New developments in the treatment of constipation in childhood
In 2014, the European and North American Societies for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN and NASPGHAN) issued guidelines on the management of paediatric constipation using1:
- Lifestyle modifications (diet, fluid, exercise);
- Oral and/or rectal laxatives;
- Behavioural therapy;
- Transabdominal electrical stimulation or sacral nerve stimulation;
- Surgical management: colectomy or stoma, including anterograde irrigation
However, new and emerging developments are occurring within each management option.
Recent developments in the management of constipation
Available evidence suggests that a dietary fibre intake of 2 g per 1000 kJ (239 kcal) is considered adequate for normal laxation in children aged >1 year.2 Accordingly, the ESPGHAN and NASPGHAN guidelines recommend that children with constipation have a normal fibre and fluid intake (0.7–1.8 L/day, depending on age)3, with daily physical activities remaining unchanged (ie, up to 180 minutes of physical activity daily, depending on a child’s age),1,4,5 because, while extra / supplemental fibre can increase defecation rates in children, it is no more effective than a placebo.3
Chronic constipation can be managed using oral laxatives, such as milk of magnesia (magnesium hydroxide) or polyethylene glycol (PEG), to increase water content in the stool,1 with PEG providing slightly better outcomes for stool frequency, form of stool, abdominal pain and the need for additional medication.6
While enemas are not very popular, they are a useful treatment for improving bowel function in constipated patients. Discomfort, pain, embarrassment and expense mean that these procedures are generally avoided in children with constipation.
Novel pharmacological agents
Pharmacological agents, such as prucalopride, lubiprostone and linaclotide, have demonstrated efficacy in the management of constipation in adult patients through numerous mechanisms, including triggering the peristaltic reflex, increasing gut motility and increasing smooth muscle contraction.7-15 However, further data is awaited before they are granted marketing approval for paediatric patients.
In children who have not responded to oral or rectal laxatives, a range of new treatment strategies may be applied, such as transabdominal electrical stimulation (TES) or sacral nerve stimulation. There is currently moderate support for the effectiveness of TES in the treatment of slow-transit constipation with improvements seen in defecation frequency, abdominal pain and laxative use.16-18 However, studies encompassing larger and more diverse patient populations who have been followed for longer periods of time are necessary to reliably determine the efficacy of TES in the treatment of constipation in children.
Sacral nerve stimulation is also a promising new treatment for constipation,19-22 but this treatment is very expensive and as a result is generally considered to be a last resort. Biofeedback therapy is another alternate therapy for constipation where the governing principle is that any behaviour, when reinforced repeatedly, can be learned and perfected. For example, visual or verbal feedback is given to encourage a child’s awareness of the urge to defecate, and to relax their external anal sphincter in response.23 However, there is currently no evidence to support the use of biofeedback therapy for the treatment of childhood constipation.23
The majority of studies exploring surgical management options for childhood constipation are case series discussing a limited number of patients.24 Furthermore, research has been hampered by an absence of a clear definition of constipation, failure to ascertain the patients’ duration of symptoms, a wide range of definitions of success and a lack of assessment of patient or carer satisfaction or quality of life.24 Therefore, there is limited data on the use of surgery to manage constipation in children, and it continues to be limited to very specific cases with a clear indication.
Traditional Asian medicines in the management of constipation
Traditional herbal medicines tend to play a greater role in Asia than Europe, although studies report that, overall, one in three people with constipation may use herbal therapies, often in combination with conventional therapies.25 Investigations of a variety of Japanese and Chinese herbal medicines have reported conflicting results.26-31
Acupuncture, another traditional Chinese medicine may also have efficacy in patients with constipation, improving physical symptoms, such as spontaneous defecation times, abdominal pain and evacuation difficulty, as well as sensory symptoms, such as endless sensation of defecation and obstruction sense of anus.32 This can reduce laxative prescription dependence and improve patient quality of life, but data supporting the use of acupuncture in children with constipation is lacking.32
Children with constipation should have a normal fibre and fluid intake, and engage in daily physical activity.1 If an additional intervention is required, PEG is the first choice as a maintenance treatment because evidence does not support the use of any non-pharmacological treatment in childhood constipation, and while novel pharmacological therapies have demonstrated efficacy in adult populations, further studies in children are required before these can be made available.1 Likewise, while there is some evidence to support the use of traditional Asian medicines, such as herbal remedies or acupuncture, to manage constipation, there is little data to support their use in children.25-32
- Tabbers, M.M. et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr, 2014. 58(2): p. 258-74.
- European Food Safety Authority. Scientific opinion on dietary reference values for carbohydrates and dietary fibre. EFSA Journal, 2010. 8(3): p. 1462.
- Gandy J. Water intake: validity of population assessment and recommendations. Eur J Nutr, 2015. 54(Suppl 2): p. S11-6.
- Canadian Society for Exercise Physiology. Canadian physical activity guidelines for the early years: 0–4 years. Available at: http://csep.ca/CMFiles/Guidelines/CSEP_PAGuidelines_early-years_en.pdf. Accessed 2 March 2017.
- Society of Health and Physical Educators.Active Start: A statement of physical activity guidelines for children from birth to age 5, 2nd edition. Available at: http://portal.shapeamerica.org/standards/guidelines/activestart.aspx. Accessed 27 March 2017.
- Gordon, M. et al. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev, 2016. 8: CD009118.
- Bouras, E.P. et al. Selective stimulation of colonic transit by the benzofuran 5HT4 agonist, prucalopride, in healthy humans. Gut, 1999. 44(5): p. 682-6.
- Camilleri, M. et al. A placebo-controlled trial of prucalopride for severe chronic constipation. N Engl J Med, 2008. 358(22): p. 2344-54.
- Quigley, E.M. et al. Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation – a 12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther, 2009. 29(3): p. 315-28.
- Yiannakou, Y. et al. A randomized, double-blind, placebo-controlled, phase 3 trial to evaluate the efficacy, safety, and tolerability of prucalopride in men with chronic constipation. Am J Gastroenterol, 2015. 110(5): p. 741-8.
- Lacy B.E. and L.C. Levy. Lubiprostone: a novel treatment for chronic constipation. Clin Interv Aging, 2008. 3(2): p. 357-64.
- Johanson, J.F. et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of lubiprostone, a locally-acting type-2 chloride channel activator, in patients with chronic constipation. Am J Gastroenterol, 2008. 103(1): p. 170-7.
- Hyman, P.E. et al. Lubiprostone for the treatment of functional constipation in children. J Pediatr Gastroenterol Nutr, 2014. 58(3): p. 283-91.
- Thomas, R. H. and K. Allmond. Linaclotide (Linzess) for irritable bowel syndrome with constipation and for chronic idiopathic constipation.T., 2013. 38(3): p. 154-60.
- Lembo, A.J. et al. Efficacy of linaclotide for patients with chronic constipation. Gastroenterology, 2010. 138(3): p. 886-95.
- Leong, L.C. et al. Long-term effects of transabdominal electrical stimulation in treating children with slow-transit constipation. J Pediatr Surg, 2011. 46(12): p. 2309-12.
- Hutson, J.M. et al. Transabdominal electrical stimulation (TES) for the treatment of slow-transit constipation (STC). Pediatr Surg Int, 2015. 31(5): p. 445-51.
- Lu, M.L. et al. Electrical stimulation therapy for slow transit constipation in children: a systematic review. Int J Colorectal Dis, 2015. 30(5): p. 697-702.
- Dinning, P.G. et al. Pancolonic motor response to subsensory and suprasensory sacral nerve stimulation in patients with slow-transit constipation. Br J Surg, 99(7): p. 1002-10.
- Van Wunnik, B.P. et al. Sacral neuromodulation therapy: a promising treatment for adolescents with refractory functional constipation. Dis Colon Rectum, 2012. 55(3): p. 278-85.
- Sulkowski, J.P. et al. Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children. J Pediatr Surg, 2015. 50(10): p. 1644-7.
- Dinning, P.G. et al. Treatment efficacy of sacral nerve stimulation in slow transit constipation: a two-phase, double-blind randomized controlled crossover study. Am J Gastroenterol, 2015. 110(5): p. 733-40.
- Rao, S.S. et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil, 2015. 27(5): p. 594-609.
- Siminas, S. and P.D. Losty. Current surgical management of pediatric idiopathic constipation: a systematic review of published studies. Ann Surg, 2015. 262(6): p. 925-33.
- Peng, W. et al. Complementary and alternative medicine use for constipation: a critical review focusing upon prevalence, type, cost, and users’ profile, perception and motivations. Int J Clin Pract, 2016. 70(9): p. 712-22.
- Bensoussan, A. et al. Efficacy of a Chinese herbal medicine in providing adequate relief of constipation-predominant irritable bowel syndrome: A randomized controlled trial. Clin Gastroenterol Hepatol, 2015. 13(11): p. 1946-54.
- Cheng, C.W. et al. Efficacy of a Chinese herbal proprietary medicine (Hemp Seed Pill) for functional constipation. Am J Gastroenterol, 2011. 106(1): p. 120-9.
- Zhong, L.L.D. et al. Chinese herbal medicine for constipation: zheng‑based associations among herbs, formulae, proprietary medicines, and herb–drug interactions. Chin Med, 2016. 11: p. 28.
- Shimoyama, T. et al. Study of the mechanisms of a Japanese traditional fermented medicine in the improvement of constipation. J Gastroenterol Hepatol, 2015. 30(Suppl 1): p. 53-9.
- Iturrino, J. et al. Randomised clinical trial: the effects of daikenchuto, TU-100, on gastrointestinal and colonic transit, anorectal and bowel function in female patients with functional constipation. Aliment Pharmacol Ther, 2013. 37(8): p. 776-85.
- Iwai, N. et al. Effects of herbal medicine Dai-Kenchu-to on anorectal function in children with severe constipation. Eur J Pediatr Surg, 2007. 17(2): p. 115-8.
- Wang, X. and J. Yin. Complementary and alternative therapies for chronic constipation. Evid Based Complement Alternat Med, 2015. 2015: p. 396396.