Enema versus polyethylene glycol for the management of rectal faecal impaction in children with constipation – a systematic review of randomised controlled trials

Abstract

IntroductionRectal faecal impaction (RFI) from functional constipation is a common problem in children. Maintenance therapy should start after successful disimpaction. However, there is uncertainty with regard to the optimal disimpaction regimen.AimWe systematically evaluated the effect of polyethylene glycol (PEG) compared to enema for treating RFI.Material and methodsThe MEDLINE, EMBASE, and the Cochrane Library, with no language restrictions, were searched up to July 2014 for randomised controlled trials (RCTs) evaluating the effect of PEG compared with enema for disimpaction in children with functional constipation. The risk of bias was assessed using the Cochrane risk of bias tool.ResultsTwo RCTs, involving 170 children aged 1 to 17 years, met the inclusion criteria. The studies were generally low in methodological quality. Compared with the enema group, the PEG 3350 group had significantly reduced chance for treatment success, but the difference was of a borderline statistical significance (RR = 0.83, 95% CI: 0.7–0.99). The use of PEG was also more likely to increase defecation frequency, but increased the risk of watery stools and increased faecal incontinence. Other outcomes, in general, were similar in both groups.ConclusionsCurrent evidence does not allow us to conclude which intervention is more effective for treating RFI in children with functional constipation. These results should be interpreted with caution due to the limited number of trials and the low quality of reporting in these trials, high or unknown risk of bias, and sparse data. Further high-quality, adequately powered RCTs are needed to determine the optimal management.

Unmet Needs in Pediatric Functional Constipation

“… 14 , 16 , 18 Dietary fibers, traditional medicine, and probiotics are commonly used; however, the clinical evidence supporting their use is not clear. 16 , 19 - 22 Prebiotics and probiotics may be effective at improving clinical symptoms, but data from RCTs are limited. 19 , 21 …”

“…14,16,18 Dietary fibers, traditional medicine, and probiotics are commonly used; however, the clinical evidence supporting their use is not clear. 16,[19][20][21][22] Prebiotics and probiotics may be effective at improving clinical symptoms, but data from RCTs are limited. 19,21 Among the nonpharmacological interventions, sacral neuromodulation provides a suitable option for refractory PFC, but it is not frequently used, and data on its clinical benefits in children are limited.…”

“…• Currently limited or no public health attention to PFC in pediatric residency programs 22,23 • Limited knowledge/understanding of idiopathic PFC pathophysiology, secondary causes, comorbidities, and treatment/management 22,[24][25][26] Nonpharmacological: 61 • Short-term improvements with enemas and surgery 17,18 • Sacral nerve modulation benefits sustained; data limited 16 Long-term outcomes: 26…”

An Update of Pharmacological Management in Children with Functional Constipation

“…The effect of enemas on disimpaction has been investigated by a limited number of studies. A systematic review included two studies comparing the effect of oral PEG to enemas (dioctyl sulfosuccinate sodium and milk and molasses) for disimpaction in children aged 1–17 years with FC [ 68 ]. The primary outcome was treatment success, defined as the absence of fecaloma in one study and no need to visit the emergency department in the other study [ 68 ].…”

Superiority of mosapride citrate to picosulfate sodium as a laxative for withdrawal from regular enemas in children with severe functional constipation

“…Patients treated with PEG were excluded from the study because PEG was not available in Japan during the start of the study. Míngues et al [22] and Dziechciarz et al [23] showed that PEG monotherapy is adequate for disimpaction in children with FC, although it is inferior to enemas [23]. In fact, a procedure similar to enema-free disimpaction has been performed in adults undergoing colonoscopy preparation [24].…”