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Running head: NATURAL ALTERNITIVES TO RELIEVE CONSTIPATION IN CHILDREN
Natural Alternatives to Relieve Constipation in Children
Amanda Schmidt BSN, RN, FNP-s
University of Mary
Amanda Schmidt
March 9, 2014
Evidenced-Based Critically Appraised Topic:
Natural Alternatives to Relieve Constipation in Children
Clinical Scenario
A 6-year-old boy has had functional constipation for the past four months with reported frequency of bowel movements less than three per week with hard stool that is difficult and often painful to pass. The mother reports that she has been treating with Miralax as needed, but wants to try something “more natural” to relieve her son’s constipation. Mom has already been employing behavior modification strategies with the use of a sticker chart, praise and positive affirmations and not scolding with episodes of incontinence.
Clinical Question
Does increasing dietary fiber and/or supplementing with probiotics a safe and effective alternative to relieve constipation in children?
Articles
Coccorullo, P., Strisciuglio, C., Martinelli, M., Miele, E., Greco, L., & Staiano, A. (2010). Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation: A double-blind, randomized, placebo-controlled study. The Journal of Pediatrics, 157(4), 598-601.
Chao, H., Lai, M., Kong, M., Chen, S., Chen, C., & Chiu, C. (2008). Cutoff volume of dietary fiber to ameliorate constipation in children.The Journal of Pediatrics, 153, 45-49
Summary and Appraisal of Key Evidence
Chao et al. (2008) organized a level IIstudy to evaluate the volume of dietary fiber that would relieve constipation in children. Subjects were between the ages of four to fourteen years old and had constipation symptoms with fewer than three bowel movements per week for at least two weeks. Families and participating children were educated at beginning of study on eating a nutrient-balanced, fiber-rich diet (cereals, bran, fruit, and vegetables). To evaluate symptom improvement, a severity scoring system tool was used to measure constipation symptoms over the course of the 12 week study. “Good” improvement was defined as 60% relief of constipation symptoms. Cutoff volumes of fiber to relieve constipation were calculated and evaluated. Over the course to study, fiber was increased over two week increments. As fiber consumed increase, severity of constipation decreased. More than half (53.8%) of subjects had good improvement in constipation. Fiber needs increased with age. The younger group (age 3.1-7.9) had a significant improvement in symptoms when fiber was increased from 9.5 to 10grams or greater per day. The older group (age8-14.9) had a significant improvement in constipation when fiber was increased from 13.5 to 14 grams or greater per day. No adverse effects were mentioned in this study.
In a level II study conducted by Coccorullo et al. (2010) found that supplementing with probiotic Lactobacillus reuteri was able to increase the frequency of bowel movements in children with functional constipation. 44 formula-fed infants at least six months in age were randomized into a double- blind, placebo-controlled study to evaluate the benefits of L. deuteri(DSM 17938) in infants with functional chronic constipation (22 in treatment group and 22 in placebo group). It has been found that Bifidobacteria and Lactobacilli species produce lactic acid and other acids in the gut resulting in a low pH in the colon which enhances peristalsis and subsequently decreases colonic transit time. Use of laxatives was not allowed in the study. Outcomes measures were frequency of bowel movements per week (success defined as greater than three defecations per week), stool consistency (hard, normal, watery), and presence on inconsolable crying. Frequency of BMs increased significantly in control group from 2.82/week at beginning of study to 4.77 at week 8 (p=.0001). Stool consistency did improve over course of study, but not at a significant value when compared against control group. Also, inconsolable crying was actually increased in both groups during treatment period (subjective to mothers’ interpretations). No adverse effects were reported.
Results
Increasing dietary fiber is strongly associated with constipation symptom improvement in children with chronic constipation. Achieving a threshold for dietary fiber was shown to provide complete relief from constipation for over half of the subjects. Dietary fiber has demonstrated to be an important first line treatment for chronic constipation in children.
Supplementation with Lactobacillus reuteri demonstrated efficiency and safety in improving the frequency of bowel movements in infants with functional constipation. It is a safe, simple, and natural way to improve constipation in children.
Critical Bottom Line
Both of these studies are valuable in developing effective treatment strategies to alleviate and correct constipation in the pediatric population. Constipation is a common childhood problem that often follows into adulthood. Early detection and intervention is critical toward improving quality of life for children with chronic constipation and resulting encopresis. Increasing dietary fiber may even abolish the need for laxative use. However, given the small sample size in the probiotic study, further research into probiotics to relieved chronic constipation is needed.
Implications for Practice
I would recommend the use of both increasing dietary fiber and supplementation with probiotics containing L. reuteri to mothers looking for alternatives to treating constipation in their children. It would be important to give guidelines on amount of dietary fiber to incorporate into the diet. As demonstrated in the Chao et al. study, amount does matter.