Laxative Choice and Treatment Outcomes in Childhood Constipation: Clinical Data in a Longitudinal Retrospective Study

The outcome of functional constipation in Saudi children

BACKGROUND

Understanding the outcome of functional constipation (FC) for both patients and physicians is essential, yet it has been infrequently reported worldwide. The objective of this report was to update the outcomes of FC in Saudi children.

METHODS

Clinical data including age, sex, response to management, duration of follow up, and type of management were collected from the notes of each clinic visits and phone call follow-ups.

RESULTS

The study included 268 children followed up for a 7 year duration. The median age of onset was 4 (0.1 to 13) years, and 123/268 (46%) were male. There was an increasing recovery rate with increasing duration of follow up with an overall recovery rate of 79%. There was no significant association between recovery and age at onset (p=0.0860) or duration of constipation (P=0.124). Management by pediatric gastroenterologists did not increase rate of recovery (81% vs. 77%, p=0.432) or being cured (47% vs. 36%, p=0.108) significantly. According to the parents of children who recovered, diet in association with polyethylene glycol (PEG) and toilet training were most helpful. Poor diet and nonadherence to medications were the most common causes of lack of recovery.

CONCLUSIONS

The higher rates of recovery in this Middle Eastern childhood population than other populations are possibly related to cultural characteristics. The parents' views support the importance of diet associated with other modalities as important parts of management.  Further research is needed to identify correctable causes of nonadherence to treatment to improve recovery.

Efficacy of lubiprostone for functional constipation treatment in adolescents and children: Randomized controlled trial

OBJECTIVES

Adolescent and pediatric functional constipation (FC) is a common clinical problem. Currently, data on lubiprostone for the treatment of pediatric FC are scarce. This study investigated the efficacy and safety of lubiprostone in the treatment of pediatric FC.

METHODS

In a single-blinded, randomized controlled study, we included 280 patients aged 8-18 years with FC. Patients were randomized either to a weight-based lubiprostone dose (n = 140) or conventional laxatives (n = 140), including lactulose, bisacodyl, or sodium picosulfate, for 12 weeks, followed by 4 weeks posttreatment follow-up.

RESULTS

Improvement in constipation was achieved in 128 (91.4%) patients in the lubiprostone group, and in 48 (34.3%) patients of the conventional therapy group (p < 0.001) and was sustained after treatment discontinuation. One quarter of the lubiprostone group experienced the first spontaneous bowel motion within 48 h after dose initiation. A total of 75.7% of the lubiprostone group could achieve and sustain Bristol stool form of 3 or 4 during the last 4 weeks of therapy and through the 4 weeks of follow-up versus 50 (35.7%) patients in the conventional therapy group (p < 0.001). No life-threatening adverse drug reactions were encountered, and no treatment-related discontinuation. Mild self-limited colicky abdominal pain and headache were the most prevalent side effects in the lubiprostone group.

CONCLUSIONS

Lubiprostone is an effective and well-tolerated pharmacotherapy for youthful age and pediatric age groups, which may alter the paradigm of pediatric FC treatment.

Clinical profile of functional constipation in Saudi children

BACKGROUND

Functional constipation (FC) is a common condition in children, and information on the clinical characteristics of FC in Saudi children is scarce.

OBJECTIVE

Describe the clinical profile of FC in Saudi children.

DESIGN

Retrospective.

SETTING

Hospital that provides primary, intermediate and tertiary care.

PATIENTS AND METHODS

All children diagnosed with FC according to the Rome IV criteria were included and had at least one follow-up clinic visit. Demographic and clinical data collected from medical records included the age at onset, duration of constipation, clinical features, treatment modalities, and factors associated with clinical response. Descriptive statistics and Pearson's chi-squared test were used in the statistical analysis to see how categorical study variables were linked to clinical response. A P value of ≤.05 was used to report statistical significance.

MAIN OUTCOME MEASURE

Compliance and clinical response to polyethylene glycol (PEG) compared with lactulose.

SAMPLE SIZE

370 children from 0.1 to 13 years of age.

RESULTS

The median (IQR) age of onset was 4 (5) years and less than one year in 14%. The median (IQR) duration of constipation was 4 months (11) and less than two months in 93/370 (25%). Abdominal pain was the most commonly associated feature (44%). Screening for celiac disease and hypothyroidism was negative. A Fleet enema was the most common disimpaction method (54%) and PEG was the most common maintenance medication (63.4%). PEG was significantly better tolerated (P=.0008) and more effective than lactulose (P<.0001). Compliance was the only variable significantly associated with clinical response.

CONCLUSIONS

PEG was better tolerated and more effective than lactulose in our study, a finding in agreement with the literature. Therefore, PEG should be the drug of choice in the initial management of FC in Saudi children. Prospective studies on the causes of noncompliance are needed to improve the response to treatment.

LIMITATIONS

The limitations of retrospective design are missing data, recall bias, and hospital-based limitation, such as missing milder cases treated at the outpatient level. However, the sample size of 370 may have minimized these limitations.

The magnitude and management of functional constipation at pediatric gastroenterology clinics: A survey study of various countries

BACKGROUND AND AIM

There have been no large-scale epidemiological study of functional constipation of pediatric gastroenterology services. This survey was undertaken to investigate the prevalence of functional constipation and magnitude of related problems in hospital settings of various countries as well as the practice of pediatric gastroenterologists in management of these conditions.

METHODS

The survey was conducted by sending questionnaires to members of Societies for Pediatric Gastroenterology Hepatology and Nutrition of various continents.

RESULTS

A total of 274 pediatric gastroenterologists from 41 countries participated in this study. Functional constipation accounted for overall 30% of patients attending pediatric gastroenterology outpatient clinics. In comparison with non-western countries, respondents from western countries reported significantly higher median annual numbers of new patients with intractable functional constipation (10 [4,25] vs 5 [2,10], P < 0.001), dyssynergic defecation (3 [0,15] vs 1 [0,4], P < 0.001), and colonic inertia (2 [0,5] vs 0 [0,1], P < 0.001). The use of high dose polyethylene glycol for fecal disimpaction was significantly more commonly among respondents from western countries, whereas rectal enema was significantly more favored in non-western countries. Respondents from different continents reported significant discrepancies in choices of investigations and management of patients with dyssynergic defecation and colonic inertia.

CONCLUSIONS

Functional constipation is a major problem for pediatric gastroenterology outpatient services worldwide. There were significant variations in the investigations of choice and therapeutic management of functional constipation, intractable functional constipation, and related problems among pediatric gastroenterologists of different geographic regions.

Prevalence of Defecation Disorders and their Symptoms is Comparable in Children and Young Adults: Cross-Sectional Study

PURPOSE

We aimed to compare the prevalence rates and associated symptoms of constipation and fecal incontinence in children and young adults and evaluate how these patient groups cope with these disorders.

METHODS

A cross-sectional study was performed in which 212 children (8-17 years) and 149 young adults (18-29 years) from the general Dutch population completed a questionnaire about defecation disorders.

RESULTS

Constipation occurred in 15.6% of children and 22.8% of young adults (p=0.55), while the prevalence of fecal incontinence was comparable between groups (7%, p=0.91). The symptoms associated with constipation occurred as often in children as in young adults, while most fecal incontinence symptoms occurred more often in young adults. Approximately 43% of children had constipation for more than 5 years, while 26% of young adults experienced constipation since childhood. Only 27% of constipated children and 21% of constipated young adults received treatment (mostly laxatives). For fecal incontinence, 13% of children and 36% of young adults received treatment (mostly antidiarrheal medications or incontinence pads).

CONCLUSION

In contrast to the general belief, the prevalence of defecation disorders and associated symptoms seem to be comparable in children and young adults. Only a few people with defecation disorders receive adequate treatment.

Clinical Features of Severely Constipated Children: Comparison of Infrequent Bowel Movement and Fecal Soiling Groups

PURPOSE

To compare the clinical features, diagnostic findings, and medications of children with infrequent bowel movements or fecal soiling.

METHODS

This study enrolled 333 children (189 male; age range, 1 month to 18 years) diagnosed with functional constipation by Rome III or IV criteria. We classified them into 3 groups (infrequent bowel movement without fecal soiling [G3-a], infrequent bowel movement with fecal soiling [G3-b], and fecal soiling only [G3-c]) and into 2 subgroups of fecal soiling (G2-b) or not (G2-a). Retrospective data on clinical characteristics, colon transit time (CTT) test results, and medications were collected. The Wilcoxon rank-sum test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were used for the statistical analysis.

RESULTS

The median age (months) and interquartile range (IQR) was 33 (45) in G3-a, 54 (40) in G3-b, and 73 (48) in G3-c (p<0.0001). G3-c had the latest onset (median, 18; IQR, 18; p=0.0219) and longest symptom duration (24 [24], p=0.0148). PEG 4000 was used in 60.6% (G3-a), 96.8% (G3-b), and 83.2% (G3-c) of patients (p<0.0001). The median age (months) and IQR were 33.0 (45.0) in G2-a and 63.5 (52.5) in G2-b (p<0.0001). G2-b had later onset (median, 12; IQR, 19.5; p=0.0062) and longer symptom duration than G2-a (24 [12], p=0.0070). PEG 4000 was used in 60.6% (G2-a) and 88.3% (G2-b) of children (p<0.0001). No statistically significant intergroup differences were seen in maintenance laxative dose, CTT, or CTT type.

CONCLUSION

Infrequent bowel movement and fecal soiling represent the advanced stage of chronic functional constipation.

A randomized controlled double blinded trial to evaluate efficacy of oral administration of black strap molasses (sugarcane extract) in comparison with polyethylene glycol on pediatric functional constipation

ETHNOPHARMACOLOGICAL RELEVANCE

As a significant health issue, Functional Constipation (FC) has a high prevalence of 0.7%-29% worldwide. In Persian ethnomedicine, several formulations of sugarcane extracts including faniz, shekar-e- sorkh and black strap molasses have been used to treat pediatric constipation.

AIM OF THE STUDY

To evaluate efficacy and safety of oral intake of black strap molasses syrup (BSM) on FC in children.

MATERIALS AND METHODS

A randomized controlled double blinded trial was performed on children aged 4-12 years diagnosed with FC according to ROMIII Constipation Measurement Questionnaire. Ninety-two patients were randomly divided in two groups of BSM or PEG syrups (40%) with a dose of 1 mL/kg body weight/day for 1 month. Symptoms were evaluated every two weeks. Possible serological side-effects and changes in children's body weight were investigated. BSM syrup constituents were determined by pharmacognostic methods.

RESULTS

Treatment was successful with both interventions with no significant difference between the groups. Defecation per week was significantly improved in both groups. Symptoms including volitional stool retention, large diameter stool, painful or hard stool and large fecal mass in the rectum decreased significantly two and four weeks after intervention (P < 0.05). There was no significant difference between groups except for the rate of large diameter stool. No side -effects were observed. The BSM naturally contained polyphenols (960 μg/mL), potassium (12430 μg/mL), iron (80 μg/mL) and calcium (3320 μg/mL).

CONCLUSION

BSM and PEG syrups had similar efficacy on FC. Compared with PEG, BSM syrup contained different natural micronutrients.