Treatment of childhood constipation by primary care physicians: Efficacy and predictors of outcome

Objective. Childhood constipation accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists. The majority of children who experience constipation and whose caregivers seek medical care are seen by primary care physicians such as pediatricians or family physicians. Little is known about how primary care physicians treat childhood constipation or the success of their treatments. With this study, we prospectively examined which treatments primary care physicians prescribe to children who present for the first time with constipation and how effective those treatments are. Methods. A total of 119 children who were between 2 and 7 years of age ( mean: 44.1 +/- 13.6 months) and presented to 26 different primary care physicians ( 15 pediatricians and 11 family physicians) for the treatment of constipation for the first time participated in this study. Parents completed daily diaries of their child's bowel habits for 2 weeks before starting treatment recommended by their primary care physician and again 2 months after treatment. The prescribed treatment was identified by reviewing office records of the treating physicians. Results. After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. The most commonly prescribed laxatives were magnesium hydroxide (77%), senna syrup (23%), mineral oil (8%), and lactulose ( 8%). In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention. Some form of behavioral intervention was mentioned in the office records of approximately one third of cases; however, in most cases, little detail was provided. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes ( 5%), the use of intermittent laxatives (9%), or no therapy (7%). Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively. Conclusion. Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic.