Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses

ABSTRACT

Introduction: Constipation occurs in many children and can become chronic. Many grow out of it but for one third, it continues into adulthood. For most patients, there is no identifiable organic disorder and it is classified as functional constipation.

Areas covered: In 2016, treatment of childhood constipation was extensively reviewed by Rome IV. This review covers meta-analyses and evidence for treatment of paediatric constipation since 2016 and new emerging treatments.

Expert opinion: Since 2016, meta-analyses conclude 1) fibre should be included in a normal diet, but further supplementation does not improve constipation; 2) probiotics may increase stool frequency in children, but evidence from larger RCTs is needed; 3) comparing laxatives, polyethylene glycol (PEG) is superior to placebo, lactulose and milk of magnesia, and 4) appendix stomas are effective and should be considered before surgery. Emerging areas of study include food intolerance, electrical stimulation and faecal microbiota transplant. For research, outcome measures need standardising to allow comparison between studies and allow meta-analyses. To assist this, validated GI instruments have been developed by Rome IV and PedsQl.

KEYWORDS:

• FODMAPS
• fructose intolerance
• electrical stimulation
• neuromodulation
• microbiome
• faecal microbiota transfer
• laxatives
• constipation

Article Highlights

• Functional constipation is common in children and may continue into adulthood in 1/3 of affected children

• Functional Bowel diseases include constipation and Irritable bowel syndrome.

• Diagnosis and treatment were extensively reviewed by Rome IV in 2016 and European Society for Paediatric Gastroenterology, Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (ESPGHAN/NASPGHAN) in 2014.

• Algorithms and questionnaires are available online from the Rome Foundation.

• Adequate fluid and fibre should be part of a normal diet, but extra intake is not supported by evidence.

• Probiotics- the level of evidence is currently poor. No single strain or combination of strains can be recommended yet based on the evidence from randomised-controlled trials (RCTs) for Functional Constipation (FC). Probiotics may increase stool frequency in children, but evidence from larger RCTs is needed.

• Lactobacillius reuteri DSM 17938 may be considered for breastfed colic infants.

• Polyethylene glycol (PEG) is more effective than other laxatives for disimpaction and maintenance. Laxatives should be given in high doses for disimpaction and continued for many months.

• Low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) diets reduce abdominal pain and bloating in IBS.

• Fructose and lactose intolerance produce constipation and diet exclusion can relieve symptoms.

• Electrical stimulation with interferential current is emerging as an adjuvant therapy for refractory patients.

• Correction of the microbiome could be a future option in children.

Declaration of Interest

B Southwell is an advisor to GI Therapies (a company producing a prototype electrical stimulation device) and holds patents for electrical stimulation devices and methods. They have been funded by the Murdoch Children’s Research Institute (Melbourne Australia) and by GI Therapies and previously by the Australian Government (National Health and Medical Research Council, Senior Research Fellowship and Project Grants).

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

A Peer reviewer on this manuscript would like to disclose that they are consulting for Allergan, Ironwood, Salix, Shire (now Takeda).

Additional information

Funding

This paper was not funded.