A comparative study: the efficacy of liquid paraffin and lactulose in management of chronic functional constipation

Efficacy of Probiotics Compared With Pharmacological Treatments for Maintenance Therapy for Functional Constipation in Children: A Systematic Review and Network Meta-analysis

CONTEXT

There has been an increase in randomized controlled trials (RCTs) comparing probiotics with various maintenance therapies, such as polyethylene glycol, lactulose, and mineral oil, to treat functional constipation in children.

OBJECTIVE

The aim was to compare probiotics with all other oral maintenance therapies for functional constipation in children and rank all treatments in terms of effectiveness in a network meta-analysis.

METHODS

RCTs were identified through systematically searching the MEDLINE, Scopus, EMBASE, and Cochrane Library databases, trial registries, and forward and backward citation searching. Within-study risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and confidence in the estimates was assessed using the CINeMA (Confidence in Network Meta-Analysis) framework. Random-effects network meta-analyses were conducted.

RESULTS

Data were pooled from 41 and 29 RCTs for network meta-analysis of defecation frequency and treatment success, respectively. Probiotics did not significantly increase the number of bowel movements per week when compared with any conventional treatment or placebo. A combination of mineral oil and probiotics was the most effective treatment for increasing defecation frequency (mean difference: 3.13; 95% confidence interval [CI]: 0.64, 5.63). The most effective treatments for increasing the risk of treatment success as compared with placebo were mineral oil (relative risk [RR]: 2.41; 95% CI: 1.53, 3.81) and a combined treatment of polyethylene glycol and lactulose (RR: 2.45; 95% CI: 1.21, 4.97). Confidence in the estimates ranged from very low to moderate.

CONCLUSION

Currently, there is no evidence to suggest that probiotics should be used as a standalone treatment for functional constipation in children. More high-quality studies are needed to evaluate different strains of probiotics and their potential benefit as an additional treatment component to conventional treatments. Mineral oil and polyethylene glycol were the most effective treatments to increase defecation frequency and treatment success rates and should remain the first line of treatment for children with functional constipation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no.

CRD42022360977 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=360977).

Faecal impaction in children aged 0-18 years: a systematic review and metanarrative analysis of definitions used

BACKGROUND

Faecal impaction is the result of functional constipation in the majority of cases. Surprisingly, a uniform definition for the term faecal impaction is lacking, leading to heterogeneity across study results.

AIM

To conduct a metanarrative systematic review to ascertain how trial studies define faecal impaction among children aged 0-18 years with functional constipation.

METHODS

We conducted a systematic metanarrative review to uncover what criteria are used to define faecal impaction and to recommend directions for creating a globally accepted definition. A comprehensive literature search was conducted using prominent databases, including CENTRAL, MEDLINE, Embase, WHO ICTR (international clinical trials registry) and ClinicalTrials.gov. All relevant publications of RCTs on both faecal impaction and functional constipation from inception to June 2024, including children aged 0-18 years without underlying organic aetiology, were included.

RESULTS

6211 studies were screened, of which 155 were reviewed for eligibility, 76 were included in the review and five are awaiting classification. Seven studies gave an explicit definition, with three referencing a previous consensus definition. 45 studies gave an implicit definition derived from their prescreening or exclusion criteria in a larger piece of research. Clinical assessment was the most common element of definitions, with a mixture of abdominal or rectal assessments reported in 44 studies. A further six studies suggested such clinical assessments are combined with radiographs, and one study reported a definition using radiographs alone. One study reported the duration of symptoms in a definition.

CONCLUSION

There is a clear lack of consensus for defining faecal impaction in children with functional constipation. Despite the clinical, diagnostic and prognostic importance of having a unified definition of faecal impaction, currently there seems to be no universally accepted definition.

Recent advances in treating constipation in children

INTRODUCTION

Functional constipation (FC) is a common childhood condition, diagnosed via the Rome IV criteria. Standard therapy includes lifestyle and dietary modification followed by initiation of osmotic laxative therapy. About 30% of children continue to experience symptoms related to FC despite appropriate management. New pharmacologic, surgical, and neuromodulatory therapies for FC are now available for use in adult and pediatric populations. In 2023, the first pharmacologic agent, linaclotide, obtained FDA approval for treatment of FC in children 6-17 years old.

AREAS COVERED

This article reviews current and emerging pharmacologic, surgical, and neuromodulation therapies for the management of FC in pediatric patients. Efficacy and safety data regarding each of these modalities was reviewed and discussed.

EXPERT OPINION

Advancements in therapeutics available for the management of FC necessitate further investigation on safety and efficacy in pediatric populations. Careful consideration should be taken in choosing an available treatment with limited pediatric evidence as adult and pediatric FC have different underlying pathophysiology and require a different therapeutic approach. Standardization of methodology and pediatric endpoints are needed to optimize ability to compare efficacy of different treatments. We predict the future of pediatric FC management will include a personalized approach to care, resulting in improved outcomes.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

An Update of Pharmacological Management in Children with Functional Constipation

Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.

Functional constipation in children: What physicians should know

Functional constipation (FC) is considered the most common functional gastrointestinal disorder in children with a pooled global prevalence of 14.4% (95% confidence interval: 11.2-17.6) when diagnosed based on the Rome IV criteria. Its pathophysiological mechanisms are thought be multifactorial and complicated, resulting in difficult management. Currently, the most effective medication, when used in parallel with toilet training, is osmotic laxatives. Children's adherence to medication and parental concern regarding long-term laxative use are the main contributors to treatment failure. Recently, novel therapies with a high safety profile have been developed, such as probiotics, synbiotics, serotonin 5-hydroxytryptamine 4 receptor agonists, chloride channel activators, and herbal and transitional medicines; nonetheless, well-designed research to support the use of these therapies is needed. This review aims to focus on multiple aspects of FC in children, including global prevalence, pathogenesis, diagnostic criteria, tools, as well as conventional and novel treatment options, such as non-pharmacological management, including adequate fiber and fluid intake, physiotherapy, or neuromodulators. We also report that in very difficult cases, surgical intervention may be required.

Childhood constipation: Current status, challenges, and future perspectives

Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.

Potential role of paraffin oil gastric lavage in acute aluminum phosphide poisoning: a randomized controlled trial

Aluminum phosphide (ALP) poisoning is a true medical emergency associated with high mortality. The lack of a specific antidote for ALP poisoning mandates searching for new treatment modalities. This study aimed to evaluate the effectiveness and safety of gastric decontamination by paraffin oil in cases with acute ALP poisoning. This study was a randomized, controlled, parallel-group, single-blind, phase II clinical trial conducted over a period of 6 months. Sixty-two patients with acute ALP poisoning were randomly allocated into two equivalent groups. In both groups, the standard ALP treatment was given. Gastric decontamination in the control group was performed by saline and sodium bicarbonate 8.4%, while in the intervention group, it was done by paraffin oil and sodium bicarbonate 8.4%. All patients were subjected to history taking, clinical examination, and laboratory investigations. The outcomes were evaluated. The median age of the studied patients was 20 years. Most of the studied cases were females, single, and from rural areas. The median delay time was 1 h. All patients included in the study alleged ingestion of ALP during suicidal attempts. Twelve hours after admission, many clinical and laboratory findings were significantly better in the intervention group. The need for intubation, mechanical ventilation, and total amount of vasopressors was significantly lower, and the mortality rate was non-significantly lower in the intervention group compared to the control. The median length of hospital stay was significantly shorter in the control group. Gastric decontamination with paraffin oil and sodium bicarbonate 8.4% could be valuable in reducing ALP poisoning severity, the need for intubation, mechanical ventilation, and vasopressors.

The Effect of Baru (Dypterix alata Vog.) Almond Oil on Markers of Bowel Habits in Hemodialysis Patients

Gastrointestinal symptoms are common in patients in hemodialysis treatment and were frequently associated with low intake of dietary fibers and liquids, oral iron supplementation, phosphate binders, and low level of physical activity. Thus, the aim of this study was to evaluate the effect of baru almond oil in comparison with mineral oil supplementation on bowel habits of hemodialysis patients. Thirty-five patients on hemodialysis (57% men, 49.9 ± 12.4 years) were enrolled in a 12-week single-blind clinical trial. Patients were allocated (1 : 2) by sex and age into (1) the mineral group: 10 capsules per day of mineral oil (500 mg each) or (2) the baru almond oil group: 10 capsules per day of baru almond oil (500 mg each). Bowel habits were assessed by the Rome IV criteria, Bristol scale, and self-perception of constipation. Food consumption, physical activity level, and time spent sitting were also evaluated at the baseline and at the end of the study. After 12 weeks of supplementation, the baru almond oil group showed reduced Rome IV score (6.1 ± 5.5 vs 2.8 ± 4.3, p=0.04) and the straining on the evacuation score (1.2 ± 1.4 vs 0.4 ± 0.7; p=0.04), while the mineral group did not show any change in the parameters. The frequency of self-perception of constipation was lower in the baru almond oil group after intervention (45.0% vs 15.0%, p=0.04). Baru almond oil improved bowel habit and the straining on evacuation in hemodialysis patients.

Comparison of efficacy of pharmacological treatments for chronic idiopathic constipation: a systematic review and network meta-analysis

OBJECTIVE

To compare efficacy of pharmacotherapies for chronic idiopathic constipation (CIC) based on comparisons to placebo using Bayesian network meta-analysis.

DATA SOURCES

We conducted searches (inception to May 2015) of MEDLINE, EMBASE, Scopus and Cochrane Central, as well as original data from authors or drug companies for the medications used for CIC.

STUDY SELECTION

Phase IIB and phase III randomised, placebo-controlled trials (RCT) of ≥4 weeks' treatment for CIC in adults with Rome II or III criteria for functional constipation; trials included at least one of four end points.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently evaluated all full-text articles that met inclusion criteria and extracted data for primary and secondary end points, risk of bias and quality of evidence.

OUTCOMES

Primary end points were ≥3 complete spontaneous bowel movements (CSBM)/week and increase over baseline by ≥1 CSBM/week. Secondary end points were change from baseline (Δ_b) in the number of SBM/week and Δ_b CSBM/week.

RESULTS

Twenty-one RCTs (9189 patients) met inclusion and end point criteria: 9 prucalopride, 3 lubiprostone, 3 linaclotide, 2 tegaserod, 1 each velusetrag, elobixibat, bisacodyl and sodium picosulphate (NaP). All prespecified end points were unavailable in four polyethylene glycol studies. Bisacodyl, NaP, prucalopride and velusetrag were superior to placebo for the ≥3 CSBM/week end point. No drug was superior at improving the primary end points on network meta-analysis. Bisacodyl appeared superior to the other drugs for the secondary end point, Δ_b in number of SBM/week.

CONCLUSIONS

Current drugs for CIC show similar efficacy. Bisacodyl may be superior to prescription medications for Δ_b in the number of SBM/week in CIC.

Osmotic and stimulant laxatives for the management of childhood constipation

BACKGROUND

Constipation within childhood is an extremely common problem. Despite the widespread use of osmotic and stimulant laxatives by health professionals to manage constipation in children, there has been a long standing paucity of high quality evidence to support this practice.

OBJECTIVES

We set out to evaluate the efficacy and safety of osmotic and stimulant laxatives used to treat functional childhood constipation.

SEARCH METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialized Trials Register from inception to 10 March 2016. There were no language restrictions. We also searched the references of all included studies, personal contacts and drug companies to identify studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which compared osmotic or stimulant laxatives to placebo or another intervention, with participants aged 0 to 18 years old were considered for inclusion. The primary outcome was frequency of defecation. Secondary endpoints included faecal incontinence, disimpaction, need for additional therapies and adverse events.

DATA COLLECTION AND ANALYSIS

Relevant papers were identified and two authors independently assessed the eligibility of trials, extracted data and assessed methodological quality using the Cochrane risk of bias tool. The primary outcome was frequency of defecation. Secondary endpoints included faecal incontinence, disimpaction, need for additional therapies and adverse events. For continuous outcomes we calculated the mean difference (MD) and 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes we calculated the risk ratio (RR) and 95% CI using a fixed-effect model. The Chi(2) and I(2) statistics were used to assess statistical heterogeneity. A random-effects model was used in situations of unexplained heterogeneity. We assessed the overall quality of the evidence supporting the primary and secondary outcomes using the GRADE criteria.

MAIN RESULTS

Twenty-five RCTs (2310 participants) were included in the review. Fourteen studies were judged to be at high risk of bias due to lack of blinding, incomplete outcome data and selective reporting. Meta-analysis of two studies (101 patients) comparing polyethylene glycol (PEG) with placebo showed a significantly increased number of stools per week with PEG (MD 2.61 stools per week, 95% CI 1.15 to 4.08). Common adverse events in the placebo-controlled studies included flatulence, abdominal pain, nausea, diarrhoea and headache. Participants receiving high dose PEG (0.7 g/kg) had significantly more stools per week than low dose PEG (0.3 g/kg) participants (1 study, 90 participants, MD 1.30, 95% 0.76 to 1.84). Meta-analysis of 6 studies with 465 participants comparing PEG with lactulose showed a significantly greater number of stools per week with PEG (MD 0.70 , 95% CI 0.10 to 1.31), although follow-up was short. Patients who received PEG were significantly less likely to require additional laxative therapies. Eighteen per cent (27/154) of PEG patients required additional therapies compared to 31% (47/150) of lactulose patients (RR 0.55, 95% CI 0.36 to 0.83). No serious adverse events were reported with either agent. Common adverse events in these studies included diarrhoea, abdominal pain, nausea, vomiting and pruritis ani. Meta-analysis of 3 studies with 211 participants comparing PEG with milk of magnesia showed that the stools per week were significantly greater with PEG (MD 0.69, 95% CI 0.48 to 0.89). However, the magnitude of this difference was quite small and may not be clinically significant. One child was noted to be allergic to PEG, but there were no other serious adverse events reported. One study found a significant difference in stools per week favouring milk of magnesia over lactulose (MD -1.51, 95% CI -2.63 to -0.39, 50 patients), Meta-analysis of 2 studies with 287 patients comparing liquid paraffin (mineral oil) with lactulose revealed a relatively large statistically significant difference in the number of stools per week favouring liquid paraffin (MD 4.94 , 95% CI 4.28 to 5.61). No serious adverse events were reported. Adverse events included abdominal pain, distention and watery stools. No statistically significant differences in the number of stools per week were found between PEG and enemas (1 study, 90 patients, MD 1.00, 95% CI -1.58 to 3.58), dietary fibre mix and lactulose (1 study, 125 patients, P = 0.481), senna and lactulose (1 study, 21 patients, P > 0.05), lactitol and lactulose (1 study, 51 patients, MD -0.80, 95% CI -2.63 to 1.03), hydrolyzed guar gum and lactulose (1 study, 61 patients, MD 1.00, 95% CI -1.80 to 3.80), PEG and flixweed (1 study, 109 patients, MD 0.00, 95% CI -0.33 to 0.33), PEG and dietary fibre (1 study, 83 patients, MD 0.20, 95% CI -0.64 to 1.04), and PEG and liquid paraffin (2 studies, 261 patients, MD 0.35, 95% CI -0.24 to 0.95).

AUTHORS' CONCLUSIONS

The pooled analyses suggest that PEG preparations may be superior to placebo, lactulose and milk of magnesia for childhood constipation. GRADE analyses indicated that the overall quality of the evidence for the primary outcome (number of stools per week) was low or very low due to sparse data, inconsistency (heterogeneity), and high risk of bias in the studies in the pooled analyses. Thus, the results of the pooled analyses should be interpreted with caution because of quality and methodological concerns, as well as clinical heterogeneity, and short follow-up. There is also evidence suggesting the efficacy of liquid paraffin (mineral oil). There is no evidence to demonstrate the superiority of lactulose when compared to the other agents studied, although there is a lack of placebo controlled studies. Further research is needed to investigate the long term use of PEG for childhood constipation, as well as the role of liquid paraffin. The optimal dose of PEG also warrants further investigation.

Comparison of Two Postoperative Bowel Regimens in Children With Scoliosis Repair

BACKGROUND

Orthopaedic procedures place children at risk for postoperative constipation due to combined effects of anesthesia, narcotics, and decreased physical mobility.

PURPOSE

This retrospective study analyzed medication use and stool outcomes of 36 children who received polyethylene glycol 3350 (PEG) or mineral oil (MO) after a spinal fusion.

METHODS AND RESULTS

A chart review found no statistical differences by group for number of bowel movements (BMs) before discharge (p = .37), time from procedure to BM, use of rescue cathartics (p = .55), or medication refusal (p = .37). In the PEG group, 90% refused the medication one or more times compared with 75% in the MO group.

CONCLUSION

Only 17% of patients had a BM before discharge. Findings suggest medication refusal may be related to the method of medication preparation, suggesting the child's choice in bowel regimens may be indicated. A prospective study with a larger, randomized sample size is needed.

Management of Functional Constipation in Children: Therapy in Practice

Functional constipation is a common healthcare problem among children worldwide and accounts for high healthcare usage and costs. Functional constipation is a clinical diagnosis; the evaluation primarily consists of a thorough medical history and a complete physical examination. Additional investigations are not necessary in most cases. Treatment consists of non-pharmacological and pharmacological interventions. Non-pharmacological interventions involve education and demystification, toilet training (with a reward system), and a defecation diary. Pharmacological treatment comprises three steps: disimpaction, maintenance treatment, and weaning. The treatment of first choice is oral laxatives, preferably polyethylene glycol. When this is insufficient, other therapeutic agents are available. This review discusses the evaluation and management of functional constipation in the pediatric population and provides a summary of drug treatment options.

Nanocrystalline cerium dioxide efficacy for gastrointestinal motility: potential for prokinetic treatment and prevention in elderly

BACKGROUND

Constipation is a common condition, with prevalence after 65 years, is a major colorectal cancer risk factor. Recent works have demonstrated advances in personalized, preventive nanomedicine, leading to the construction of new materials and nanodrugs, in particular, nanocrystalline cerium dioxide (NCD), having strong antioxidative prebiotic effect. The aim of our study was to investigate the influence of NCD on motor function of the stomach and colon in vivo and contractive activity of smooth muscles in different year-old rats.

METHODS

We included 80 rats: 3- (weight 130-160 g, n = 40) and 24-month old (weight 390-450 g, n = 40), divided into four groups as follows: І-control group; rats of II-ІV groups were injected intragastrically one injection per day during 10 days, 3 ml of water 3 ml/kg stabilizing solution, аnd 1 mmol/ml NCD, respectively. In all animals, we recorded spontaneous and carbachol-stimulated (0.01 mg/kg) gastrointestinal tract motor activity. We used the index of motor activity (IMA), expressed in cmH2O, for characterization of the motor function. We investigated smooth muscle contraction by tenzometric method, studied the spontaneous and stimulated motility by ballonographic method.

RESULTS

IMA reduced by 21.1 + 0.2% (p < 0.01) in the old rats of the control group compared with the young rats. A 10-day administration of NCD increased IMA in the stomach of young rats by 9.3% (р < 0.001) vs the control group. The exposure of NCD increased the amplitude of contraction to 34.2 ± 5.4 mN (n = 10) in the stomach of old rats and increased by 32.1 ± 2.4% vs the control group (p < 0.05). NCD did not influence acetylcholine (ACh) contractions in the stomach of young rats; however, in the stomach of old rats, V nr increased by 90 ± 15.2% (р < 0.001).

CONCLUSIONS

The index of motor activity is decreased in old rats. Nanocrystalline cerium dioxide increased the index of motor activity in all groups of rats and also evoked a significant increase of colon contractions in old rats.

Systematic review of stimulant and nonstimulant laxatives for the treatment of functional constipation

BACKGROUND

Constipation is an uncomfortable and common condition that affects many, irrespective of age. Since 1500 BC and before, health care practitioners have provided treatments and prevention strategies to patients for chronic constipation despite the significant variation in both medical and personal perceptions of the condition.

OBJECTIVE

To review relevant research evidence from clinical studies investigating the efficacy and safety of commercially available pharmacological laxatives in Canada, with emphasis on studies adopting the Rome criteria for defining functional constipation.

SEARCH METHODS

PubMed, Medline, Embase and Evidence-Based Medicine Reviews databases were searched for blinded or randomized clinical trials and meta-analyses assessing the efficacy of nonstimulant and stimulant laxatives for the treatment of functional constipation.

RESULTS

A total of 19 clinical studies and four meta-analyses were retrieved and abstracted regarding study design, participants, interventions and outcomes. The majority of studies focused on polyethylene glycol compared with placebo. Both nonstimulant and stimulant laxatives provided better relief of constipation symptoms than placebo according to both objective and subjective measures. Only one study compared the efficacy of a nonstimulant versus a stimulant laxative, while only two reported changes in quality of life. All studies reported minor side effects due to laxative use, regardless of treatment duration, which ranged from one week to one year. Laxatives were well tolerated by both adults and children.

The short-term effects of olive oil and flaxseed oil for the treatment of constipation in hemodialysis patients

OBJECTIVES

To evaluate the effects of olive oil and flaxseed oil compared with mineral oil for the treatment of constipation in patients undergoing hemodialysis.

METHODS

A 4-week, double-blind, randomized, and controlled trial was conducted. Fifty constipated patients (29% male, 51 ± 12 years) diagnosed by the Rome III criteria were randomly assigned to receive mineral oil (control group; n = 17), olive oil (n = 16), or flaxseed oil (n = 17). The initial oil dose was 4 mL/day, and adjustments during the follow-up could be made as needed. The impact of the intervention was assessed by the Rome III criteria scores.

RESULTS

The most frequent symptoms of constipation evaluated by the Roma III criteria at baseline were comparable among the groups and included "incomplete evacuation" (92%), "lumpy or hard stools," (72%) and "anorectal obstruction" (70%). The Rome III score improved significantly in patients receiving mineral oil (10.5 ± 5.0 to 4.1 ± 4.0; P < .01), olive oil (10.3 ± 4.2 to 3.2 ± 3.8; P = .01), and flaxseed oil (9.6 ± 4.2 to 6.0 ± 5.1; P < .01), with no significant group-by-time interaction (P = .15). The scores of 5 from 6 constipation symptoms reduced similarly in the mineral oil and olive oil groups, whereas only the frequency of evacuation and the consistency of stools improved in the flaxseed oil group.

CONCLUSIONS

We demonstrated that the daily use of olive oil or flaxseed oil was as effective as mineral oil in the treatment of constipation in patients undergoing hemodialysis.

Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN

BACKGROUND

Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.

METHODS

Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

RESULTS

This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children.

CONCLUSIONS

This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

Pharmacokinetic and pharmacodynamic considerations for the current chronic constipation treatments

INTRODUCTION

Chronic constipation is a frequent condition often treated pharmacologically. The laxatives available belong to very different pharmacologic groups.

AREAS COVERED

This is a short but comprehensive review of the pharmacology, efficacy and safety of currently available laxatives for chronic constipation. Pertinent publications were retrieved from reference lists of publications and by literature searches via PubMed, lastly performed in November 2012.

EXPERT OPINION

The most relevant laxative groups are the older representatives osmotic salts, sugars and sugar alcohols, macrogol, anthraquinones, diphenolic laxatives or diphenyl methanes (bisacodyl and sodium picosulfate) and the newer compounds prucalopride, lubiprostone and linaclotide. For all of these laxatives efficacy has been shown in controlled trials. Electrolyte losses do not occur when laxatives are given in therapeutic doses (rare exceptions with phosphate salts and salinic laxatives). The older laxatives are also safe regarding teratogenicity, abortion and lactation. For the newer compounds no respective data are available as yet. It is questionable whether the newer compounds offer advantages over the older ones. Unfortunately, comparative trials are lacking.

The effect of cassia fistula emulsion on pediatric functional constipation in comparison with mineral oil: a randomized, clinical trial

Background

The prevalence of Pediatric Functional Constipation (FC) has been reported between 0.7% to 29.6%. This study was conducted to compare the laxative effect of cassia fistula emulsion (CFE) with mineral oil (MO) on FC. Cassia fistula is named in Traditional Iranian Medicine (TIM) as “Folus”.

Materials and methods

A randomized clinical trial was carried on 81 children (age range: 4–13 years) with FC, according to Rome III criteria in Amirkola Children’s Hospital, Babol, Iran. They received CFE or MO randomly for three weeks. CFE was produced according to the order of TIM references. Children were counted as improved when they exited from Rome III criteria of FC. Frequency of defecation, fecal incontinence, retentive posturing, severity of pain, consistency of stool and anal leakage of oily material were compared between the two groups and with baselines. An intent-to-treat analysis was used. Safety of drugs was assessed with the evaluation of clinical adverse effects.

Results

41 children were assigned randomly to receive CFE and 40 children received MO. After three weeks of medication, 84% of children in CFE group and 50% in MO group (p = 0.002) exited from the criteria of FC, so called improved. All measurable criteria improved in both groups. The frequency of defecation in CFE group improved from 1.7 per week (before the study) to 10.6 per week (at the third week) while this parameter differed in MO group from 2 to 6.1 (p < 0.001). The severity of pain during defecation and consistency of stool improved significantly better in CFE group than MO group (p < 0.05), but there were not any significant differences between the two groups in fecal incontinence and retentive posturing. Anal leakage of oily material occurred as an important complication in MO group while the children in CFE group did not complaint it. Drug’s compliances were not significantly different in the two groups. CFE and MO did not cause clinically significant side effects.

Conclusions

CFE was most effective than MO in the 3-week treatment of children with FC.

Osmotic and stimulant laxatives for the management of childhood constipation

BACKGROUND

Constipation within childhood is an extremely common problem. Despite the widespread use of osmotic and stimulant laxatives by health professionals to manage constipation in children, there has been a long standing paucity of high quality evidence to support this practice.

OBJECTIVES

We set out to evaluate the efficacy and safety of osmotic and stimulant laxatives used to treat functional childhood constipation.

SEARCH METHODS

The search (inception to May 7, 2012) was standardised and not limited by language and included electronic searching (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register), reference searching of all included studies, personal contacts and drug companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which compared osmotic or stimulant laxatives with either placebo or another intervention, with patients aged 0 to 18 years old were considered for inclusion. The primary outcome was frequency of defecation. Secondary endpoints included faecal incontinence, disimpaction, need for additional therapies and adverse events.

DATA COLLECTION AND ANALYSIS

Relevant papers were identified and the authors independently assessed the eligibility of trials. Methodological quality was assessed using the Cochrane risk of bias tool.The Cochrane RevMan software was used for analyses. Patients with final missing outcomes were assumed to have relapsed. For continuous outcomes we calculated a mean difference (MD) and 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes we calculated an odds ratio (OR) and 95% confidence intervals (95% CI) using a fixed-effect model. The chi square and I(2) statistics were used to assess statistical heterogeneity. A random-effects model was used in situations of unexplained heterogeneity

MAIN RESULTS

Eighteen RCTs (1643 patients) were included in the review. Nine studies were judged to be at high risk of bias due to lack of blinding, incomplete outcome data and selective reporting. Meta-analysis of two studies (101 patients) comparing polyethylene glycol (PEG) with placebo showed a significantly increased number of stools per week with PEG (MD 2.61 stools per week, 95% CI 1.15 to 4.08). Common adverse events in the placebo-controlled studies included flatulence, abdominal pain, nausea, diarrhoea and headache. Meta-analysis of 4 studies with 338 participants comparing PEG with lactulose showed significantly greater stools per week with PEG (MD 0.95 stools per week, 95% CI 0.46 to 1.44), although follow up was short. Patients who received PEG were significantly less likely to require additional laxative therapies. Eighteen per cent of PEG patients required additional therapies compared to 30% of lactulose patients (OR 0.49, 95% CI 0.27 to 0.89). No serious adverse events were reported with either agent. Common adverse events in these studies included diarrhoea, abdominal pain, nausea, vomiting and pruritis ani. Meta-analysis of 3 studies with 211 participants comparing PEG with milk of magnesia showed that the stools/wk was significantly greater with PEG (MD 0.69 stools per week, 95% CI 0.48 to 0.89). However, the magnitude of this difference is quite small and may not be clinically significant. One child was noted to be allergic to PEG, but there were no other serious adverse events reported. Meta-analysis of 2 studies with 287 patients comparing liquid paraffin (mineral oil) with lactulose revealed a relatively large statistically significant difference in the number of stools per week favouring paraffin (MD 4.94 stools per week, 95% CI 4.28 to 5.61). No serious adverse events were reported. Adverse events included abdominal pain, distention and watery stools. No statistically significant differences in the number of stools per week were found between PEG and enemas (1 study, 90 patients, MD 1.00, 95% CI -1.58 to 3.58), dietary fibre mix and lactulose (1 study, 125 patients, P = 0.481), senna and lactulose (1 study, 21 patients, P > 0.05), lactitol and lactulose (1 study, 51 patients, MD -0.80, 95% CI -2.63 to 1.03), and PEG and liquid paraffin (1 study, 158 patients, MD 0.70, 95% CI -0.38 to 1.78).

AUTHORS' CONCLUSIONS

The pooled analyses suggest that PEG preparations may be superior to placebo, lactulose and milk of magnesia for childhood constipation. GRADE analyses indicated that the overall quality of the evidence for the primary outcome (number of stools per week) was low or very low due to sparse data, inconsistency (heterogeneity), and high risk of bias in the studies in the pooled analyses. Thus, the results of the pooled analyses should be interpreted with caution because of quality and methodological concerns, as well as clinical heterogeneity, and short follow up. However, PEG appears safe and well tolerated. There is also evidence suggesting the efficacy of liquid paraffin (mineral oil), which was also well tolerated.There is no evidence to demonstrate the superiority of lactulose when compared to the other agents studied, although there is a lack of placebo controlled studies. Further research is needed to investigate the long term use of PEG for childhood constipation, as well as the role of liquid paraffin.

Management of chronic functional constipation in childhood

Chronic functional constipation is a common problem in childhood, with soiling a significant issue. The morbidity is high and the treatment is complex. There is a very poor evidence base for the drug treatments used and there are considerable differences in practice in different units. The key to successful management is early diagnosis and prompt treatment with an emphasis on holistic care with multidisciplinary support where needed. For example, the practical approach in our unit at the Southampton General Hospital, Southampton, England emphasizes the non-drug aspects including patient education and behavioral modification and uses stimulant laxatives, usually in a high dose as first-line therapy. There is an urgent need for prospective comparative studies to investigate different treatment regimens and for longitudinal studies to examine the long-term outcome of chronic constipation and the factors that determine it. The lack of a significant evidence base for the use of the most widely used agents proves a significant challenge in the production of evidence-based guidelines and highlights the paucity of data for most of the widely used treatments for childhood constipation.