October 30, 2017
ARTICLE:

Constipation (part two)

By Dr Megan Yap - Paediatrician

Hi again mums and dads!

So to continue on from where we left off last week on this “hard” topic (ha ha!), we were going to discuss the different products that are on the market to treat constipation.

Back in the day (like ~20 years ago) when I worked in community pharmacies (first as a pharmacy assistant, then later as a pharmacist), the products used to treat constipation were kept in the “Tums and Bums” section of the shop (kept with all the antacids, enemas, suppositories etc).  There has always been a wide variety of products available, but the first line recommended treatments for children have changed over the years.

Let’s have a chat about what is out there… and I’ll talk you through what I usually recommend.

 

PRODUCTS

Coloxyl infant drops (active ingredient is poloxamer) – this product is a stool softener.  It works by decreasing the surface tension of water and allowing it to more easily penetrate the stool.  I only really recommend it in babies, I don’t find it that useful or effective in older children.

Actilax, Duphalac (active ingredient is lactulose) – this is a syrupy sweet medicine that works as an osmotic laxative.  That basically means that the sugars that are in it do not get absorbed in the gut, but stay in the digestive tract, drawing water out of the tissues so it mixes with the poo and makes it more liquid/soft. You can technically use these products from 6 months of age, but I don’t really recommend them at all.  They can cause bloating and tummy pain.

Parachoc, Agarol (vanilla), plain paraffin oil (active ingredient: paraffin oil) – this product is an oily product that is essentially NOT absorbed by the body but works by lubricating (ie greasing up) the bowel wall (so the poo can slide through more easily) and softening the stool.  You can use it in kids from 12 months of age.  I still see this prescribed quite a lot by other doctors, but it is not one of my favourites.  The main reason is that there is a risk that, if children regurgitate it (reflux, vomit), it can be accidentally aspirated (ie breathed into the lungs) and cause breathing problems.  It is recommended to not be given within 2 hours of lying down.  Oh, and it can cause an orange coloured, oily seepage in the undies.

{Interestingly and for a bit of a laugh…  When I was at uni, I heard a story of a group of guys (who were long time friends), playing a joke on one of the group when they were off camping on a boy’s weekend.  They made breakfast pancakes, one batch made with vanilla flavoured Agarol…  This one mate slept in that morning, and I’ll let you imagine what happened to this poor unsuspecting lad later that morning when the boys were all out fishing, wearing waders in the surf…}

Stimulant laxatives (eg bisacodyl (Dulcolax); senna preparations (eg Laxettes, Coloxyl with senna)) – I don’t recommend these at all in children.   Technically bisacodyl can be used in kids over 4 years, and senna preparations in kids over 12 years, but they are not very nice.  They work by stimulating the bowel to contract.  They can cause painful tummy cramping, are not useful in longstanding constipation and cannot be used for a long time or they start to make your bowel “lazy”).

Glycerol/glycerine suppositories – these are pretty harmless but aren’t that nice to administer.  They work in 2 ways, melting and lubricating the rectal passage so the poo will just slide on out, AND by virtue of inserting the suppository (usually with a little KY lubricant), the incidental stimulation of the anal sphincter causes the bowel to contract – expelling the faeces.

Enemas (eg Microlax) – a small volume of liquid inserted (via a nozzle) into the rectum that releases water in the poo to soften the stool up.  I would not generally advise that you use an enema on your child unless they have been seen by and are under the supervision of your doctor.  We do use enemas in children, but usually in more severe cases of longstanding constipation (and sometimes impaction).

Last but not least, iso-osmotic laxatives (eg Movicol (which tastes a little salty as it has both the iso-osmotic laxative AND some electrolytes in it); Osmolax; Clearlax).  This group of medications has really become the main stay of constipation treatment (acute OR chronic) in kids over 2 years.  You mix a powder with liquid (water only in the case of Movicol in kids 2 years and older; or any drink in the case of Osmolax in kids 4 years and older – eg tea, coffee, milk, juice etc etc) and it works by preventing the absorption of the liquid in which it is dissolved in the gut, meaning the water stays in the gut lumen (ie the middle of the tube) making the stool softer.

This last group is the laxative that I use in children the most to treat constipation.

 

Okay, so the product you choose really dose depend on the age of the child you are treating…

So in little babies – we tend to go pretty easy.  There are a few things you need to know about constipation in little bubs:

  • If your baby is less than 6 weeks old and appears constipated, you will need to go and see your doctor for sure.  Constipation in really young infants is often due to an underlying medical condition
  • It takes a little while for babies to figure out how to co-ordinate their “pushing” of the poo, with relaxing the muscles of their anus/pelvic floor to allow the faeces to come out.  It can LOOK like they are constipated (they strain, grunt, cry and go red in the face) but when the poo finally comes out, it is soft, pasty and normal looking.  This is called “dyschezia” and basically means unco-ordinated pooping.  It is harmless, very common, and resolves with time as the baby figures out what to do.  You can HELP them by gently holding their knees up towards their stomach as they push. If they are really struggling, short term you can use a little paediatric glycerine suppository (with a bit of KY jelly lubricant on it) or the lubricated end of a rectal thermometer to gently stimulate the anus (this helps it to relax).  I would advise that you seek the advice of your doctor (and have your baby examined properly) though if you get to the point of considering this!
  • Breast fed babies can poo many times a day (like, 8 times or more after every feed) or as INFREQUENTLY as once every 7-10 days.  This is normal.  Don’t worry.

In babies less than 6 months old, I would advise

  • brown sugar (about a half a metric tsp) in about 30 mL of warm water – three times a day before feeds until the stool becomes soft and then stop
  • pear (when my little one was a baby, I could only ever find pear+apple juice – this is fine) or prune juice, usually I water this down, and there is no strict rules around “dosage” but I’d say start with about 20-30mL once or twice a day initially and see how you go.
  • Coloxyl drops (a stool softener)

In babies and toddlers (6 months – 2 years) 

  • I would usually recommend Coloxyl drops (note this does NOT contain a stimulant – this is just the stool softener) or
  • Lactulose

In children older than 2 years, I would use one of the iso-osmotic laxatives in a “scaling-up” regimen until a soft stool (around the consistency of wet cement) is passed every day.

  • Movicol Half sachets in kids from 2 years (has been much easier to get kids to take this since they brought out the chocolate flavour!  You can also give it in lime cordial to hide the salty taste a bit better)
  • And I prefer to use Osmolax in kids from 4 years old – reason being it doesn’t taste like anything, you can stick it in any drink and kids tend to not mind having it for this reason.

 

Take home messages:

  • Constipation is really common, affecting something like 1 in every 3 children!
  • In the case of chronic/long-standing constipation, it is important to STAY ON the medication for at least 3-6 months to allow the bowel to regain its sensitivity and function.
  • Talk to your GP or paediatrician if your child has issues with constipation – there are many products on the market and it is important to choose the right one!
  • Constipation can usually be well controlled with good toileting habits and sometimes the use of medicines.

 

I hope this post has been useful to help explain the types of products on the market for children with constipation, and give you an idea of how to approach treating it!

 

Pharmacy and paediatric friends out there – feel free to comment and let me know if you have favourite products that you use, and if I am outdated in my product knowledge (it has been a looooong time since I worked in retail pharmacy!)

 

Stay well!

xxDr Megs

For more articles from Dr Megan Yap visit her blog – “Dr Megs – Paeds & Feeds” at http://www.kids-health.guru/

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