Introduction:
According to the World Health Organization, a wide range of childhood diseases require supportive and palliative care. Among these conditions, malignancies have a particularly important place. When comprehensive supportive and palliative care is not available at the same time, the required services should be provided according to the patient's condition. Prevention and management of problems such as constipation are among these measures.
Definition:
Normal bowel movements vary among individuals, ranging from once a day to twice a week. Various definitions of constipation have been described in medical literature. In general, constipation refers to a change in a person's usual bowel habits, characterized by difficulty or delay in passing stool or incomplete evacuation. According to available clinical guidelines, the severity of constipation is graded from 0 to 4.
Causes:
Causes of constipation include the following:
- Inadequate food and fluid intake
- Reduced physical activity
- Medication-related causes, including opioids, anticholinergics, antidepressants, antihistamines, serotonin receptor inhibitors, and anticonvulsants
- Use of certain anticancer medications, such as vincristine
- Psychosocial issues, such as fear of using the hospital bathroom
- Supplements such as iron and calcium
- Previous use of laxatives
- Local anal problems, such as ulcers or abscesses
- Electrolyte disorders, such as hypokalemia and hypercalcemia
- Pressure effects caused by tumors, such as spinal cord compression or bowel obstruction
- Hypothyroidism
Evaluation:
After establishing appropriate communication with the child and parents, taking a detailed medical history, investigating underlying causes, assessing psychosocial issues, and performing a complete physical examination are the basic principles in determining the cause of constipation. Because a rectal examination can be stressful for children, it is recommended only when necessary and by a skilled physician after providing adequate explanation. Contraindications to rectal examination, including thrombocytopenia, leukopenia, or mucosal inflammation, should be considered. When deemed appropriate by the physician, laboratory tests and imaging studies may also be helpful.
Treatment:
Treatment of constipation is important because of its complications and its impact on quality of life:
- Symptoms such as nausea, vomiting, loss of appetite, abdominal pain, and bloating
- Avoidance of bowel movements, leading to anal wounds or fissures and worsening constipation
- Anxiety in the child and family
- Complications such as gastrointestinal obstruction, urinary retention, or urinary tract infection
Therefore, the following treatment steps are recommended:
First, depending on the patient's condition, reversible causes of constipation should be treated, followed by appropriate measures to control the symptom.
1- Non-pharmacological treatments:
A) Providing appropriate conditions for bowel movements
B) Improving dietary habits
Adequate intake of water and fluids
Increasing fiber intake, vegetables, and fruits that help relieve constipation
It should be noted that in some cases, particularly in the final stages of life, adding fiber to the diet may not be beneficial because of clinical limitations in oral fluid intake and may even worsen constipation.
C) Increasing daily activity according to the patient's ability
2- Pharmacological treatments: (must be administered under the supervision of the treating physician)
The choice of medication depends on the patient's condition and the severity of constipation. These medications include:
A) Lubricants and stool softeners: Medications such as liquid paraffin (mineral oil) and glycerin suppositories soften stool by promoting water retention and facilitating bowel movements. Therefore, unlike some other laxatives, they do not cause abdominal pain and bloating.
It should be noted that contraindications to rectal examination and suppository use in children with cancer must be taken into consideration.
B) Stimulant laxatives: Medications such as senna and bisacodyl work by increasing fluid secretion into the intestine and stimulating intestinal peristalsis. They act quickly and may be used as a single dose for transient constipation.
C) Osmotic laxatives: These include lactulose, polyethylene glycol, magnesium hydroxide (milk of magnesia), and sorbitol. They draw fluid into the intestine, soften the stool, and stimulate intestinal peristalsis. Lactulose is often the first choice and can be taken with milk or fruit juice, although it may cause abdominal cramps.
D) Bulk-forming laxatives: These include psyllium, methylcellulose, natural fibers, herbal granules, and industrial polymers. It should be noted that, except for natural fibers, the role of bulk-forming agents in the treatment of constipation in children has not been well established.
Key points:
- Sometimes a combination of two or more types of laxatives is needed to soften the stool and increase intestinal peristalsis.
- Because neutropenia and thrombocytopenia are common in children with cancer, the use of suppositories and enemas is restricted in these patients.
** Bisacodyl tablets are not recommended for most patients with cancer because of the risk of abdominal cramping.
Dr. Neda Ashayeri
Pediatric Hematologist & Oncologist
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