2.7 years) who were diagnosed with CFC according to the Rome III Criteria. Children were randomly divided into 2 groups: 50 children received AFPFF (16.8 g daily) and 50 children received PEG+E (0.5 g/kg daily) for 8 weeks. Primary outcome measures were frequency of bowel movements, stool consistency, fecal incontinence, and improvement of other associated gastrointestinal symptoms. Safety was assessed with evaluation of clinical adverse effects and growth measurements. RESULTS Compliance rates were 72% for AFPFF and 96% for PEG+E. A significant improvement of constipation was seen in both groups. After 8 weeks, 77.8% of children treated with AFPFF and 83% of children treated with PEG+E had improved (P = .788). Neither PEG+E nor AFPFF caused any clinically significant side effects during the entire course of the study period. CONCLUSIONS In this randomized study, we did not find any significant difference between the efficacy of AFPFF and PEG+E in the treatment of children with CFC. Both medications were proved to be safe for CFC treatment, but PEG+E was better accepted by children.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, University "Federico II," Naples, Italy
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Abstract
Constipation is a common clinical problem. Initial management of chronic constipation should include lifestyle maneuvers, and increased fiber and fluids. Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide were all more effective than placebo for treating chronic idiopathic constipation. Many commonly used agents lack quality evidence supporting their use.
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Affiliation(s)
- Meredith Portalatin
- Department of Gastroenterology, Ochsner Clinic Foundation, New Orleans, Louisiana.
| | - Nathaniel Winstead
- Department of Gastroenterology, Ochsner Clinic Foundation, New Orleans, Louisiana.
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Wang Y, Wang B, Jiang X, Jiang M, Xu C, Shao C, Jia L, Huang Z, Xu X, Liu H, Shang L. Polyethylene glycol 4000 treatment for children with constipation: A randomized comparative multicenter study. Exp Ther Med 2012; 3:853-856. [PMID: 22969980 DOI: 10.3892/etm.2012.491] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 01/20/2012] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the efficacy and safety of polyethylene glycol 4000 (PEG 4000) for the treatment of constipation in children over 8 years of age. A total of 216 children from 7 hospitals were enrolled. A total of 105 patients received oral PEG 4000 (20 g/day) and 111 patients received oral lactulose (15 ml/day) for 2 weeks. The stool frequency, stool consistency and abdominal pain of the patients were monitored. In the PEG group, following one week and two weeks of treatment, the median weekly stool frequency improved from 2 times prior to treatment to 6 and 7 times, respectively, following treatment. The clinical remission rates of the PEG and lactulose groups following one week of treatment were 70.48 and 39.64%, respectively, and following two weeks of treatment were 72.38 and 41.44%, respectively. Abdominal pain disappeared in 74.6% of patients following two weeks of PEG 4000 treatment. No significant clinical adverse effects or abnormalities in the laboratory tests were observed in the two treatment groups. In conclusion, PEG 4000 is a safe and more effective drug compared to lactulose for the treatment of constipation in children.
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Affiliation(s)
- Yishi Wang
- Department of Pediatrics, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038
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Abstract
BACKGROUND Constipation occurs in children receiving chemotherapy for cancer but there are no data about prevalence, risk factors, and severity of constipation in this group of children. METHODS We prospectively studied 61 children receiving chemotherapy for cancer. We administered questionnaires to children and parents and collected data on demographics, chemotherapy, and bowel movement pattern during chemotherapy. We used North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition criteria for the diagnosis of constipation. Parental perception of constipation as a problem and impact on lifestyle during chemotherapy were assessed on a 0 to 3 scale with 0 being no problem, 1 minor, 2 significant, and 3 being a major problem. RESULTS Thirty-five children (57%) had acute constipation lasting for 2 or more weeks during chemotherapy. Several risk factors were analyzed and only combined use of vincristine and opiates emerged as significant risk factor for the development of constipation. In children with constipation, 15 of 35 parents (43%) perceived constipation as a major/significant problem and 8 children and their parents (23%) perceived constipation having a major/significant impact on lifestyle during chemotherapy. CONCLUSIONS Acute constipation was diagnosed in 57% of children receiving chemotherapy for cancer. Combined use of vincristine and opiates was associated with the development of constipation. Constipation can be a significant problem with a negative impact on lifestyle during chemotherapy and needs aggressive management.
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Phatak UP, Johnson S, Husain SZ, Pashankar DS. Two-day bowel preparation with polyethylene glycol 3350 and bisacodyl: a new, safe, and effective regimen for colonoscopy in children. J Pediatr Gastroenterol Nutr 2011; 53:71-4. [PMID: 21694539 DOI: 10.1097/mpg.0b013e318210807a] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To assess the safety, efficacy, and acceptance of a 2-day bowel preparation with polyethylene glycol (PEG) 3350 without electrolytes and bisacodyl for colonoscopy in children. PATIENTS AND METHODS In a prospective study, 111 children of mean age 11.9 years were given 2 g/kg of PEG and a 5-mg tablet of bisacodyl daily for 2 days before colonoscopy. Stool frequency, consistency, and adverse effects were monitored for the duration of the bowel preparation. Compliance and quality of colonic preparation were assessed on the day of the colonoscopy. RESULTS The average daily stool frequency increased from a baseline of 2, to 4* on day 1, and 6.5* on day 2 of the bowel preparation (*P < 0.001 for difference vs baseline). The colonic preparations were rated as excellent or good in 92% and 93% of the patients in the right and left colon, respectively. Adverse effects were mild nausea (19%), abdominal pain (11%), and vomiting (4%). The compliance was rated as excellent in 95% of the patients. CONCLUSIONS A 2-day bowel preparation with PEG and bisacodyl is safe, effective, and well accepted for colonoscopy in children without any major adverse effects.
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Affiliation(s)
- Uma P Phatak
- Division of Gastroenterology, Department of Pediatrics, Yale University, New Haven, CT 06520, USA
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Abstract
Constipation remains a frequent presentation to paediatricians, with significant health resource implications. We present a practical guide to the management of paediatric constipation and evaluate the current evidence for treatment regimens, to help the clinician in treating a condition that can be distressing and has a significant impact on affected families.
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Affiliation(s)
- Nadeem A Afzal
- Paediatric Department, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Rd, Southampton, Hants, SO16 6YD, England.
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Gomes PB, Melo MDCB, Duarte MA, Torres MRF, Xavier AT. [NO TITLE AVAILABLE]. REVISTA PAULISTA DE PEDIATRIA 2011. [DOI: 10.1590/s0103-05822011000200017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Rever a literatura sobre o uso do polietile-noglicol no tratamento da constipação intestinal crônica funcional em crianças. FONTES DOS DADOS: Foram selecionadas publicações entre 1998 e 2009, utilizando as bases de dados Medline e SciELO. Foram incluídos estudos relevantes referentes à constipação, ao uso do polietilenoglicol em adultos, a diretriz recente da NASPGHAN e os critérios de ROMA III relativos às doenças intestinais funcionais. SÍNTESE DOS DADOS: O tratamento da constipação intestinal em crianças é dividido em várias etapas não consecutivas. O uso prolongado de laxativos é uma dessas etapas; no entanto, as opções terapêuticas são restritas. Os efeitos adversos e a dificuldade de aceitação pela criança são os principais problemas que surgem com o uso prolongado de laxativos. O polietilenoglicol é um laxativo osmótico utilizado para o tratamento da constipação, com absorção de 0,2%, insípido e inodoro, disponível com os pesos moleculares 3350 e 4000 Dalton, com ou sem adição de eletrólitos. Estudos randomizados e controlados demonstraram ser o polietilenoglicol um agente efetivo na melhora dos sintomas, além de ser seguro, pois não foram relatados efeitos colaterais significativos. CONCLUSÕES: O polietilenoglicol é superior aos outros agentes osmóticos em relação ao sabor e à aceitação pelas crianças. O uso diário é seguro e efetivo e pode ser considerado uma opção terapêu-tica na constipação intestinal crônica funcional em pediatria.
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Infante Pina D, Miserachs Barba M, Segarra Canton O, Alvarez Beltrán M, Redecillas Ferreiro S, Vilalta Casas R, Nieto Rey JL. [Safety and efficacy of polyethylene glycol 3350 plus electrolytes for the treatment of functional constipation in children]. An Pediatr (Barc) 2011; 75:89-95. [PMID: 21429833 DOI: 10.1016/j.anpedi.2011.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Accepted: 01/23/2011] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Polyethylene glycol 3350 plus electrolytes (PEG+E) efficacy has been validated in some studies, but not many have evaluated its safety in children. The aim of our study was to evaluate the safety; renal, malabsorption or excessive production of gas and efficacy of PEG+E treatment in our paediatric population. PATIENTS AND METHODS Fifteen patients who suffered functional constipation (Rome III criteria) were evaluated. Median age was 6.2 years (r 2-9). All patients had normal renal function. PEG+E were administered for 4 weeks (4WP). The mean dose was 0.44 g/kg/day, titrated according to age, weight and response. Urine screens (sodium and osmolality) were performed at the beginning and 4WP. Stool sample NIRA (near-infrared reflectance analysis) and hydrogen breath test analysis samples were performed at 4WP. To analyse the efficacy of the treatment, the number of stools per week and stool form type (Bristol stool scale) were recorded. RESULTS The number of stools per week was higher after 4 weeks (2.46 ± 0.71 vs 5.29 ± 1.68, P<.001), as well as the stool form score (2.47 ± 1.24 vs 4.5 ± 0.91, P<.001). No statistical differences were obtained between urine sodium and urine osmolality values at the beginning and 4WP. After 4WP the NIRA median values were normal in all patients [fat 4.45% (range (r) 3.6-7.09); nitrogen 0.78% (r 0.4-1); sugars 1.4% (r 0.47-2.35) and water 68% (r 59-74)]. Median breath hydrogen test was 7 ppm (r 2-18). CONCLUSIONS No adverse effects on biochemistry values or gastrointestinal disturbances were observed. PEG+E can be recommended for the treatment of functional constipation in children.
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Affiliation(s)
- D Infante Pina
- Unidad Gastroenterología, Hepatología y Nutrición Pediátrica, Hospital Universitario Materno Infantil Vall d'Hebron, Barcelona, España.
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Rajindrajith S, Devanarayana NM. Constipation in children: novel insight into epidemiology, pathophysiology and management. J Neurogastroenterol Motil 2011; 17:35-47. [PMID: 21369490 PMCID: PMC3042216 DOI: 10.5056/jnm.2011.17.1.35] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 12/24/2010] [Accepted: 12/31/2010] [Indexed: 12/12/2022] Open
Abstract
Constipation in children is a common health problem affecting 0.7% to 29.6% children across the world. Exact etiology for developing symptoms is not clear in children and the majority is considered to have functional constipation. Alteration of rectal and pelvic floor function through the brain-gut axis seems to play a crucial role in the etiology. The diagnosis is often a symptom-based clinical process. Recently developed Rome III diagnostic criteria looks promising, both in clinical and research fields. Laboratory investigations such as barium enema, colonoscopy, anorectal manometry and colonic transit studies are rarely indicated except in those who do not respond to standard management. Treatment of childhood constipation involves several facets including education and demystification, toilet training, rational use of laxatives for disimpaction and maintenance and regular follow-up. Surgical options should be considered only when medical therapy fails in long standing constipation. Since most of the management strategies of childhood constipation are not evidence-based, high-quality randomized controlled trials are required to assess the efficacy of currently available or newly emerging therapeutic options. Contrary to the common belief that children outgrow constipation as they grow up, a sizable percentage continue to have symptoms beyond puberty.
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Affiliation(s)
- Shaman Rajindrajith
- Department of Pediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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González Jiménez D, Díaz Martin J, Bousoño García C, Jiménez Treviño S. Patología gastrointestinal en niños con parálisis cerebral infantil y otras discapacidades neurológicas. An Pediatr (Barc) 2010; 73:361.e1-6. [DOI: 10.1016/j.anpedi.2010.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 02/07/2010] [Accepted: 03/07/2010] [Indexed: 12/27/2022] Open
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Abstract
Colonoscopy is a routinely performed procedure in children and adolescents. Proper visualization of the intestinal mucosa, completion of the procedure, including examination of the terminal ileum, detection of pathological lesions, and therapeutic maneuvers, all are highly dependent on the quality of the bowel preparation. A significant proportion of patients, in some reports up to one third, are inadequately prepared for the examination, which leads to extended procedure time, incomplete examination, or need for repeat procedure. Aside from efficacy and safety, the most important aspects of colon preparation in pediatrics are ease of administration, palatability, dietary restriction, and minimization of disruption of daily routine. An ideal preparation does not exist and a wide variety of regimens are being used. Several of these have been investigated in pediatric clinical trials. This article reviews the published literature with an emphasis on the most commonly used agents, their mechanism of action, efficacy and ease of use, and safety.
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Abstract
Constipation is a common problem in children. It is also a long-term problem persisting for many months to years in children. Approximately 95% of childhood constipation is functional in nature without any obvious cause. Evaluation of a child with constipation requires a thorough history and physical examination. Hirschsprung's disease is an important cause of constipation arising in infancy and requires a thorough diagnostic evaluation and surgical treatment. Treatment of functional constipation in children requires a well-designed plan and a team approach involving the child, parents, and a health care provider. Treatment involves education of the family about constipation and encopresis, fecal disimpaction, and long-term maintenance therapy of laxatives and behavioral modification. Laxatives such as magnesium hydroxide, lactulose, and mineral oil have been used in children for a long time. A new laxative, polyethylene glycol 3350, has been used successfully in children with constipation and encopresis. Several novel therapeutic interventions have been tried for children presenting with intractable constipation, refractory to conventional treatment.
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Seinelä L, Sairanen U, Laine T, Kurl S, Pettersson T, Happonen P. Comparison of polyethylene glycol with and without electrolytes in the treatment of constipation in elderly institutionalized patients: a randomized, double-blind, parallel-group study. Drugs Aging 2010; 26:703-13. [PMID: 19685935 DOI: 10.2165/11316470-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Polyethylene glycol (PEG) is a commonly used osmotic laxative. PEG with electrolytes is mixed with water, but PEG without electrolytes can also be mixed with, for example, juice, coffee or tea, making it more palatable. Laxatives, including PEG, are commonly used by the elderly, particularly those living in institutions. Few clinical studies, however, have investigated the use of PEG in this population. OBJECTIVE To test whether PEG 4000 without electrolytes (hypotonic PEG) is at least as effective and safe as PEG 4000 with electrolytes (isotonic PEG) in elderly institutionalized constipated patients. The acceptability of the treatments was also compared. METHODS This randomized, double-blind, parallel-group study was conducted at ten private assisted-living facilities or communal nursing homes in Finland. Eligible patients were required to have used isotonic PEG at a stable dose without any other treatment for constipation (except for Plantago ovata seeds) for at least 2 weeks prior to a run-in period. After the 1-week run-in, 62 patients (mean age 86 years; range 66-99 years) were randomly either switched to receive hypotonic PEG or continued to receive isotonic PEG, both dissolved in water, 12 g once or twice daily or once every other day, for 4 weeks. Stool frequency, stool consistency, stool straining and gastrointestinal symptoms were recorded. Safety laboratory tests were conducted before and after the treatment period. Acceptability was assessed at the end of the study. RESULTS At week 4, mean (SD) weekly stool frequencies in the hypotonic and isotonic PEG groups were 8.5 (4.5) and 8.4 (3.6), respectively. The mean stool frequency ratio (95% CI) was 0.90 (0.74, 1.10); thus, the PEG products were considered equally effective. At week 4, the proportion of patients with soft or normal stool consistency was higher in the hypotonic PEG group than in the isotonic PEG group (70% vs 52%), but this difference was not statistically significant. There were no differences between the groups in stool straining or gastrointestinal symptoms. In the safety laboratory tests, no clinically significant differences between the groups were detected, although plasma sodium level was statistically significantly lower in the hypotonic PEG group at the end of the study (137.7 vs 138.9 mmol/L, respectively; p = 0.012). Most patients were willing to continue their study treatment (85% in the hypotonic PEG and 63% in the isotonic PEG group; p = 0.070). Compared with only 12% of the patients receiving hypotonic PEG, however, 31% of the patients in the isotonic PEG group rated the taste of the study treatment as bad or very bad (p = 0.101). CONCLUSION Hypotonic PEG solution is as effective as isotonic PEG in the treatment of constipation in elderly institutionalized patients. Both treatments appear safe, well tolerated and, when dissolved in water, well accepted by the majority of the patients. When desired, switching from isotonic to hypotonic PEG can safely take place in elderly individuals without compromising efficacy.
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Safder S, Demintieva Y, Rewalt M, Elitsur Y. Stool consistency and stool frequency are excellent clinical markers for adequate colon preparation after polyethylene glycol 3350 cleansing protocol: a prospective clinical study in children. Gastrointest Endosc 2008; 68:1131-5. [PMID: 18950761 DOI: 10.1016/j.gie.2008.04.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 04/14/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colon preparation for a colonoscopy in children is a difficult task because of the unpalatable taste and large volume of cleansing solution that needs to be consumed to ensure a clean colon. Consequently, an unprepared colon frequently occurs in routine practices, which causes early termination and a repeated procedure. OBJECTIVE (1) To assess the effectiveness of polyethylene glycol solution (PEG 3350) in preparing the colon of children scheduled for a colonoscopy and (2) to investigate clinical markers associated with an adequate colon preparation before a colonoscopy. PATIENTS A total of 167 children scheduled for a colonoscopy. DESIGN In a prospective study, children scheduled for a colonoscopy were given PEG 3350 solution (1.5 g/kg per day, up to 100 g/d) over a 4-day preparation period. Each day, a simple questionnaire that documents the amount of liquid consumed, adverse effects, and the number and consistency of stool was completed by the parents. After a colonoscopy procedure, the colon preparation was assigned a number grade. The data were later assessed and were compared to determine the association between the grade of cleansing and the frequency and/or consistency of stool during preparation. RESULTS Colon preparation was completed in 149 children, 133 of whom were adequately prepared. Inadequate preparation was found in 16 children; the procedure was terminated prematurely in 2 of these patients because of unacceptable conditions. No significant adverse effects were noted. A number of >or=5 stools/d, and liquid stool consistency in the last 2 days of preparation were associated with adequate colon preparation. CONCLUSIONS PEG 3350 solution is safe, efficacious, and tolerable for children. Stool frequency and consistency in the last 2 days of preparation were excellent markers (positive predictive value 91%-95%), which predict an adequately clean colon before a colonoscopy in children.
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Affiliation(s)
- Shaista Safder
- Department of Pediatrics, Gastroenterology Division, Joan C Edwards School of Medicine, Marshall University, Huntington, West Virginia 25701, USA
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Nijman RJM. Diagnosis and management of urinary incontinence and functional fecal incontinence (encopresis) in children. Gastroenterol Clin North Am 2008; 37:731-48, x. [PMID: 18794006 DOI: 10.1016/j.gtc.2008.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The ability to maintain normal continence for urine and stools is not achievable in all children by a certain age. Gaining control of urinary and fecal continence is a complex process, and not all steps and factors involved are fully understood. While normal development of anatomy and physiology are prerequisites to becoming fully continent, anatomic abnormalities, such as bladder exstrophy, epispadias, ectopic ureters, and neurogenic disturbances that can usually be recognized at birth and cause incontinence, will require specialist treatment, not only to restore continence but also to preserve renal function. Most forms of urinary incontinence are not caused by an anatomic or physiologic abnormality and, hence, are more difficult to diagnose and their management requires a sound knowledge of bladder and bowel function.
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Affiliation(s)
- Rien J M Nijman
- Department of Urology, University Medical Centre Groningen, Hanzeplein 1,9713 GZ Groningen, The Netherlands.
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Nurko S, Youssef NN, Sabri M, Langseder A, McGowan J, Cleveland M, Di Lorenzo C. PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial. J Pediatr 2008; 153:254-61, 261.e1. [PMID: 18534221 DOI: 10.1016/j.jpeds.2008.01.039] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2007] [Revised: 12/05/2007] [Accepted: 01/29/2008] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To establish the efficacy and best starting dose of polyethylene glycol (PEG)3350 in the short-term treatment of children with functional constipation. STUDY DESIGN Prospective, randomized, multicenter, double-blinded, placebo-controlled, dose-ranging study of PEG3350 in children with functional constipation. Patients were randomly assigned to either placebo or 0.2 g/kg per day, 0.4 g/kg per day, or 0.8 g/kg per day of PEG3350 after a 1 week run-in period, followed by 2 weeks of treatment. All received behavior modification. The primary outcome was the proportion of patients with a successful treatment response: >or=3 bowel movements (BM) in the second week. RESULTS 103 children (mean, 8.5 +/- 3.1 years) were enrolled. 77%, 74%, and 73% of the 0.2, 0.4, and 0.8 g/kg groups were successfully treated, as compared with 42% receiving placebo (P < .04). There was a significant increase in BM (P < .001) and straining improvement (P < .05) with the different PEG3350 doses. Stool consistency improved significantly for doses 0.4 g/kg or higher (P < .001). There was more abdominal pain and fecal incontinence in patients receiving 0.8 g/kg. PEG3350 was well tolerated. CONCLUSIONS This placebo-controlled study confirms the efficacy and safety of PEG3350 for the short-term treatment of children with functional constipation. We recommend a starting dose of 0.4 g/kg per day.
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Affiliation(s)
- Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, MA 02115, USA.
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Thomson MA, Jenkins HR, Bisset WM, Heuschkel R, Kalra DS, Green MR, Wilson DC, Geraint M. Polyethylene glycol 3350 plus electrolytes for chronic constipation in children: a double blind, placebo controlled, crossover study. Arch Dis Child 2007; 92:996-1000. [PMID: 17626140 PMCID: PMC2083581 DOI: 10.1136/adc.2006.115493] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of polyethylene glycol 3350 plus electrolytes (PEG+E) for the treatment of chronic constipation in children. DESIGN Randomised, double blind, placebo controlled crossover trial, with two 2-week treatment periods separated by a 2-week placebo washout. SETTING Six UK paediatric departments. PARTICIPANTS 51 children (29 girls, 22 boys) aged 24 months to 11 years with chronic constipation (lasting > or =3 months), defined as < or =2 complete bowel movements per week and one of the following: pain on defaecation on 25% of days; > or =25% of bowel movements with straining; > or =25% of bowel movements with hard/lumpy stools. 47 children completed the double blind treatment. MAIN OUTCOME MEASURES Number of complete defaecations per week (primary efficacy variable), total number of complete and incomplete defaecations per week, pain on defaecation, straining on defaecation, faecal incontinence, stool consistency, global assessment of treatment, adverse events and physical examination. RESULTS The mean number of complete defaecations per week was significantly higher for children on PEG+E than on placebo (3.12 (SD 2.05) v 1.45 (SD 1.20), respectively; p<0.001). Further significant differences in favour of PEG+E were observed for total number of defaecations per week (p = 0.003), pain on defaecation (p = 0.041), straining on defaecation (p<0.001), stool consistency (p<0.001) and percentage of hard stools (p = 0.001). Treatment related adverse events (all mild or moderate) occurred in similar numbers of children on PEG+E (41%) and placebo during treatment (45%). CONCLUSIONS PEG+E is significantly more effective than placebo, and appears to be safe and well tolerated in the treatment of chronic constipation in children.
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Affiliation(s)
- M A Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Western Bank, Sheffield, UK.
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Abstract
Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.
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Affiliation(s)
- Alexander von Gontard
- Klinik für Kinder- und Jugendpsychiatrie und Psychoterapie, Universitätsklinikum des Saarlandes, Homburg/Saar.
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Hardikar W, Cranswick N, Heine RG. Macrogol 3350 plus electrolytes for chronic constipation in children: a single-centre, open-label study. J Paediatr Child Health 2007; 43:527-31. [PMID: 17635680 DOI: 10.1111/j.1440-1754.2007.01116.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM A Macrogol 3350-based, iso-osmotic laxative has become available for the treatment of chronic constipation in adults. This open-label, non-randomised study aimed to evaluate the safety and efficacy of this preparation in the treatment of chronic constipation in children. METHODS Seventy-eight children, aged 2-11 years, with chronic constipation for greater than 3 months were enrolled. All children received Macrogol 3350 plus electrolytes for 12 weeks. The primary efficacy variable was the number of spontaneous defaecations per week. Secondary efficacy variables were faecal form, abdominal pain, rectal bleeding, pain on defaecation, straining, soiling, amount of stool, stool withholding and assessments of efficacy by the investigators and parents. Safety and compliance were also assessed. RESULTS The mean number of spontaneous defaecations per week increased from 1.4 +/- 0.55 (SD) at baseline to 6.8 +/- 3.45 after 14 days, and 7.1 +/- 3.45 at 12 weeks (P < 0.001). Similar improvements were found in the secondary efficacy variables. There was a significant reduction in reported abdominal pain from 53 (69%) children at baseline to 3 (4%) at the final visit (P < 0.0001). Similarly, 61 (79%) children had pain on defaecation at baseline, compared with 7 (9%) at the final visit (P < 0.0001). Treatment was well tolerated. Of 318 adverse events, 262 (82%) were considered mild, and 241 (76%) were deemed unrelated to treatment. Only 3 (4%) children were withdrawn because of poor compliance. CONCLUSIONS Macrogol 3350 plus electrolytes is a safe and effective treatment for constipation in children aged 2-11 years.
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Affiliation(s)
- Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia.
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Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2006; 43:405-7. [PMID: 16954970 DOI: 10.1097/01.mpg.0000232574.41149.0a] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Constipation is a common pediatric problem. To assist health care professionals who care for children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) previously published a clinical guideline based on an integration of medical evidence with expert opinion. To evaluate studies published since then, the NASPGHAN Constipation Guideline Committee performed a comprehensive and systematic review of the medical literature since 1997, to identify, review and rate the quality of new evidence. Based on this review, the recommendations of the original clinical guideline were reaffirmed with several modified according to the new evidence. Below is a summary of the evidence reviewed for this update. The complete revised guideline is available online in its entirety.
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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:e1-13. [PMID: 16954945 DOI: 10.1097/01.mpg.0000233159.97667.c3] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. The Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has formulated a clinical practice guideline for the management of pediatric constipation. The Constipation Guideline Committee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Guideline Committee also provided recommendations for management by the pediatric gastroenterologist.
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Loening-Baucke V, Pashankar DS. A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence. Pediatrics 2006; 118:528-35. [PMID: 16882804 DOI: 10.1542/peds.2006-0220] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes. METHODS Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical adverse effects and blood tests. RESULTS Thirty-nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycol-treated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol. CONCLUSIONS In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.
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