Clinical Evidence: A Publication of the BMJ Publishing Group

Childhood Constipation

Am Fam Physician. 2003 Mar 1;67(5):1041-1042.

Question Addressed

  • What are the effects of treatments for childhood constipation?

Summary of Interventions

Likely to be beneficial

Trade off between benefits and harms

Osmotic laxatives

Cisapride*

Medical treatment plus toilet training

Unknown effectiveness

Biofeedback training (short-term benefit only)

Increased dietary fiber

Stimulant laxatives


*—Not widely licensed for use in children. Clinical use in adults recently restricted because of heart rhythm abnormalities.

Summary of Interventions

View Table

Summary of Interventions

Likely to be beneficial

Trade off between benefits and harms

Osmotic laxatives

Cisapride*

Medical treatment plus toilet training

Unknown effectiveness

Biofeedback training (short-term benefit only)

Increased dietary fiber

Stimulant laxatives


*—Not widely licensed for use in children. Clinical use in adults recently restricted because of heart rhythm abnormalities.

Definition

Constipation is characterized by infrequent bowel evacuations; hard, small feces; or difficult or painful defecation. The frequency of bowel evacuation varies from person to person.1 Encopresis is defined as involuntary bowel movements in inappropriate places at least once a month for three months or more in children four years and older.2

Incidence/Prevalence

Constipation with or without encopresis is common in children. It accounts for 3 percent of consultations to pediatric outpatient clinics and 25 percent of pediatric gastroenterology consultations in the United States.3 Encopresis has been reported in 2 percent of children at school entry. The peak incidence is at two to four years of age.

Etiology/Risk Factors

No cause is discovered in 90 to 95 percent of children with constipation. Low fiber intake and a family history of constipation may be associated factors.4 Psychosocial factors are often suspected, although most children with constipation are developmentally normal.3 Chronic constipation can lead to progressive fecal retention, distension of the rectum, and loss of sensory and motor function. Organic causes for constipation are uncommon but include Hirschsprung's disease (one per 5,000 births; male-to-female ratio of 4:1; constipation invariably present from birth), cystic fibrosis, anorectal physiologic abnormalities, anal fissures, constipating drugs, dehydrating metabolic conditions, and other forms of malabsorption.3

Prognosis

Childhood constipation can be difficult to treat and often requires prolonged support, explanation, and medical treatment. In one long-term follow-up study of children presenting before five years of age, 50 percent recovered within one year and 65 to 70 percent recovered within two years; the remainder required laxatives for daily bowel movements or continued to soil for years.3 It is not known what proportion continue to have problems into adult life, although adults presenting with megarectum or megacolon often have a history of bowel problems from childhood.

Clinical Aims

To remove fecal impaction and to restore a bowel habit in which stools are soft and passed without discomfort.

Clinical Outcomes

Number of defecations per week; number of episodes of soiling per month; gut transit time as measured by timing the passage of radio-opaque pellets, which may be ingested within a gelatin capsule; use of laxatives.

Definition

Constipation is characterized by infrequent bowel evacuations; hard, small feces; or difficult or painful defecation. The frequency of bowel evacuation varies from person to person.1 Encopresis is defined as involuntary bowel movements in inappropriate places at least once a month for three months or more in children four years and older.2

Incidence/Prevalence

Constipation with or without encopresis is common in children. It accounts for 3 percent of consultations to pediatric outpatient clinics and 25 percent of pediatric gastroenterology consultations in the United States.3 Encopresis has been reported in 2 percent of children at school entry. The peak incidence is at two to four years of age.

Etiology/Risk Factors

No cause is discovered in 90 to 95 percent of children with constipation. Low fiber intake and a family history of constipation may be associated factors.4 Psychosocial factors are often suspected, although most children with constipation are developmentally normal.3 Chronic constipation can lead to progressive fecal retention, distension of the rectum, and loss of sensory and motor function. Organic causes for constipation are uncommon but include Hirschsprung's disease (one per 5,000 births; male-to-female ratio of 4:1; constipation invariably present from birth), cystic fibrosis, anorectal physiologic abnormalities, anal fissures, constipating drugs, dehydrating metabolic conditions, and other forms of malabsorption.3

Prognosis

Childhood constipation can be difficult to treat and often requires prolonged support, explanation, and medical treatment. In one long-term follow-up study of children presenting before five years of age, 50 percent recovered within one year and 65 to 70 percent recovered within two years; the remainder required laxatives for daily bowel movements or continued to soil for years.3 It is not known what proportion continue to have problems into adult life, although adults presenting with megarectum or megacolon often have a history of bowel problems from childhood.

Clinical Aims

To remove fecal impaction and to restore a bowel habit in which stools are soft and passed without discomfort.

Clinical Outcomes

Number of defecations per week; number of episodes of soiling per month; gut transit time as measured by timing the passage of radio-opaque pellets, which may be ingested within a gelatin capsule; use of laxatives.

Evidence-Based Medicine Findings

SEARCH DATE: CLINICAL EVIDENCE UPDATE SEARCH AND APPRAISAL APRIL 2002

Dietary Fiber

We found no randomized controlled trials (RCTs) on the effects of increasing dietary fiber in children.

Cisapride

Two RCTs in people two to 18 years of age found that cisapride versus placebo significantly improved stool frequency and symptoms of constipation after eight to 12 weeks of treatment in an outpatient setting. We found no evidence from primary care settings. Cisapride has been withdrawn in several countries because of suspected adverse cardiac effects.

Osmotic Laxatives

One RCT in children eight months to 16 years of age found no significant difference with lactitol versus lactulose in stool frequency and consistency of stools, but found that lactulose significantly increased the proportion of children with abdominal pain and flatulence. Another RCT in children 11 months to 13 years of age found limited evidence that lactitol versus lactulose significantly increased stool frequency and consistency from baseline after 15 days of treatment. A third RCT in infants zero to six months of age found that lactulose significantly improved ease of evacuation and consistency of stools from baseline after 14 days of treatment. However, the benefits shown in these three RCTs are comparisons of outcomes before and after treatment, and were not necessarily because of the treatments. One small RCT in children with encopresis found short-term benefit from the addition of toilet training or biofeedback to stimulant or osmotic laxatives.

Stimulant Laxatives

We found no RCTs in children on the effects of stimulant laxatives versus placebo or alternative treatments. One small RCT found short-term benefit from the addition of toilet training or biofeedback to stimulant or osmotic laxatives.

Biofeedback

Three RCTs found that biofeedback plus conventional treatment (laxatives alone or laxatives plus dietary advice and toilet training) versus conventional treatment alone significantly improved defecation dynamics and reduced rates of soiling after three to seven months. Two of the RCTs found no significant difference in soiling, stool frequency, or laxative use after one year.

Adapted with permission from Rubin GP. Childhood constipation. Clin Evid 2002;8:313–8.

editor's note: Lactitol is not available in the United States.

 

REFERENCES

1. Nelson R, Wagget J, Lennard-Jones JE, et al. Constipation and megacolon in children and adults. In: Misiewicz JJ, Pounder RE, Venables CW, eds. Diseases of the gut and pancreas. 2d ed. Oxford: Blackwell Science, 1994;843–64.

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.

3. Loening-Baucke V. Chronic constipation in children. Gastroenterology. 1993;105:557–63.

4. Roma E, Adamidis D, Nikolara R, Constantopoulos A, Messaritakis J. Diet and chronic constipation in children: the role of fiber. J Pediatr Gastroenterol Nutr. 1999;28:169–74.

This is one in a series of chapters excerpted from Clinical Evidence, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence is published in print twice a year and is updated monthly online. Each topic is revised every eight months, and users should view the most up-to-date version at www.clinicalevidence.com. This series is part of the AFP's CME. See “Clinical Quiz” on page 923.


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