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Three Part Question

In a [child presenting with constipation] is an [osmotic laxative or a stimulant laxative] more [effective at preventing recurrences]?

Clinical Scenario

An eight year old child presents to the A and E department complaining of abdominal pains and not having passed a stools for two weeks. You wonder whether the use of an osmotic laxative would have a lower risk of recurrence of constipation and if it would mean fewer side effects for the child over the course of the treatment.

Search Strategy

Medline via ovid to week 3 Oct 2007 and Embase 1980 to May 2007 using OVID interface. The Cochrane Library Issue 3 2007
(constipation.mp OR exp Constipation/ OR exp defeaction/ OR defaecation.mp OR exp Feces/ OR stool$.mp OR face$.mp)
AND
(cathartic.mp OR exp Cathartics/ OR laxative.mp OR [osmotic adj laxative.mp] OR glycerine.mp OR lactulose.mp OR exp Lactulose/ OR exp Polyethylene Glycols/ OR glycol.mp)
AND
[stimulant adj laxative] OR exp Bisacodyl/ OR bisacodyl.mp OR danthron.mp OR docusate.mp OR oxyphenisation.mp OR senn$.mp OR sen$.mp or sodium picosulphate.mp
LIMIT to human and English and all child 0-18 years

Search Outcome

234 papers were found and one randomised control trial and one meta-analysis. 49 results in cochrane 0 relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Price KJ, Elliott TM 2001 UK	Children between the ages of 0 and 18	Article Review	Effect of stimulant laxatives	Not enough trials found, Effectiveness of stimulant laxatives in children can not be commented on.	No trials found
Perkin, J M 1977 UK	20 children under 15 years of age	Randomised Control Trial- The twenty children were randomly assigned to either Lactulose or Senna for a week. There was then one weeks break after which the other laxative was taken for a period of one week.	Character of stools passed	In the Lactulose week the children passed a greater number of normally formed stools than on the corresponding day of the Senna week. The difference was highly significant	For laxatives to take full effect takes time and one week of treatment would not be enough to see if the laxative was fully effective. The article did not follow up the patients to discover the long term effects of the laxatives. The sample size was very small
			Amount of patients reporting adverse effects	Only 1 patient reported side effects in the Lactulose week, compared to 4 in the no treatment week, and 12 patients reporting adverse effects in the Senna week.
			Number of days in which adverse effects were reported	In the Lactulose group side effects were only reported on one day, compared to six days in the no-treatment week and 31 days in the Senna week

Comment(s)

Trials comparing effectiveness of different laxative for the treatment of constipation in children are limited in number. Information on the effectiveness of stimulant laxatives in children was scarce. More research needs to be done comparing the effectiveness of the different laxatives in children before the use of stimulant laxatives can be recommended as the first line in treatment for constipation in children. Articles commenting on the treatment of childhood constipation suggest the use of laxatives though none is usually recommended as the best treatment. The one trial that was found comparing the use of stimulant laxatives to Osmotic laxatives favoured the use of Lactulose over Senna in the treatment of constipation. The trial provided good evidence that the use of Lactulose leads to fewer adverse effects in children compared to Senna, though I don't believe the efficacy of the respective laxatives could fully be explored in such a short length of time. There is an abundance of evidence advocating the use of osmotic laxatives such as Lactulose and PEG (Polyethylene Glycol). The use of Osmotic laxatives should take precedence over Stimulant laxatives as the first line treatment, as the long-term efficacy and safety of PEG and Lactulose has been proven.

Clinical Bottom Line

Osmotic laxatives should be used as the first line treatment in the treatment of children who present with constipation to the Emergency Department.

References

1. Price KJ. Elliott TM. What is the role of stimulant laxatives in the management of childhood constipation and soiling Cochrane Database of Systematic Reviews (3):CD002040, 2001
2. Perkin JM. Constipation in childhood: a controlled comparison between lactulose and standardized senna. Current Medical Research & Opinion 4(8):540-3, 1977