Because of the multi-dimensional etiology of constipation, a multi-faceted approach to treatment seems most appropriate and effective. Since the vast majority of cases of constipation are functional in origin, treatment discussed will assume a non-organic etiology. The intervention plan for functional constipation includes medication, behavioral modification, bowel retraining, and education. The North American Society for Pediatric Gastroenterology and Nutrition position statement on constipation in infants and children (Baker et al., 1999) recommends an intervention algorithm that begins with treating fecal impaction if present (see Figure 1), followed by education, diet modification, medications, and follow-up.
Treatment Algorithm for Pediatric Constipation*
*Note: Adapted from Baker et al. (1999), Constipation in infants and children: Evaluation and treatment. Retrieved from www.naspgn.org
Levy (2001) suggests a similar stepwise approach beginning with disimpaction followed by maintenance of a clean colon, establishment of more effective toileting patterns, and improvement in family and social interactions. The goal of treatment is complete evacuation of the lower bowel on a daily, or near-daily, basis by the easy passage of soft stools. Treatment to regain muscle tone of the anal canal may be required for 2-6 months (Castiglia, 2001), and maintenance therapy may be needed for up to 2 years (Thompson, 2001). Offering support to parents throughout this time period is essential, as there is no easy or definitive cure, and frustrating relapses can occur (Pyles & Gray, 1997).
In the event that fecal impaction is present, initial treatment is aimed at evacuation of bowel contents either by oral or rectal medications. High doses of mineral oil and polyethylene glycol (PEG, MiraLax) electrolyte solutions are commonly used oral means, while phosphate soda, saline, or mineral oil enemas can be used rectally (Baker et al., 1999). The use of enemas, however, should be avoided if possible (Rogers, 1997) since they are likely to cause more discomfort than oral means. In extreme cases, large volumes of bowel cleansing agents such as GoLytely(r) can be administered in the hospital, but treatment at home with milder substances is preferred.
Once disimpaction has been accomplished, maintenance therapy can begin. A wide variety of laxatives are used, generally in incrementally decreasing dosages (see Table 1 ). Asking parents to keep a diary of bowel movement frequency, consistency, and amount can assist the practitioner in adjusting dosages of medications (Lewis & Muir, 1996). Effective medications available include lubricants such as mineral oil; osmotic laxatives such as lactulose, sorbitol, or PEG; and magnesium hydroxide. Stimulant laxatives such as senna (Senokot(r), Ex-lax(r), Fletcher's Castoria(r)) and bisacodyl (Ducolax(r)) may be needed intermittently as rescue therapy to prevent recurrence of impaction but should be avoided for long-term, daily use (Baker et al., 1999). Use of mineral oil carries with it some danger of aspiration and should be avoided in children who resist taking it or who have dysphagia or vomiting. It has not been documented to interfere with absorption of fat-soluble vitamins (Levy, 2001).
Several studies have been done comparing the effectiveness of different types of laxatives in the management of chronic constipation in children. Gremse, Hixon, and Crutchfield (2002) performed an unblinded, randomized study comparing PEG to lactulose. They found that there were no significant differences in stool frequency, form, and ease of passage between the two medications but that PEG significantly decreased the total colonic transit time compared to lactulose. Parents and caregivers cited PEG as effective in 84% of the children and lactulose as effective in only 46%. PEG overall was the laxative of choice not only for effectiveness but also for ease of administration and tolerability.
In another study, Pashankar and Bishop (2001) also examined the efficacy of PEG as well as the optimal dosing in children. They found that all 20 participants in the study had improved bowel habits with PEG on a mean dose of 0.84 g/kg/d. Beginning on high doses and adjusting accordingly to achieve desired number and consistency of bowel movements was recommended. Side effects were limited to transient diarrhea and flatulence as dosages were adjusted. Unlike lactulose, PEG was found not to cause persistent gas, abdominal pain, or perianal irritation.
Cisapride (Propulsid(r)), a prokinetic agent that increases colonic propulsion, has also been tested as a treatment for constipation in children. Nurko, Garcia-Aranda, Worona, and Zlochisky (2000) performed a double-blind, placebo controlled study over a 2-year period in Mexico. Cisapride was found to improve the number of soft bowel movements achieved by the study participants, but the response was not immediate. This led the investigators to suggest that it not be used as first-line treatment for constipation in children but rather as an option when other laxatives and interventions have failed.
To supplement the effects of treatment with laxatives, changes in diet are recommended. Because a decrease in appetite is sometimes associated with constipation, though, this can prove to be a challenge to parents. It has long been thought that increasing fluids and fiber in the diet aid passage of stool, however the literature is mixed on this issue. Thompson (2001) suggests that fiber does not play a beneficial role in the management of constipation, citing that its role in alleviating constipation has been "overemphasized" (p. 29). Baker et al. (1999) found "no randomized controlled studies that demonstrated a proven effect on stools of increasing intake of fluids, nonabsorbable carbohydrates or dietary fiber in children" (p. 7). Nonetheless, many authors continue to recommend diets that include increased fluids and soluble fiber and that are low in sugar, fat, starch, and insoluble fiber (Abel, 2001; Levy, 2001; Pyles & Gray, 1997; Young, 1996). Including carbohydrates, particularly sorbitol found in some fruit juices, is reported to be helpful (Baker, 1999) though high osmolarity liquids such as Karo(r) syrup have not been proven effective (Young, 1996).
Another controversial area is the effectiveness of biofeedback as a treatment option for constipation. Biofeedback operates by making the child more aware of bodily functions, such as rectal sensitivity to distention, that then "helps alter physiological responses through behavioral modification techniques" (Pyles & Gray, 1997, p. 73). Loening- Bauke (1997) says this type of training can be attempted but the effectiveness of it "has not been well established" (p. 2234). It appears that for severe cases of constipation and those leading to encopresis, biofeedback may be an effective management technique (Baker et al.; Pyles & Gray; Vitito, 1999).
In addition to the use of medications and changes in diet, behavioral modification and parental education are effective interventions in establishing toileting patterns. Encouraging regular toilet use to normalize the behavior and facilitate positive associations with toileting is effective. Colonic stimulation is greatest 10-15 minutes after eating, thus this can be an opportune time to encourage sitting on the toilet for intervals of 10 minutes or so. The child should be comfortable and relaxed; a footstool can help facilitate proper positioning for a bowel movement (Loening- Bauke, 1997; Vitito, 1999). Systems of positive reinforcement can be employed for successful use of the toilet such as stickers on calendars or charts, special activities, and praise (Kuhn et al., 1999; Loening-Bauke, 1997; Pyles & Gray, 1997; Vitito, 1999). Since the process of constipation management can be lengthy, the focus should remain on continuing improvement, not on complete resolution (Vitito, 1999). Successful treatment is contingent on patience and time-consuming interventions on the part of the family. Continual support through close follow- up is, therefore, essential (Baker et al., 1999).
Pediatric nurses and pediatric nurse practitioners can perhaps be most effective at intervening through education. Educating parents about normal stooling patterns, appropriate toilet training practices, and supportive management if problems do arise can prevent or minimize the number and extent of episodes of constipation a child may have. If anticipatory guidance is offered, which enables parents to recognize the early signs of constipation, potentially more deleterious conditions such as impaction and encopresis may be avoided. During well-child visits, continual review of feeding and stooling patterns; dietary habits, including transitions between breastmilk, formulas, and solid foods; and exercise/activity patterns can prevent problems that might lead to constipation. Kuhn, Marcus, and Pitner (1999) suggest using the 15- or 18- month well-child visit to discuss plans for toilet training and make sure that parents understand the importance of developmental readiness of the child. If constipation does occur, continual validation of parental concern, reinforcement of efforts being made, and a review of symptom management and the treatment plan can contribute to a successful outcome for the child (Abel, 2001). If encopresis is involved, teaching parents that soiling is outside the child's control can help alleviate some of the anger and frustration that may ensue. Scheduling follow-up visits every 3-4 weeks, as well as making periodic telephone calls provides excellent opportunities to ascertain management success and provide additional information and support to families.
Pediatr Nurs. 2003;29(4) © 2003 Jannetti Publications, Inc.