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 Rectum distention Faecal impaction

Faecal incontinence
• 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