generated during reconstitution and that the solution
should be allowed to cool before drinking.lMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug.
Powder
CAUTIONARY AND ADVISORY LABELS10, 13
ELECTROLYTES:May contain Magnesium, potassium
▶Picolax(Ferring Pharmaceuticals Ltd)
Sodium picosulfate 10 mg, Magnesium oxide 3.5 gram, Citric acid
anhydrous 12 gramPicolax oral powder 16. 1 g sachets sugar-free|
2 sachetp£ 3. 39
2.2 Constipation
Constipation 06-Jun-2017
Description of condition
Constipation is defaecation that is unsatisfactory because of
infrequent stools, difficult stool passage, or seemingly
incomplete defaecation. It can occur at any age and is
common in childhood.
Overview
Before prescribing laxatives it is important to be sure that
the childisconstipated and that the constipation is not
secondary to an underlying undiagnosed complaint. Early
identification of constipation and effective treatment can
improve outcomes for children. Without early diagnosis and
treatment, an acute episode of constipation can lead to anal
fissure and become chronic. In children with secondary
constipation caused by a drug, the drug should be reviewed.
Laxatives
Bulk-forming laxatives
Bulk-forming laxatives include bran, ispaghula husk p. 40 ,
methylcellulose p. 40 and sterculia p. 41. They are of
particular value in children with small hard stools iffibre
cannot be increased in the diet.gThey relieve
constipation by increasing faecal mass, which stimulates
peristalsis; children and their carers should be advised that
the full effect may take some days to develop. Adequatefluid
intake must be maintained to avoid intestinal obstruction,
though this may be difficult for children.h
Methylcellulose, ispaghula husk and sterculia may be used
in patients who cannot tolerate bran. Methylcellulose also
acts as a faecal softener.
Stimulant laxative
Stimulant laxatives include bisacodyl p. 45 , sodium
picosulfate p. 47 , and members of the anthraquinone group,
senna p. 46 , co-danthramer p. 45 and co-danthrusate p. 46.
Stimulant laxatives increase intestinal motility and often
cause abdominal cramp; they should be avoided in intestinal
obstruction.
The use of co-danthramer and co-danthrusate is limited to
constipation in terminally ill patients because of potential
carcinogenicity (based on animal studies) and evidence of
genotoxicity.
Docusate sodium p. 44 is believed to act as both a
stimulant laxative and as a faecal softener (below). Glycerol
suppositories act as a lubricant and as a rectal stimulant by
virtue of the mildly irritant action of glycerol.
Faecal softeners
Faecal softeners are claimed to act by decreasing surface
tension and increasing penetration of intestinalfluid into
the faecal mass. Docusate sodium, and glycerol suppositories
p. 46 have softening properties. Enemas containing arachis
oil p. 44 (ground-nut oil, peanut oil) lubricate and soften
impacted faeces and promote a bowel movement. Liquid
paraffin has also been used as a lubricant for the passage of
stool but manufacturer advises that it should be used with
caution because of its adverse effects, which include anal
seepage and the risks of granulomatous disease of the
gastro-intestinal tract or of lipoid pneumonia on aspiration.
Osmotic laxatives
Osmotic laxatives increase the amount of water in the large
bowel, either by drawingfluid from the body into the bowel
or by retaining thefluid they were administered with.
Lactulose p. 41 is a semi-synthetic disaccharide which is not
absorbed from the gastro-intestinal tract. It produces an
osmotic diarrhoea of low faecal pH, and discourages the
proliferation of ammonia-producing organisms. It is
therefore useful in the treatment of hepatic encephalopathy.
Macrogols (such as macrogol 3350 with potassium chloride,
sodium bicarbonate and sodium chloride p. 42 ) are inert
polymers of ethylene glycol which sequesterfluid in the
bowel; givingfluid with macrogols may reduce the
dehydrating effect sometimes seen with osmotic laxatives.
Macrogols are an effective non-traumatic means of
evacuation in children with faecal impaction and can be used
in the long-term management of chronic constipation.
Bowel cleansing preparations
Bowel cleansing preparations are used before colonic
surgery, colonoscopy, or radiological examination to ensure
the bowel is free of solid contents; examples include
macrogol 3350 with anhydrous sodium sulfate, potassium
chloride, sodium bicarbonate and sodium chloride p. 37 ,
citric acid with magnesium carbonate p. 37 , magnesium
citrate with sodium picosulfate p. 38 and sodium acid
phosphate with sodium phosphate p. 43. Bowel cleansing
preparations are not treatments for constipation.Management
gThefirst-line treatment for children with constipation
requires the use of a laxative in combination with dietary
modification or with behavioural interventions. Diet
modification alone is not recommended asfirst-line
treatment.
In children, an increase in dietaryfibre, adequatefluid
intake and exercise is advised. Diet should be balanced and
contain fruits, vegetables, high-fibre bread, baked beans and
wholegrain breakfast cereals. Unprocessed bran (which may
cause bloating andflatulence and reduces the absorption of
micronutrients) isnotrecommended.
If faecal impaction is not present (or has been treated),
the child should be treated promptly with a laxative. A
macrogol (such as macrogol 3350 with potassium chloride,
sodium bicarbonate and sodium chloride) is preferred as
first-line management. If the response is inadequate, add a
stimulant laxative or change to a stimulant laxative if the
first-line therapy is not tolerated. If stools remain hard,
lactulose or another laxative with softening effects, such as
docusate sodium can be added.
In children with chronic constipation, laxatives should be
continued for several weeks after a regular pattern of bowel
movements or toilet training is established. The dose of
laxatives should then be tapered gradually, over a period of
months, according to response. Some children may require
laxative therapy for several years.
A shorter duration of laxative treatment may be possible
in some children with a short history of constipation.
Laxatives should be administered at a time that produces
an effect that is likely tofit in with the child’s toilet routine.
h
Faecal impaction
gTreatment of faecal impaction may initially increase
symptoms of soiling and abdominal pain. In children over
1 year of age with faecal impaction, an oral preparation
containing a macrogol (such as macrogol 3350 with
potassium chloride, sodium bicarbonate and sodium
chloride) is used to clear faecal mass and to establish and
maintain soft well-formed stools, using an escalating doseBNFC 2018 – 2019 Constipation 39
Gastro-intestinal system1