Editorial

Pediatric Constipation Presents with Added Levels of Complex Care

Edward V. Loftus Jr.

Though I see some interesting mirrors between pediatric and adult gastroenterology in the management of constipation, this month’s cover story brings to light the added hurdles our pediatric gastroenterologists must conquer when treating their patients.

Part of it is driven by the need to work not only with a patient but with his or her parents. The parents definitely add another level of complexity to the medical care of a child with constipation.

Cleanout, then Maintenance

The key message is that most of the time when kids are constipated, treatment is going to involve some sort of cleanout and that may be difficult for parents to handle. Before any long-term maintenance can be implemented, you must alleviate the initial problem and that may require laxatives and it may not be pleasant.

The cover story alludes to the fact that many parents are resistant to the ideas of laxatives or cleanout, which are often necessary in the acute phase of constipation, but our job is to educate the patient and the parent. It’s similar to the resistance we sometimes encounter to effective therapies for inflammatory bowel disease. People have concerns about safety, but you must educate them that often it’s the lack of treatment that will be a bigger issue long term.

In examining our At Issue, the parental concerns of MiraLAX (polyethylene glycol, Bayer) safety seems somewhat reminiscent of the anti-vaccine debate. The mechanism of action of these laxatives are designed not to be absorbed via the bowel and, therefore, should be a safe option for children. It’s encouraging that the Children’s Hospital of Philadelphia will be studying this rigorously to confirm our knowledge for parents who are concerned. Hopefully this will shine the light of evidence-based medicine on this issue and allay fears of parents whose children need that treatment.

We need to get the message out that cleanout is necessary and then high fiber diets or natural options can be introduced, such as the prune and other juices mentioned in the cover story. These natural remedies are unlikely to be effective in the short-term.

With maintenance, we should emphasize fiber supplementation. It’s amazing how often you find when you discuss diet with adults, kids, parents and families, that their diets lack the necessary fiber elements. It’s a reeducation of the entire family, which can be difficult in a busy GI practice. Referrals to dieticians can be greatly helpful in these cases, especially if that dietician specializes in either children or GI issues, or both.

Additionally, many parents show concern for ER visits and the unnecessary abdominal X-ray with a child or a CT scan with a young adult. We should continue to educate our emergency medicine colleagues that constipation is a logical first diagnosis and these images may not be necessary.

Pelvic Floor Dysfunction

The pediatric gastroenterologists should know that on the adult side of constipation, we are seeing an influx of pelvic floor dysfunction/dyssynergia diagnoses. This can be suspected via digital rectal examination and checking for paradoxical movement of the pelvic floor during simulated defecation. The problem is at the level of the anal sphincter and not a slow transit in the colon. Failure to relax those muscles causes the constipation. Though perhaps not as common in the pediatric realm, these dysfunctions do occur and should be remembered when examining a child with constipation.

With dyssynergia, laxatives are just a short-term fix. Definitive treatment involves biofeedback therapy and pelvic floor retraining with our physical medicine and rehabilitation colleagues. It’s remarkably successful and should be considered if a pediatric patient is unresponsive to traditional treatments. Stated another way, one should have a low threshold for ordering anorectal manometry in the work-up of constipation, both in adults and children.

There’s a wide variety of approaches to constipation and even though there may be guidelines out there, I’m not sure everyone is following the guidelines. As always, let me know your thoughts in our Twitter conversations through @EdwardLoftus2 and @HealioGastro.

Disclosure: Loftus reports consulting for Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Eli Lilly, CVS Caremark, Celltrion Healthcare, and Napo Pharma; and research support from Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Robarts Clinical Trials, MedImmune, Allergan, Genentech, and Seres Therapeutics.

Edward V. Loftus Jr.

Though I see some interesting mirrors between pediatric and adult gastroenterology in the management of constipation, this month’s cover story brings to light the added hurdles our pediatric gastroenterologists must conquer when treating their patients.

Part of it is driven by the need to work not only with a patient but with his or her parents. The parents definitely add another level of complexity to the medical care of a child with constipation.

Cleanout, then Maintenance

The key message is that most of the time when kids are constipated, treatment is going to involve some sort of cleanout and that may be difficult for parents to handle. Before any long-term maintenance can be implemented, you must alleviate the initial problem and that may require laxatives and it may not be pleasant.

The cover story alludes to the fact that many parents are resistant to the ideas of laxatives or cleanout, which are often necessary in the acute phase of constipation, but our job is to educate the patient and the parent. It’s similar to the resistance we sometimes encounter to effective therapies for inflammatory bowel disease. People have concerns about safety, but you must educate them that often it’s the lack of treatment that will be a bigger issue long term.

In examining our At Issue, the parental concerns of MiraLAX (polyethylene glycol, Bayer) safety seems somewhat reminiscent of the anti-vaccine debate. The mechanism of action of these laxatives are designed not to be absorbed via the bowel and, therefore, should be a safe option for children. It’s encouraging that the Children’s Hospital of Philadelphia will be studying this rigorously to confirm our knowledge for parents who are concerned. Hopefully this will shine the light of evidence-based medicine on this issue and allay fears of parents whose children need that treatment.

We need to get the message out that cleanout is necessary and then high fiber diets or natural options can be introduced, such as the prune and other juices mentioned in the cover story. These natural remedies are unlikely to be effective in the short-term.

With maintenance, we should emphasize fiber supplementation. It’s amazing how often you find when you discuss diet with adults, kids, parents and families, that their diets lack the necessary fiber elements. It’s a reeducation of the entire family, which can be difficult in a busy GI practice. Referrals to dieticians can be greatly helpful in these cases, especially if that dietician specializes in either children or GI issues, or both.

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Additionally, many parents show concern for ER visits and the unnecessary abdominal X-ray with a child or a CT scan with a young adult. We should continue to educate our emergency medicine colleagues that constipation is a logical first diagnosis and these images may not be necessary.

Pelvic Floor Dysfunction

The pediatric gastroenterologists should know that on the adult side of constipation, we are seeing an influx of pelvic floor dysfunction/dyssynergia diagnoses. This can be suspected via digital rectal examination and checking for paradoxical movement of the pelvic floor during simulated defecation. The problem is at the level of the anal sphincter and not a slow transit in the colon. Failure to relax those muscles causes the constipation. Though perhaps not as common in the pediatric realm, these dysfunctions do occur and should be remembered when examining a child with constipation.

With dyssynergia, laxatives are just a short-term fix. Definitive treatment involves biofeedback therapy and pelvic floor retraining with our physical medicine and rehabilitation colleagues. It’s remarkably successful and should be considered if a pediatric patient is unresponsive to traditional treatments. Stated another way, one should have a low threshold for ordering anorectal manometry in the work-up of constipation, both in adults and children.

There’s a wide variety of approaches to constipation and even though there may be guidelines out there, I’m not sure everyone is following the guidelines. As always, let me know your thoughts in our Twitter conversations through @EdwardLoftus2 and @HealioGastro.

Disclosure: Loftus reports consulting for Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Eli Lilly, CVS Caremark, Celltrion Healthcare, and Napo Pharma; and research support from Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Robarts Clinical Trials, MedImmune, Allergan, Genentech, and Seres Therapeutics.