Pijpers MA, Tabbers MM, Benninga MA, Berger MY. Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary measures. Arch Dis Child 2009;94:117-31.
Question
Among children with functional constipation, how effective are different laxatives and dietary measures for treatment of the constipation?
Design
Systematic review.
Data Sources
Medline and Embase databases were searched to identify studies evaluating the effect of a pharmacologic treatment or dietary intervention on functional constipation.
Study Selection and Assessment
Of the 736 studies found, 28 met the inclusion criteria. The quality was assessed using a validated list of criteria. In total 10 studies were of high quality.
Outcomes
Frequency of defecation per week and other related measures.
Main Results
The included studies were clinically and statistically heterogeneous in design. Most laxatives were not compared with placebo. Compared with all other laxatives, polyethylene glycol (PEG) achieved more treatment success (pooled relative risk (RR): 1.47; 95% CI 1.23 to 1.76). Lactulose was less than or equally effective in increasing the defecation frequency compared with all other laxatives investigated. There was no difference in effect on defecation frequency between fiber and placebo (weighted standardized mean difference 0.35 bowel movements per week in favor of fibre, 95% CI 20.04 to 0.74).
Conclusions
Insufficient evidence exists supporting that laxative treatment is better than placebo in children with constipation. Compared with all other laxatives, PEG achieved more treatment success, but results on defecation frequency were conflicting. Based on the results of this review, we can give no recommendations to support one laxative over the other for childhood constipation.
Commentary
This review about laxative treatments for pediatric constipation highlights the need for more high-quality, evidence-based studies on this common medical problem. Investigations regarding this condition have been increasing; however, many studies in this area predate current standards for design and statistical methods and are further compromised by differing definitions, insufficient power and other factors. Therefore, we agree that this common childhood problem deserves a greater effort to determine the best evidence for the components of treatment, including the effect of combinations or multimodal approaches.1, 2 Nonetheless, we have concerns about how readers will interpret the findings of this study. The conclusions of this article could lead practitioners to assume there is no evidence that laxatives help children with constipation. Even though this conclusion might be reached using only studies of efficacy in controlled situations, this belies the availability of studies of effectiveness in typical, complex social circumstances. Although such “lower quality” studies are inherently confounded by a variety of situational and behavioral factors including child development, child adjustment, and parent-child dynamics, so is life. Methods other than randomized controlled trials may more practically determine treatment effectiveness in general application.3 Overall, we hope the readers will learn from this article that better studies in this area are needed; however, we hope that readers will not be deterred in the meantime from using the guidance available from guidelines and consensus statements that have used the best available evidence and have sought the experience from providers across clinical settings including primary care.4
References
1. 1Felt BT, Brown P, Harrison RV, Kochhar PK, Patton S. Functional constipation and soiling in children (Update). Ann Arbor, MI: Office of Clinical Affairs, University of Michigan Health System; 2008;www.med.umich.edu/1info/FHP/practiceguides/newconstipation/peds08.pdf[Available from the Agency for Healthcare Research and Quality at www.guideline.gov] [practice guideline].
2. 2McGrath ML, Mellon MW, Murphy L. Empirically supported treatments in pediatric psychology: Constipation and encopresis. J Pediatr Psychol. 2000;25:225–254. MEDLINE |
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3. 3Berwick DM. The science of improvement. JAMA. 2008;299:1182–1184.
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4. 4Burgers J, Grol R, Eccles M. Clinical guidelines as a tool for implementing change in patient care. In: Grol R, Wensing M, Eccles M editor. Improving Patient Care: Implementation of Change in Clinical Practice. New York, NY: Elsevier; 2005;.
University of Michigan Medical Center, Ann Arbor, Michigan
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