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![ Polyethylene glycol without electrolytes (PEG 3350
powder; Miralax® and others) — 1 to 1.5 gm/kg/day for
three days. The daily dose is dissolved in approximately
10 mL/kg of water or flavored beverage. In a randomized
placebo-controlled study, these doses successfully
disimpacted 95 percent of children with chronic
constipation [36].
Of note, PEG 3350 was found to be as effective as
enemas in treating impaction, but children treated with
PEG had more fecal incontinence [37].
Further safety studies are needed before this approach
can be recommended in infants.
Polyethylene glycol-electrolyte solution 25 mL/kg per hour
to a maximum of 1000 mL/hr by nasogastric tube until
stool appears clear, or 20 mL/kg per hour for four hours
per day [10,34].](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-27-320.jpg)
![ TREATMENT OF INFANTS — Constipation is treated somewhat differently in infants as compared to
children. When constipation presents early in life, the clinician should be particularly alert for evidence
of organic disease, including cystic fibrosis and Hirschsprung disease. Guidelines and an algorithm for
diagnosing and treating constipation in infants were developed by the North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and are included in a Clinical
Practice Guideline at the society's Web site (http://www.naspghan.org/). The functional and organic
causes of constipation in infants are discussed in a separate topic review. (See "Constipation in
children: Etiology and diagnosis", section on 'Functional versus organic'.)
Infants with functional constipation frequently respond to treatment with non-digestible osmotically
active carbohydrates, such as sorbitol-containing juices. Dark corn syrup has been used in the past.
However, current preparations of dark corn syrup may not contain the glycoproteins that are fermented
into osmotically active particles in the colon, so the syrup may be ineffective for treating constipation. If
these measures are unsuccessful, addition of osmotic laxatives and/or occasional disimpaction with
glycerin suppositories can be useful. (See "Prevention and treatment of acute constipation in infants
and children", section on 'Acute constipation' and "Prevention and treatment of acute constipation in
infants and children", section on 'Recurrent constipation' and 'Laxatives' below.)
The choice of medications for treatment of functional constipation in infants is similar to that in children.
(See 'Treatment of children' below.) However, there are some important differences in treatment
decisions for infants:
Osmotic laxatives such as lactulose or sorbitol are frequently used and are usually effective in infants.
The use of polyethylene glycol without electrolytes (PEG-3350, or Miralax®) for infants <24 months of
age was reported in two small case series [2,3]. The treatment was generally effective and no adverse
effects were noted in either study. The mean effective maintenance dose was approximately 0.8 g/kg
body weight per day. Thus, experience with polyethylene glycol is increasing in infants, although the
safety is less well established than with older age groups.
Mineral oil is not recommended in infants, or in other children prone to gastroesophageal
reflux, because of potential risks of pneumonitis if aspirated.
Use of enemas and stimulant laxatives (such as bisacodyl or senna) are also not recommended in this
age group because of potential complications.](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-28-320.jpg)
![ TREATMENT OF CHILDREN
Overview — Treatment of chronic functional constipation and fecal incontinence should
be tailored to the severity of constipation and the child's developmental stage [4]. A
comprehensive program, including the use of laxatives, behavior changes, dietary
changes, and close follow-up is often necessary, particularly for children who have gone
several days between bowel movements, have an anal fissure with bleeding, or have
very large-diameter stools with marked straining [4-10]. A suggested treatment plan for
children with chronic constipation but without overflow incontinence that can be printed
out and given to parents is shown in the table (table 2). A suggested treatment plan for
children with chronic constipation and fecal incontinence is provided separately (table
3).
The goal of therapy is the achievement of one soft stool per day. Weeks to months, and
sometimes years, of laxative and behavior therapy may be necessary before this goal is
achieved. Nonetheless, improvement can be expected in most patients. (See
'Outcome' below.)
The combined laxative and behavioral approach has been used since the 1960s [11]. It
has been evaluated in only a few controlled studies [12-14] but is largely supported by
cohort studies, case-control studies, and clinical experience [15-22].
Analysis of intervention trials is complicated by the varied methods used for laxative and
behavioral treatments. Consequently, conclusions also vary, but generally support the
use of combination therapy with both of these modalities. As an example, a large study
found that the combination of behavioral intervention and laxative therapy was more
effective than behavioral therapy alone (achievement of remission: 63 versus 43
percent, respectively) [12]. Another study showed that combination therapy was more
effective than laxative therapy alone (improvement rates: 78 versus 45
percent, respectively) [13], whereas a similar randomized study did not show such an
effect [23]. A systematic review concluded that combined behavioral and laxative
treatment was more effective than either intervention alone [9]. Evidence supporting
biofeedback was lacking [9,13].](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-29-320.jpg)
![ Guidelines for management of infants and children with
constipation were developed by the North American
Society for Pediatric Gastroenterology, Hepatology, and
Nutrition (NASPGHAN), and were endorsed by the
American Academy of Pediatrics [10]. These guidelines
include a management algorithm, and are available as a
Clinical Practice Guideline at the society's Web site
(http://www.naspghan.org/). The position statement
recommends the following actions in children with
functional constipation for more than two weeks [10]:
Provide parental education.
Determine whether impaction is present.
Remove the impaction via oral or rectal medication.
Start maintenance therapy with laxatives, behavior
modification, and dietary changes; adjust laxatives as
necessary.
Provide close follow-up.
The following sections will provide further detail in some of
the elements involved in the care of these patients.](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-30-320.jpg)
![ Oral — Oral medications for disimpaction are noninvasive and may help
the child feel in control [10]. Oral medications are usually preferred for
children with a history of painful defecation, perineal trauma, or the
inability to tolerate enemas [4,28]. However, adherence with the
necessary volume may be difficult [10].
Polyethylene glycol without electrolytes, polyethylene glycol-electrolyte
solutions, or high-dose mineral oil has been shown to be effective for
initial disimpaction [28,33-37]. The polyethylene glycol without electrolytes
is generally the most palatable of these options and better accepted by
children [10]. The doses are as follows:
Polyethylene glycol without electrolytes (PEG 3350 powder; Miralax® and
others) — 1 to 1.5 gm/kg/day for three days. The daily dose is dissolved in
approximately 10 mL/kg of water or flavored beverage. In a randomized
placebo-controlled study, these doses successfully disimpacted 95
percent of children with chronic constipation [36]. Of note, PEG 3350 was
found to be as effective as enemas in treating impaction, but children
treated with PEG had more fecal incontinence [37]. Further safety studies
are needed before this approach can be recommended in infants.
Polyethylene glycol-electrolyte solution — 25 mL/kg per hour to a
maximum of 1000 mL/hr by nasogastric tube until stool appears clear, or
20 mL/kg per hour for four hours per day [10,34].
Mineral oil — 15 to 30 mL per year of age, up to 240 mL per day. In
infants, neurologically impaired children, and others at high risk for
gastroesophageal reflux, mineral oil should not be used because of risks
of pneumonitis if the oil is aspirated [38,39].](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-31-320.jpg)
![ Polyethylene glycol — Polyethylene glycol without electrolytes (PEG 3350, Miralax®) is an
osmotic laxative. It is approved for short-term management of constipation in adults, and is
available without prescription in the United States. Experience in children is increasing [2,3,60-
66]. Because it is more palatable and has fewer adverse effects than other agents, PEG without
electrolytes has become the preferred laxative for children in many centers, even though it is
not yet labeled for this use. The typical dose is 0.4 to 0.8 gm/kg per day (up to 17 gm)
[60,61,63,67]. In a dose-ranging trial, the dose of 0.4 g/kg/day was most likely to give high
success rates (74 percent) while generating fewer complaints of abdominal pain or fecal
incontinence than higher doses [68].
We recommend an initial dose of 4 tsp (17 gm = approximately 3.5 tsp), increased or decreased
by 1/2 tsp to 1 tsp every other day until the consistency of the stools is soft to loose. We have
rarely had to use more than 6 to 7 tsp per day.
Initial experience suggests that PEG without electrolytes has efficacy similar to that of
lactulose and magnesium hydroxide with fewer adverse effects and greater acceptance, as
illustrated below [60,64,65,69]:
One of the largest controlled trials compared PEG without electrolytes (4 to 8 g per day) to
lactulose (3.3 to 6.7 g per day) in 96 children (aged 6 months to 3 years) with functional
constipation [65]. At the end of 6 and 12 weeks of therapy, stool frequency was similar in both
groups. However, compared to the children in the lactulose group, those in the PEG group had
fewer hard stools (9 versus 34 percent and 6 versus 28 percent at 6 and 12
weeks, respectively), fewer episodes of fecal impaction (2 versus 13 percent during the 12
weeks), and less use of enemas (30 versus 43 percent and 17 versus 41 percent during the first
and second six week periods, respectively). Children in the PEG group also had less vomiting
and flatulence than did those treated with lactulose.
In another controlled trial, 79 children with chronic constipation and fecal incontinence were
randomly assigned to treatment with PEG without electrolytes or milk of magnesia for 12
months [69]. Significant improvement in frequency of bowel movements, episodes of
incontinence, and resolution of abdominal pain occurred in both groups. However, compliance
was higher in the PEG group (95 versus 65 percent).](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-32-320.jpg)
![ Oral preparations of PEG with electrolytes
(Transipeg®, Movicol) are available outside the
United States. The addition of electrolytes alters the
taste, which may decrease palatability. One trial from
the Netherlands compared the efficacy of PEG with
electrolytes (Transipeg®) to lactulose in 100 children
with functional constipation [70]. Compared to the
pretreatment period, defecation frequency
increased, and episodes of fecal incontinence
decreased in both groups after eight weeks of
therapy. However, success (defined as ≥3 bowel
movements per week and ≤1 episode of fecal
incontinence every two weeks) occurred more
frequently in the PEG group (56 versus 29 percent).
Children in the PEG group reported less abdominal
pain, straining, and pain at defecation, but
complained of bad taste more often than those in the
lactulose group. Similar results were reported in a
smaller study [35].](https://image.slidesharecdn.com/estreimientoenlainfancia-130617132759-phpapp02/85/Estrenimiento-en-la-infancia-33-320.jpg)
Subido porEcogastropediatría
Estreñimiento en la infancia
Este documento trata sobre el estreñimiento en la infancia. Explica que el estreñimiento funcional representa el 90% de los casos y que es importante diferenciarlo de las causas orgánicas. Describe los criterios de Roma para diagnosticar el estreñimiento funcional y la fisiopatología multifactorial de este trastorno. Finalmente, resume las estrategias para el tratamiento, incluyendo medidas dietéticas, desimpactación y prevención de recaídas.
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Estreñimiento en la infancia
- 1. ESTREÑIMIENTO EN LAINFANCIA. ¿CUÁNDO DERIVAR AL ESPECIALISTA? Dr. Miguel Ángel López Casado Unidad de Gastroenterología Infantil Hospital Virgen de las Nieves de Granada
- 2. ESTREÑIMIENTO. INTRODUCCIÓN En Algunasculturas un patrón de defecación normal se considera señal de buena salud. El estreñimiento es un síntoma y no una enfermedad. Es tarea importante del pediatra diferenciar el estreñimiento funcional (90%) del que puede estar relacionado con causas orgánicas (10%)
- 3. ESTREÑIMIENTO. CONCEPTO El patrónde defecación normal en el niño es variable según la edad y tipo de alimentación. En la 1ª semana de vida pueden ser normales cuatro deposiciones, disminuyendo progresivamente con los cambios en la alimentación. Por encima de los cuatro años el hábito intestinal es similar al adulto, variando desde 3 deposiciones al día a tres deposiciones semana.
- 4. EPIDEMIOLOGÍA La prevalencia deestreñimiento en niños ha aumentado en las últimas décadas, estimándose entre el 0,3- 28%. La amplitud del rango se debe a los distintos criterios diagnósticos utilizados y a las diferencias culturales. Supone el 3% de los niños remitidos al pediatra general y el 25% de los remitidos al gastroenterólogo pediátrico. La prevalencia es mayor en los niños de muy bajo peso al nacimiento y en los afectos de parálisis cerebral. El estreñimiento es discretamente más frecuente en varones a diferencia de los adultos, en que es más frecuente en mujeres. La incontinencia fecal es más frecuente en varones.
- 5. ESTREÑIMIENTO FUNCIONAL (EF) Sehan hecho intentos para definir los criterios diagnósticos y establecer la terminología adecuada del EF. En 1997, un grupo de expertos se reunió en Roma para definir los criterios diagnósticos (Roma II) de varios trastornos funcionales gastrointestinales en los niños. Posteriormente se revisaron estos criterios (Roma III) llegando a un consenso basado en la experiencia clínica y la revisión de la literatura.
- 6. CRITERIOS DE ROMAII Disquecia del lactante Llanto o irritabilidad de al menos 10 minutos de duración antes de la emisión de heces blandas en un lactante por lo demás sano. Estreñimiento funcional En lactantes y niños preescolares al menos dos semanas de: Escíbalos, heces caprinas, heces duras en la mayoría de ocasiones o heces de consistencia firme con frecuencia igual o inferior a dos veces por semana, y ausencia de anomalía estructural o enfermedad endocrinológica o metabólica.
- 7. CRITERIOS DE ROMAII Retención fecal funcional Desde el periodo de lactante hasta el adolescente, una historia de al menos dos semanas de heces voluminosas con una frecuencia inferior a dos veces por semana. Postura de retención, evitando la defecación mediante contracción del suelo pélvico y músculos glúteos. Manchado fecal no retentivo En mayores de cuatro años En las 12 semanas precedentes de una o más veces por semana : Defecación en momento o lugar inadecuado (contexto social) Ausencia de enfermedad estructural o inflamatoria ausencia de signos de retención fecal.
- 8. ROME III CRITERIAFOR THE DIAGNOSIS OF FUNCTIONAL CONSTIPATION IN CHILDREN Infants and toddlers At least two of the following present for at least one month Two or fewer defecations per week At least one episode of incontinence after the acquisition of toileting skills History of excessive stool retention History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of large-diameter stools that may obstruct the toilet
- 9. ROME III CRITERIAFOR THE DIAGNOSIS OF FUNCTIONAL CONSTIPATION IN CHILDREN Children with developmental age 4 to 18 years At least two of the following present for at least two months Two or fewer defecations per week At least one episode of fecal incontinence per week History of retentive posturing or excessive volitional stool retention History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of large-diameter stools that may obstruct the toilet
- 10. TERMINOLOGÍA RECOMENDADA POREL GRUPO PACCT. (2005) (PACCT) ―The Paris consensus on childhood constipation terminology Group‖
- 11. FISIOLOGÍA DE LADEFECACIÓN Depende de una compleja combinación de funciones autónomas y voluntarias. El recto termina en el suelo pélvico, pasa a través del músculo elevador del ano y se continúa como canal anal. El canal anal está rodeado por los esfínteres interno (musculatura lisa) y externo (musculatura estriada), cuyo tono basal crea una zona de alta presión. Esta zona de alta presión es un mecanismo de continencia, actuando como una barrera frente a la presión rectal.
- 12. DEFECACIÓN NORMAL La transmisióndel impulso nervioso, producido por la distensión rectal, en sentido distal, a través de los plexos mientéricos de la pared rectal, produce la relajación refleja de la musculatura lisa del esfínter anal interno (reflejo inhibitorio anal). . Si el momento no es oportuno, la contracción voluntaria del músc. puborrectal y del esfinter anal externo, reducen este ángulo evitando la defecación y acomodan el recto a su contenido. El aumento de la presión intrarrectal impulsa las heces hacia el canal, el músculo puborrectal se relaja y baja el suelo pélvico rectificando el ángulo anorrectal, se relaja el esfinal anal externo y se evacúan las heces
- 13. FISIOLOGÍA DE LADEFECACIÓN II El control voluntario dela defecación se adquiere a partir de los 18 meses. El 98% de los niños de 3 años controla esfínteres. La frecuencia de la defecación disminuye con la edad y se relaciona estrechamente con el tiempo de tránsito intestinal. La frecuencia declina desde 4 deposiciones diarias durante la primera semana de vida hasta 1-2 deposiciones por día a los cuatro años de edad. Habitualmente, a los 4 años de edad la frecuencia de defecación es similar a la del adulto, variando desde 3 deposiciones diarias a 3 por semana.
- 14. LAS CAUSAS ORGÁNICASDE ESTREÑIMIENTO Trastornos anatómicos (ano anterior, estenosis anal) Neurológicos (PCI, hipotonía, mielomeningocele, SIC, enfermedad de Hirschsprung…) Endocrinológicos (hipotiroidismo, diabetes insípida) Metabólicos (hipercalcemia, acidosis tubular renal).
- 15. FISIOPATOLOGÍA ESTREÑIMIENTO CRÓNICO Lafisiopatología del estreñimiento funcional es multifactorial y es idiopático en el 95% de los casos. Existen problemas conductuales en los niños estreñidos, pero habitualmente son leves y pueden ser secundarios a la disfunción intestinal. En algunos casos puede relacionarse el comienzo con algún factor desencadenante (inicio de la lactancia artificial, cambio de residencia, inicio escolaridad, nacimiento de un hermano, enfermedad aguda con reposo en cama, problema familiar, etcétera), pero en la mayor parte de los casos no es posible identificar el desencadenante.
- 16. FISIOPATOLOGÍA ESTREÑIMIENTO FUNCIONALII El paso de heces secas y duras puede causar dolor y fisura anal y puede establecerse un círculo vicioso de dolor-retención-dolor. La etiología basada en el dolor se apoya en que un elevado porcentaje de niños con incontinencia fecal tiene antecedentes de defecación dolorosa. La predisposición genética es otro de los factores importantes en el desarrollo de un estreñimiento crónico. Muchos niños inician el estreñimiento en los primeros meses de vida y tienen historia familiar de estreñimiento.
- 17. FISIOPATOLOGÍA ESTREÑIMIENTO FUNCIONALIII La postura retentiva es probablemente uno de los causas principales factores para el desarrollo o persistencia del estreñimiento en la infancia. El período de entrenamiento del control de la defecación es especialmente crítico. Cuando el niño retentivo experimenta urgencia defecatoria, adopta una postura erecta con estiramiento de las piernas y contracción de la musculatura pélvica y glútea. El recto se acomoda a su contenido y la urgencia defecatoria desaparece. Las heces retenidas son más difíciles de evacuar y se produce una distensión rectal progresiva con incontinencia por rebosamiento, pérdida de la sensibilidad rectal y desaparición de la percepción consciente de urgencia defecatoria. Esta conducta anómala se asocia con frecuencia a una contracción inconsciente del esfínter anal externo durante la defecación (disinergia anal).
- 18. CLÍNICA El estreñimiento crónicoalcanza su máxima frecuencia entre los 2 y los 4 años de edad. La mayoría de los niños estreñidos muestran una disminución de la frecuencia de defecación asociada a incontinencia fecal, heces voluminosas y duras, postura retentiva y defecación dolorosa. La incontinencia fecal es más frecuente en varones, puede ser intermitente o diaria, habitualmente sólo diurna (sobre todo, por la tarde y con el ejercicio) y puede asociarse a problemas emocionales y de conducta. Otros síntomas asociados frecuentemente al estreñimiento crónico son dolor abdominal, irritabilidad, anorexia y distensión abdominal. La existencia de fracaso de desarrollo, vómitos, distensión abdominal persistente y dolor abdominal intenso deben hacer sospechar una causa orgánica responsable del estreñimiento.
- 19. DIAGNÓSTICO Una buena anamnesisy un examen físico cuidadoso suelen ser suficientes para establecer el diagnóstico. Sólo se realizarán exploraciones complementarias en estreñimientos severos o con mala respuesta al tratamiento y cuando se sospeche una causa orgánica. El diagnóstico diferencial fundamental del estreñimiento funcional en el lactante debe establecerse con la enfermedad de Hirschsprung. La historia clínica debe prestar especial atención al calibre, volumen y frecuencia de las deposiciones, edad de comienzo, historia dietética y familiar, existencia de incontinencia fecal, desarrollo ponderoestatural, actitud retentiva, defecación dolorosa, síntomas y signos asociados, búsqueda de factor desencadenante y respuesta al tratamiento previo. El examen físico debe incluir la exploración abdominal (distensión, masa palpable) y de las zonas sacra y anorrectal (localización del ano, fisura, celulitis, tono del esfínter, ampolla rectal vacía o llena de heces).
- 20. DIAGNÓSTICO II La manometríaanorrectal está indicada en niños con estreñimiento severo y cuando debe excluirse la existencia de una enfermedad de Hirschsprung. Si no se observa reflejo anal inhibitorio, debe realizarse enema de bario y biopsia rectal. Pueden observarse, de manera más o menos frecuente, disminución de la sensibilidad rectal, aumento del tono del esfínter anal y contracción paradójica del esfínter anal externo (disinergia anal). La radiología simple puede ser útil para valorar la retención fecal y para el examen de la columna lumbosacra. Los estudios con contraste no están indicados en el estreñimiento no complicado. En algunos casos puede tener utilidad el estudio del tiempo de tránsito colónico con marcadores radioopacos.
- 21. TRATAMIENTO Las medidas terapéuticasdeben adaptarse al grado y severidad del estreñimiento y a la existencia o no de incontinencia fecal. Los niños con estreñimiento simple pueden requerir únicamente medidas dietéticas, evitando los hábitos indeseables y las dietas bajas en fibra. Debe recomendarse una adecuada ingesta de líquidos y añadir frutas, vegetales o preparados de carbohidratos a la dieta. Durante los primeros meses de vida estas medidas deben aplicarse con precaución porque la fermentación puede producir una excesiva distensión gaseosa. Las medidas dietéticas deben asociarse a un entrenamiento del hábito de defecación (acudir al baño después de las comidas y adoptar una postura adecuada). El estreñimiento crónico con megarrecto e incontinencia precisa un programa terapéutico más rígido. El objetivo inicial es mantener el recto vacío para disminuir el tamaño rectal, incrementar la sensibilidad rectal y evitar la incontinencia. Consta de tres fases: 1) educación,2) desimpactación y 3) prevención de la reacumulación de heces.
- 22. EDUCACIÓN Y MEDIDASDIETÉTICAS Información sobre los patrones normales de defecación, entrenamiento del hábito de defecación, refuerzo verbal y recompensas selectivas. No existen estudios randomizados controlados sobre la eficacia del incremento de la ingesta de líquidos, carbohidratos y oligosacáridos en niños con estreñimiento crónico. En algunos estudios, el incremento de la ingesta de líquidos produce un incremento en la producción de orina y no influye en la frecuencia y consistencia de las deposiciones. La relación entre ingesta de fibra y estreñimiento es controvertida. Algunos estudios encuentran una baja ingesta de fibra en niños estreñidos comparados con controles sanos, pero en otros no se observa ninguna diferencia. Se ha referido la eficacia del empleo de glucomanán en niños estreñidos mayores de 4 años.
- 23. DESIMPACTACIÓN La desimpactación rectales necesaria para que el tratamiento de mantenimiento sea efectivo. Si se omite la desimpactación, el tratamiento oral con laxantes puede producir efectos paradójicos con incremento de la incontinencia. La desimpactación puede realizarse por vía oral, rectal o la combinación de ambas. El polietilenglicol (PEG) a dosis de 1,5 g/kg/día durante 3-4 días ha sido utilizado con éxito y seguridad en la desimpactación fecal en niños. Cuando el tratamiento oral adecuado no es efectivo puede recurrirse a los enemas (aceite de parafina, fosfatos, laurilsulfato sódico) (Tabla II). Los efectos del empleo de enemas a largo plazo no han sido bien estudiados. Los enemas de fosfatos pueden producir hiperfosfatemia e hipocalcemia en niños pequeños.
- 24. DESIMPACTION In childrenwith fecal retention, disimpaction and/or catharsis are usually necessary before maintenance therapy can begin. Disimpaction and catharsis can be effectively accomplished with oral or nasogastric medications, rectal medications, or a combination. The parents and child should be involved in the decision regarding the appropriate route. Disimpaction can usually be performed in the outpatient setting . It is important to assess the response to the regimen as soon as possible after it is completed. Successful catharsis is usually indicated by parental report of abundant fecal production and decreased episodes of soiling. Hospitalization may be necessary if several attempts of outpatient management have failed to yield abundant stool. Inpatient regimens may include the combination of an enema and suppository, or the nasogastric administration of a balanced electrolyte solution (ie, GoLYTELY) to flush out the colon. Pulsed irrigation enhanced-evacuation systems and enemas with Gastrografin and Tween-80 (a nonionic surfactant solution) are other techniques that have been successfully used for disimpaction in cases of stool retention. These enemas can be administered in or out of the hospital. Consultation with a pediatric gastroenterologist should be considered if disimpaction is unsuccessful or if hospitalization is necessary.
- 25. MANTENIMIENTO Tras ladesimpactación, debe iniciarse inmediatamente el tratamiento con laxantes orales y mantenerlo durante meses para prevenir la reacumulación de heces retenidas y la recurrencia de la impactación. Laxantes osmóticos: la función de los laxantes osmóticos es disminuir la consistencia de las heces, facilitar su transporte y expulsión y disminuir el dolor durante la defecación. La dosis se incrementa hasta obtener los efectos deseados y debe mantenerse al menos durante 3 meses. El lactitiol y la lactulosa se han mostrado efectivos en incrementar la frecuencia de la defecación y normalizar la consistencia de las heces con pocos efectos secundarios. Las sales de magnesio ejercen un efecto osmótico y estimulan la motilidad colónica por estimulación secretora hormonal. El aceite mineral es un laxante no osmótico que ablanda y lubrica las heces facilitando la expulsión del bolo fecal disminuyendo el dolor. Está contraindicado en menores de un año.
- 26. POLYETYLENGLYCOL (PEG) Las solucionesde PEG con electrolitos se utilizan desde hace más de una década para la limpieza intestinal en la preparación de las exploraciones endoscópicas. Más recientemente se ha propuesto su uso a dosis bajas de 0,3-0,8 g/kg/día para el tratamiento del estreñimiento. El PEG es un compuesto no absorbible de alto peso molecular que no es metabolizado por la flora cólica y ejerce un efecto osmótico en la luz intestinal. Es más efectivo que otros laxantes osmóticos y por su mínima absorción y nula fermentación produce muy pocos efectos secundarios. Varios estudios demuestran su eficacia y seguridad en el tratamiento de niños con estreñimiento crónico.
- 27. Polyethylene glycolwithout electrolytes (PEG 3350 powder; Miralax® and others) — 1 to 1.5 gm/kg/day for three days. The daily dose is dissolved in approximately 10 mL/kg of water or flavored beverage. In a randomized placebo-controlled study, these doses successfully disimpacted 95 percent of children with chronic constipation [36]. Of note, PEG 3350 was found to be as effective as enemas in treating impaction, but children treated with PEG had more fecal incontinence [37]. Further safety studies are needed before this approach can be recommended in infants. Polyethylene glycol-electrolyte solution 25 mL/kg per hour to a maximum of 1000 mL/hr by nasogastric tube until stool appears clear, or 20 mL/kg per hour for four hours per day [10,34].
- 28. TREATMENT OFINFANTS — Constipation is treated somewhat differently in infants as compared to children. When constipation presents early in life, the clinician should be particularly alert for evidence of organic disease, including cystic fibrosis and Hirschsprung disease. Guidelines and an algorithm for diagnosing and treating constipation in infants were developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and are included in a Clinical Practice Guideline at the society's Web site (http://www.naspghan.org/). The functional and organic causes of constipation in infants are discussed in a separate topic review. (See "Constipation in children: Etiology and diagnosis", section on 'Functional versus organic'.) Infants with functional constipation frequently respond to treatment with non-digestible osmotically active carbohydrates, such as sorbitol-containing juices. Dark corn syrup has been used in the past. However, current preparations of dark corn syrup may not contain the glycoproteins that are fermented into osmotically active particles in the colon, so the syrup may be ineffective for treating constipation. If these measures are unsuccessful, addition of osmotic laxatives and/or occasional disimpaction with glycerin suppositories can be useful. (See "Prevention and treatment of acute constipation in infants and children", section on 'Acute constipation' and "Prevention and treatment of acute constipation in infants and children", section on 'Recurrent constipation' and 'Laxatives' below.) The choice of medications for treatment of functional constipation in infants is similar to that in children. (See 'Treatment of children' below.) However, there are some important differences in treatment decisions for infants: Osmotic laxatives such as lactulose or sorbitol are frequently used and are usually effective in infants. The use of polyethylene glycol without electrolytes (PEG-3350, or Miralax®) for infants <24 months of age was reported in two small case series [2,3]. The treatment was generally effective and no adverse effects were noted in either study. The mean effective maintenance dose was approximately 0.8 g/kg body weight per day. Thus, experience with polyethylene glycol is increasing in infants, although the safety is less well established than with older age groups. Mineral oil is not recommended in infants, or in other children prone to gastroesophageal reflux, because of potential risks of pneumonitis if aspirated. Use of enemas and stimulant laxatives (such as bisacodyl or senna) are also not recommended in this age group because of potential complications.
- 29. TREATMENT OFCHILDREN Overview — Treatment of chronic functional constipation and fecal incontinence should be tailored to the severity of constipation and the child's developmental stage [4]. A comprehensive program, including the use of laxatives, behavior changes, dietary changes, and close follow-up is often necessary, particularly for children who have gone several days between bowel movements, have an anal fissure with bleeding, or have very large-diameter stools with marked straining [4-10]. A suggested treatment plan for children with chronic constipation but without overflow incontinence that can be printed out and given to parents is shown in the table (table 2). A suggested treatment plan for children with chronic constipation and fecal incontinence is provided separately (table 3). The goal of therapy is the achievement of one soft stool per day. Weeks to months, and sometimes years, of laxative and behavior therapy may be necessary before this goal is achieved. Nonetheless, improvement can be expected in most patients. (See 'Outcome' below.) The combined laxative and behavioral approach has been used since the 1960s [11]. It has been evaluated in only a few controlled studies [12-14] but is largely supported by cohort studies, case-control studies, and clinical experience [15-22]. Analysis of intervention trials is complicated by the varied methods used for laxative and behavioral treatments. Consequently, conclusions also vary, but generally support the use of combination therapy with both of these modalities. As an example, a large study found that the combination of behavioral intervention and laxative therapy was more effective than behavioral therapy alone (achievement of remission: 63 versus 43 percent, respectively) [12]. Another study showed that combination therapy was more effective than laxative therapy alone (improvement rates: 78 versus 45 percent, respectively) [13], whereas a similar randomized study did not show such an effect [23]. A systematic review concluded that combined behavioral and laxative treatment was more effective than either intervention alone [9]. Evidence supporting biofeedback was lacking [9,13].
- 30. Guidelines formanagement of infants and children with constipation were developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and were endorsed by the American Academy of Pediatrics [10]. These guidelines include a management algorithm, and are available as a Clinical Practice Guideline at the society's Web site (http://www.naspghan.org/). The position statement recommends the following actions in children with functional constipation for more than two weeks [10]: Provide parental education. Determine whether impaction is present. Remove the impaction via oral or rectal medication. Start maintenance therapy with laxatives, behavior modification, and dietary changes; adjust laxatives as necessary. Provide close follow-up. The following sections will provide further detail in some of the elements involved in the care of these patients.
- 31. Oral —Oral medications for disimpaction are noninvasive and may help the child feel in control [10]. Oral medications are usually preferred for children with a history of painful defecation, perineal trauma, or the inability to tolerate enemas [4,28]. However, adherence with the necessary volume may be difficult [10]. Polyethylene glycol without electrolytes, polyethylene glycol-electrolyte solutions, or high-dose mineral oil has been shown to be effective for initial disimpaction [28,33-37]. The polyethylene glycol without electrolytes is generally the most palatable of these options and better accepted by children [10]. The doses are as follows: Polyethylene glycol without electrolytes (PEG 3350 powder; Miralax® and others) — 1 to 1.5 gm/kg/day for three days. The daily dose is dissolved in approximately 10 mL/kg of water or flavored beverage. In a randomized placebo-controlled study, these doses successfully disimpacted 95 percent of children with chronic constipation [36]. Of note, PEG 3350 was found to be as effective as enemas in treating impaction, but children treated with PEG had more fecal incontinence [37]. Further safety studies are needed before this approach can be recommended in infants. Polyethylene glycol-electrolyte solution — 25 mL/kg per hour to a maximum of 1000 mL/hr by nasogastric tube until stool appears clear, or 20 mL/kg per hour for four hours per day [10,34]. Mineral oil — 15 to 30 mL per year of age, up to 240 mL per day. In infants, neurologically impaired children, and others at high risk for gastroesophageal reflux, mineral oil should not be used because of risks of pneumonitis if the oil is aspirated [38,39].
- 32. Polyethylene glycol— Polyethylene glycol without electrolytes (PEG 3350, Miralax®) is an osmotic laxative. It is approved for short-term management of constipation in adults, and is available without prescription in the United States. Experience in children is increasing [2,3,60- 66]. Because it is more palatable and has fewer adverse effects than other agents, PEG without electrolytes has become the preferred laxative for children in many centers, even though it is not yet labeled for this use. The typical dose is 0.4 to 0.8 gm/kg per day (up to 17 gm) [60,61,63,67]. In a dose-ranging trial, the dose of 0.4 g/kg/day was most likely to give high success rates (74 percent) while generating fewer complaints of abdominal pain or fecal incontinence than higher doses [68]. We recommend an initial dose of 4 tsp (17 gm = approximately 3.5 tsp), increased or decreased by 1/2 tsp to 1 tsp every other day until the consistency of the stools is soft to loose. We have rarely had to use more than 6 to 7 tsp per day. Initial experience suggests that PEG without electrolytes has efficacy similar to that of lactulose and magnesium hydroxide with fewer adverse effects and greater acceptance, as illustrated below [60,64,65,69]: One of the largest controlled trials compared PEG without electrolytes (4 to 8 g per day) to lactulose (3.3 to 6.7 g per day) in 96 children (aged 6 months to 3 years) with functional constipation [65]. At the end of 6 and 12 weeks of therapy, stool frequency was similar in both groups. However, compared to the children in the lactulose group, those in the PEG group had fewer hard stools (9 versus 34 percent and 6 versus 28 percent at 6 and 12 weeks, respectively), fewer episodes of fecal impaction (2 versus 13 percent during the 12 weeks), and less use of enemas (30 versus 43 percent and 17 versus 41 percent during the first and second six week periods, respectively). Children in the PEG group also had less vomiting and flatulence than did those treated with lactulose. In another controlled trial, 79 children with chronic constipation and fecal incontinence were randomly assigned to treatment with PEG without electrolytes or milk of magnesia for 12 months [69]. Significant improvement in frequency of bowel movements, episodes of incontinence, and resolution of abdominal pain occurred in both groups. However, compliance was higher in the PEG group (95 versus 65 percent).
- 33. Oral preparationsof PEG with electrolytes (Transipeg®, Movicol) are available outside the United States. The addition of electrolytes alters the taste, which may decrease palatability. One trial from the Netherlands compared the efficacy of PEG with electrolytes (Transipeg®) to lactulose in 100 children with functional constipation [70]. Compared to the pretreatment period, defecation frequency increased, and episodes of fecal incontinence decreased in both groups after eight weeks of therapy. However, success (defined as ≥3 bowel movements per week and ≤1 episode of fecal incontinence every two weeks) occurred more frequently in the PEG group (56 versus 29 percent). Children in the PEG group reported less abdominal pain, straining, and pain at defecation, but complained of bad taste more often than those in the lactulose group. Similar results were reported in a smaller study [35].
- 34. Laxantes estimulantes:cuando el uso de laxantes osmóticos no es suficiente, puede asociarse un laxante estimulante como sen o bisacodilo. No se aconseja su uso a largo plazo, aunque son fármacos razonablemente seguros a dosis bajas. Otros tratamientos: en caso de incontinencia fecal con alteración de conducta y de incontinencia fecal no- retentiva es preciso el apoyo psicológico. La disinergia anal y los niños con tono esfinteriano bajo de causa no orgánica pueden mejorar con la manometría anorrectal terapéutica (biofeedback). El tratamiento quirúrgico queda reservado para casos muy seleccionados.
- 35. PRONÓSTICO La respuesta terapéuticaes buena, pero un 50% de losniños recaen en los primeros 5 años tras el tratamientoinicial y entre un 30-50% presentan síntomas recurrentes a largo plazo. El comienzo precoz del estreñimiento (<1 año) y la existencia de incontinencia fecal en la valoración inicial son indicadores de mal pronóstico
- 36. ¿CUÁNDO ENVIAR ALNIÑO CON ESTREÑIMIENTO CRÓNICO AL ESPECIALISTA? Todos los niños con estreñimiento severo y aquellos con sospecha de enfermedad orgánica gastrointestinal deben ser valorados por un especialista en gastroenterología pediátrica. Asimismo los pacientes que no mejoran en 6 meses, a pesar de haber hecho correctamente el tratamiento, también deben ser referidos Diagnóstico diferencial • Estreñimiento Funcional (95 %) • Causas orgánicas – Ano anterior – Estenosis anal – Enf. De Hirschsprüng y postoperatorio de la misma – Anomalías de la médula espinal (mielomeningocele, disrrafismos, etc) – Pseudoobstrucción crónica intestinal • Asociado a enfermedades metabólicas (diabetes, hipotiroidismo, acidosis renal, hipercalcemia) • Asociado a tratamientos farmacológicos (fenitoína, codeína, etc)