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'Top-down' approach treats chronic constipation: bowel clean-out, regular maintenance.

KIAWAH ISLAND, S.C. -- A thorough bowel clean-out followed by regular maintenance therapy is the key to correcting chronic functional constipation in children, Dr. Vita Goei said at a pediatric update sponsored by the Medical College of Georgia.

Dr. Goei suggests a "top-down" approach for clean-out, rather than enemas and suppositories. "By the time most of these kids come to see you, they've been constipated for years. So another 2 weeks isn't going to make any difference. Take the focus off their bottom; let them forget that area is a problem for a while."

The vast majority of constipation is idiopathic--only 5% results from organic disease. There is usually some psychosocial component as well, said Dr. Goei, a pediatric gastroenterologist at the college. "The kids may be anxious, have poor self-esteem, and be less able to cope with stress. But we don't really know which comes fast, the behaviors or the condition. Behavioral abnormalities usually improve when the condition does."

Functional constipation is defined as at least 2 weeks of hard, pebble-like, infrequent stools--in the absence of structural, endocrine, or metabolic disease. It's sometimes initiated by illness, a stressful life event, a vacation during which children avoid defecation in an unfamiliar place, or a frightening association with the toilet bowl. This could be something as obscure as a cartoon or movie image of monsters emerging from the toilet, or an encounter with loud and scary automatic--flushing toilets, Dr. Goei said. It's important to talk to both child and parents and try to uncover any negative associations like this that might be contributing to stool withholding.

In addition to identifying any precipitating event, it's important to ease the family's fears of disease and explain your treatment rationale, proposed treatment course, and expected outcomes.

Conventional therapy starts with an effective clean-out. Dr. Goei advises a week-long course of the osmotic agent polyethylene glycol (MiraLax). Young children should receive 1/2 capful (8.5 g) in 4 ounces of noncarbonated liquid; older children should receive 1 capful (17 g) in 8 ounces of liquid twice a day. The mixture should be consumed on an empty stomach.

Maintenance therapy is usually necessary to assure a regular pattern of at least one large, soft stool daily. The MiraLax regimen can be continued; mineral oil or senna may be substituted. Ex-Lax is now a senna preparation, Dr. Goei noted. Medications may be weaned after about 6 months of regularity .

Children also should increase their fiber intake to 15-20 grams per day. "I usually recommend 10 grams plus whatever the child's age is," she said. "So a 6-year-old would need 16 grams of fiber." This can be done by increasing fruit, vegetable, and whole grain intake, with fiber supplements like Citrucel and Metamucil, or with a special fiber--fortified juice product.

Dr. Goei recommends Juice+Fibre, which contains 10 grams of acacia gum soluble fiber in an 8-ounce box of pure fruit juice made from concentrate (

"This stuff tastes really good and it looks just like any regular juice box," Dr. Goei said. Most children find it extremely palatable.

Teachers should be informed of the treatment plan for school-age children, she noted. Children should be given unlimited access to the bathroom in a way that does not attract the attention of the class.

Good posture on the toilet is important, too. Feet should be flat on the floor with thighs parallel to floor. Balancing on a large toilet causes children to tighten muscles that need to be relaxed to have a bowel movement.
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Title Annotation:Children's Health
Author:Sullivan, Michele G.
Publication:Family Practice News
Geographic Code:1USA
Date:Nov 1, 2003
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