Pediatric Hospital Medicine Journal Club - Macrogol For Treatment Of Constipation
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Pediatric Hospital Medicine Journal Club Moises Auron MD FAAP February 19, 2009.
Summary •
Very limited evidence base supporting the use of laxatives in children • Systematic review – RCT of polyethylene glycol (PEG) versus either placebo or active comparator
• • • • • •
Patients with primary chronic constipation. Outcomes were global assessments of effectiveness or differences in defaecation rates. Seven studies (n = 594 children) Five were comparisons of PEG with lactulose, one with milk of magnesia and one with placebo. PEG based treatments having been proven to be effective and well-tolerated first-line treatment.
Constipation • • • • • •
Experience of painful bowel movements Toilet training Changes in routine or diet Stressful events Intercurrent illness Delaying defaecation.
Constipation Water reabsorption
Hard stools Difficult and painful to pass Decreased urge
Faecal incontinence
Rectum distention
Faecal impaction
•
75–80% of the weight of the normal stool – H2O
•
A difference of only 10% will result in marked changes in stool consistency.
•
PEG - water soluble polymer - form hydrogen bonds with 100 molecules of water per molecule of PEG (MW 3350).
•
Colonic content hydration improved transit and painless defaecation
•
Standard management of chronic constipation tends to begin with correction of dietary and lifestyle factors which predispose to the condition, in particular by increasing dietary fibre and fluid intake. However, dietary manipulation alone, including the use of corn syrup, was successful in resolving all symptoms of constipation in only 25% of children aged up to 2 years in one US study. Where simple measures fail, or where disimpaction is required, the next step involves one or more
Literature search
Study criteria
Discussion • Improved evidence based information • Once disimpacted, even severely affected children can be maintained satisfactorily on low doses of PEG • PEG can be used as monotherapy • 1/3 of patients on lactulose required senna • No patient on PEG+E reimpacted compared with almost one in four on lactulose. • Different PEG doses - cannot necessarily assume equivalence. • Different doses - titration vs. fixed dose • No clinical studies comparing PEG with PEG+E
Summary •
Very limited evidence base supporting the use of laxatives in children • Systematic review – RCT of polyethylene glycol (PEG) versus either placebo or active comparator
• • • • • •
Patients with primary chronic constipation. Outcomes were global assessments of effectiveness or differences in defaecation rates. Seven studies (n = 594 children) Five were comparisons of PEG with lactulose, one with milk of magnesia and one with placebo. PEG based treatments having been proven to be effective and well-tolerated first-line treatment.
Constipation • • • • • •
Experience of painful bowel movements Toilet training Changes in routine or diet Stressful events Intercurrent illness Delaying defaecation.
Constipation Water reabsorption
Hard stools Difficult and painful to pass Decreased urge
Faecal incontinence
Rectum distention
Faecal impaction
•
75–80% of the weight of the normal stool – H2O
•
A difference of only 10% will result in marked changes in stool consistency.
•
PEG - water soluble polymer - form hydrogen bonds with 100 molecules of water per molecule of PEG (MW 3350).
•
Colonic content hydration improved transit and painless defaecation
•
Standard management of chronic constipation tends to begin with correction of dietary and lifestyle factors which predispose to the condition, in particular by increasing dietary fibre and fluid intake. However, dietary manipulation alone, including the use of corn syrup, was successful in resolving all symptoms of constipation in only 25% of children aged up to 2 years in one US study. Where simple measures fail, or where disimpaction is required, the next step involves one or more
Literature search
Study criteria
Discussion • Improved evidence based information • Once disimpacted, even severely affected children can be maintained satisfactorily on low doses of PEG • PEG can be used as monotherapy • 1/3 of patients on lactulose required senna • No patient on PEG+E reimpacted compared with almost one in four on lactulose. • Different PEG doses - cannot necessarily assume equivalence. • Different doses - titration vs. fixed dose • No clinical studies comparing PEG with PEG+E
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