New Treatment Options in Childhood Constipation?

Abstract

To date, the worldwide prevalence of symptoms of constipation in children varies widely and is estimated to range between 0.3–28%. Childhood constipation is recognized by infrequent, hard stools and the involuntary loss of faeces in the underwear. It is a debilitating condition that is often associated with abdominal pain. It causes distress to the child and to the family and can result in severe emotional disturbance and family discord. Importantly, childhood constipation often continues into adulthood and it is suggested that longstanding faecal impaction from childhood-on may result in a more complex pathophysiological end-state later in life (1). This again emphasizes the significance of an effective therapeutic intervention in children. To date however, treatment modalities are mainly based on empiricism and have little evidence of long-term efficacy. Although many compounds have been tried, there are little data to support there use. Moreover, there is a huge lack of large double-blind randomised controlled trials in children with well defined outcome measures. As in many more other fields in the medical treatment of children only a minority of the drugs used to treat constipated children have been studied adequately in the population, have appropriate use information on the product label and the information regarding safety and efficacy for pediatric patients is insufficient or absent. Currently acute simple constipation is usually treated with a high fibre diet and sufficient fluid intake, filling out a diary and toilet training. Based on the American medical position statement the treatment of chronic constipation consists of 4 important phases: 1) education, 2) disimpaction, 3) prevention of re-accumulation of faeces and 4) follow up (2). In this paper firstly recent advances in the treatment of constipation in adults and children are discussed, such as the selective 5-HT4, agonist, tegaserod, preand probiotics and sacral nerve stimulation. The second part will cover the use of polyethylene glycol which has been described as an effective and welltolerated treatment choice for pediatric constipation, especially as an adjunct to education and behavioural training. PEG 3350 and PEG 4000 have been proved an option for children with constipation who have failed or are intolerant of other pharmacotherapies. Serotonin plays a key role in mediating peristalsis and stimulating intestinal secretion via 5-HT4 receptors in the gut wall. Tegaserod, a selective agonist that acts at 5-HT4 receptors and increases small bowel transit, stimulates intestinal secretion and inhibits visceral afferent responses has proven effective in the treatment of chronic constipation in adults (3,4). Two randomized placebo controlled trials including more than 3000 patients with constipation showed a significant increase in spontaneous bowel movements per week and a significant reduction in straining, abdominal bloating/distension, and abdominal pain/discomfort. The most common adverse events, headache and abdominal pain, were more frequent with placebo than with tegaserod. In children with hard stools, caused by excessive straining, 5-HT4 agonist might benefit children with constipation and tendency to form hard stools, scybala and large rectal masses. This seems to be present more frequently in children.The role of this promising new agent in pediatric constipation has to be established in future studies. National and international collaboration to evaluate the efficacy of Tegaserod in children is of imminent importance to match similar quality and valuable results as described in adults with constipation. Researchers claim a positive effect on intestinal transit and stool consistency of preand probiotics. Nondigestible oligosaccharides consist mainly of fructooligosaccharides (FOS). FOS is a soluble dietary fibre, which reduces faecal pH, increases the water/holding capacity of stool and faecal weight and decreases intestinal transit time. Furthermore, it has prebiotic effects by selectively stimulating the growth of probiotic bacteria, such as bifidobacteria. A double-blind randomized controlled study in healthy infants comparing a fructooligosaccharide-supplemented cereal (0.75 g FOS per cereal serving) with placebo showed a significant increase in mean numbers of stool per infant and softer stools (5). The FOS supplemented cereal was well tolerated. In another study in healthy women, the probiotic strain Bifidobacterium animalis shortened both the total colonic transit time and the rectosigmoid transit time (6). However, the number of stools per week did not significantly change between the Bifidobacterium and M. A. Benninga, MD, PhD (e-mail: m.a.benninga@amc.uva.nl). Journal of Pediatric Gastroenterology and Nutrition 41:S56–S57 September 2005 Lippincott Williams & Wilkins, Philadelphia