What treatments work best for constipation in children?
Another good-quality RCT showed that PEG + E effectively relieved fecal impaction (92% of 63 children) and was superior to lactulose for maintenance treatment. The rate of adverse effects (abdominal pain) was 64% with PEG + E and 83% with lactulose.4
One fair-quality RCT of 48 children with fecal impaction compared PEG with mineral oil. PEG was more effective, but high-volume PEG caused more vomiting and less compliance.5
A small RCT found that mineral oil treated constipation more successfully than senna at 3 and 10 months of follow-up.6 One poor-quality RCT found that senna was less effective than lactulose and had more side effects (colicky pain, diarrhea).7
,A Cochrane systematic review found no RCTs of stimulant laxatives for CFC and concluded that evidence concerning the efficacy of these agents is insufficient.8
Few studies focus on nonpharmacologic management
A Cochrane systematic review of 9 small, poor-quality RCTs in children with functional fecal incontinence found no significant improvement when biofeedback was added to conventional treatment for as long as 12 months (odds ratio=1.11; 95% confidence interval, 0.78-1.58).9 In 1 small trial, however, adding behavior modification to laxative therapy significantly reduced soiling episodes.
Notably, few studies have focused on nonpharmacologic management of CFC, and most laxative trials are of short duration.
Recommendations
The Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology states that using medication in combination with behavior management can decrease time to remission in children with CFC. Lubricants (mineral oil) and osmotic laxatives (magnesium hydroxide, lactulose, and sorbitol) are safe and effective. Stimulants (senna and bisacodyl) can help some patients whose conditions are difficult to treat. Low doses of PEG may be an effective long-term therapy for hard-to-manage constipation.10
The University of Michigan Guidelines on CFC and soiling are similar. After clean-out, they recommend a maintenance phase that includes behavioral, dietary, and medication components. Osmotic laxatives and lubricants are recommended for long-term treatment; stimulant laxatives should be reserved for short-term use.11
