An ongoing evolution in the clinical management of functional constipation in children is in regard to treatment. Nurko highlights that treatment of constipation in children is evolving from expert recommendations to evidence-based treatments.
Table 6 lists the recommendations for treatment based on the current evidence in the guidelines. Table 7 lists specific treatments not recommended in routine cases.
In his presentation, Nurko discussed a number of these recommendations, highlighting and clarifying the current evidence on many of them. From the current evidence, polyethylene glycol (PEG)-based therapies remain the mainstay for both disimpaction and first-line maintenance therapies. Although the evidence showed a similar efficacy between PEG-based therapy and enemas to treat fecal impaction, the guidelines prioritize PEG-based therapy as first-line treatment because it can be administered orally.3 The guidelines recommend PEG-based solutions as the first-line maintenance medication, or lactulose if PEG is not available. The guidelines do not recommend adding an enema to PEG therapy in routine cases based on evidence showing no benefit to the combined therapy versus PEG alone.
The guidelines also recommend PEG-based therapy for maintenance therapy. If PEG-based therapy is not available, the guidelines recommend lactulose based on its safety and more available data compared with other therapies such as milk of magnesia and mineral oil.3
Important to highlight is the duration of treatment. Although evidence remains lacking on this issue, expert opinion suggests that maintenance therapy should continue for at least 2 months with a gradual tapering of treatment only after a full month after symptoms of constipation have resolved. For infants, expert opinion suggests stopping therapy only after toilet training has been achieved. As for nonpharmacologic treatments, Nurko says that no evidence indicates a benefit for additional fluid or fiber intake in children with constipation. He also notes that no evidence shows a benefit of combining behavioral therapy with laxatives compared with conventional treatment that includes education and toileting. However, evidence does suggest considering referral for children with behavioral problems to behavioral therapy or mental health services.
Key message: Pharmacotherapy treatment should be administered for at least 2 months and be only gradually discontinued after 1 full month of resolution of constipation symptoms.
Functional constipation in children is a common problem. For most cases, history and physical exam are sufficient to make the diagnosis without the need for additional imaging or other tests. The mainstay of treatment is PEG-based therapy, with current recommendations suggesting a duration of treatment of at least 2 months with a gradual reduction of therapy only after resolution of constipation symptoms for 1 month.
1. Koppen IJ, Lammers LA, Benninga MA, Tabbers MM. Management of functional constipation in children: therapy in practice. Paediatr Drugs. 2015;17(5):349-360.
2. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154(2):258-262.
3. Tabbers MM, DiLorenzo C, Berger MY, et al; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274.
4. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):405-407.
5. Yang CH, Punati J. Practice patterns of pediatricians and trainees for the management of functional constipation compared with 2006 NASPGHAN guidelines. J Pediatr Gastroenterol Nutr. 2015;60(3):308-311.
6. Nurko S. Got Colon Congestion? New Evidence-Based Guidelines for Evaluating and Treating Functional Constipation in Kids. Presented at: American Academy of Pediatrics (AAP) National Conference and Exhibition; October 24-27, 2015; Washington, DC.
7. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150(6):1443.e2-1455.e2.
8. Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016;150(6):1456.e2-1468.e2.
9. Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83.e2-88.e2.
10. Benninga MA, Tabbers MM, van Rijn RR. How to use a plain abdominal radiograph in children with functional defecation disorders. Arch Dis Child Educ Pract Ed. 2016;101(4):187-193.