FUNCTIONAL CONSTIPATION MANAGEMENT

MANAGEMENT OF CHILDRENWITH FUNCTIONAL CONSTIPATION
The general approach to the child with functional constipation includes the following steps:
- determine whether fecal impaction is present, treat the impaction if present,
- initiate treatment with oral medication, provide parental education and close follow-up, and adjust medications as necessary.

Education
The education of the family and thedemystification of constipation, including an explanation of the pathogenesis of constipation, are the first steps in treatment. If fecal soiling is present, an important goal is to remove negative attributions for both the child and the parent. It is especially important for parents to understand that soiling from overflow incontinence is not a willful and defiant maneuver. Parents are encouraged to maintain a consistent, positive and supportive attitude for all aspects of treatment. Itmay be necessary to repeat the education and demystification processes several times during treatment.

Disimpaction
A fecal impaction is defined as a hard mass in the lower abdomen identified on physical examination, a dilated rectum filled with a large amount of stool on rectal examination or excessive stool in the colon on abdominal radiography. Disimpaction is necessary prior to starting maintenance therapy. Disimpaction may be carried out with either oral or rectal medication. In uncontrolled clinical trials disimpaction by the oral route, the rectal route or a combination of the two has been shown to be effective.

There are no randomized studies that compare the effectiveness of one to the other. The oral approach is not invasive and gives a sense of power to the child but adherence to the treatment regimen may be a problem. The rectal approach is faster but is invasive. The choice of treatment is best determined after discussing the options with the family and child.

Disimpaction with oral medication has been shown to be effective when high doses of mineral oil, polyethylene glycol electrolyte solutions or both are used. Although there are no controlled trials demonstrating the effectiveness of high dose magnesium hydroxide, magnesium citrate, lactulose, sorbitol, senna or bisacodyl for initial disimpaction, these laxatives have been used successfully in that role. It is recommended that mineral oil, oral electrolyte solutions, or the above-mentioned laxatives be used alone or in combination for initial disimpaction when the oral route is selected. Rectal disimpaction may be carried out with phosphate soda enemas, saline enemas, or mineral oil enemas followed by a phosphate enema. These enemas arewidely used and are effective. The use of soapsuds, tap water andmagnesium enemas is not recommended because of their potential toxicity. Rectal disimpaction has also been effectively carried out with glycerin suppositories in infants and bisacodyl suppositories in older children.

The Subcommittee discussed the use of digital disimpaction in chronic constipation in the primary care setting. However, there was insufficient literature on the subject and the Subcommittee could not reach consensus on whether to discourage or recommend its use.

Maintenance Therapy
Once the impaction has been removed, the treatment focuses on the prevention of the reoccurrence.
For the child presentingwithout impaction or after successful disimpaction, maintenance therapy is begun. This treatment consists of dietary interventions, behavioral modification and laxatives to assure that bowel movements occur at normal intervals with a good evacuation.

Dietary changes are commonly advised, particularly increased intake of fluids and absorbable and nonabsorbable carbohydrate, as a method to soften stools. Carbohydrates and especially sorbitol, found in some juices, such as prune, pear and apple juice, can cause increased frequency and water content of stools. No randomized controlled studies were found that demonstrated a proven effect on stools of increasing intakes of fluids, nonabsorbable carbohydrates or dietary fiber in children. A balanced diet that includes whole grains, fruits and vegetables is recommended as part of the treatment for constipation in children. Forceful implementation is undesirable.

Behavioral Modification
An important component of treatment includes behavior modification and regular toileting. Unhurried time on the toilet after meals is recommended. As part of the treatment of constipation, with or without overflow incontinence, it is often helpful to have children and their caregivers keep diaries of stool frequency. This can be combinedwith a reward system. For example, a child can use a calendar with stickers to record each stool that is passed in the toilet. The calendar can then be brought to visitswith the health care provider and serves as both a diary and a point for positive reinforcement. In cases where motivational or behavior problems are interfering with successful treatment referral to a mental health care provider for behavior modification or other intervention may be helpful.

The successful treatment of constipation, especially with overflow incontinence, requires a family that is well organized, can complete time-consuming interventions, and is sufficiently patient to endure gradual improvements and relapses. Close follow-up by telephone andwith office visits is recommended. Some families may need counseling support to help them effectively deal with this problem.

Medication
It is often necessary to use medication to help constipated children achieve regular bowel movements. A prospective, randomized trial showed that the addition of medications to behavior management in children with constipation is beneficial. Children who received medications achieved remission significantly sooner than children who did not. The use of laxatives was most advantageous for children until they were able to maintain regular toileting.

When medication is necessary in the daily treatment of constipation, mineral oil (a lubricant) or magnesium hydroxide, lactulose or sorbitol (osmotic laxatives), or a combination of the two, is recommended. At this stage in the treatment of constipation, the chronic use of stimulant laxatives is not recommended. Extensive experience with long term use of mineral oil, magnesium hydroxide and lactulose or sorbitol has been reported. Long term studies show that these therapies are effective and safe.

Since mineral oil, magnesium hydroxide, lactulose or sorbitol seem to be equally efficacious, the choice among these is based on safety, cost, the child’s preference, ease of administration and the practitioner’s experience.

A stimulant laxative may be necessary intermittently, for short periods of time, to avoid recurrence of an impaction. In this situation the use of stimulant laxatives is sometimes termed rescue therapy. Maintenance therapy may be necessary for many months. Only when the child has been having regular bowel movements without difficulty is weaning considered. Primary care providers and families need to be aware that relapses are common and difficulty with bowel movements may continue into adolescence. Long term follow-up studies have demonstrated that a significant number of children continue to require therapy to maintain regular bowel movements.