Non-Pain Symptoms
Constipation:
This is often described as the slow movement of faeces through the large intestine resulting in the passage of dry, hard stools.
For some children it may be normal to pas stools only every few days, but hard stools that are difficult to pass accompanied by pain or sense of incomplete bowel evacuation should be considered as constipation(5).
Causes:
Some causes include:
- Gastrointestinal tract
- obstruction
- painful anorectal conditions (anal fissures, hemorrhoids)
- Drugs (opioids, anticholinergic, antacids, 5 HT antagonist, anticonvulsants and vinca alkaloids)
- Metabolic disturbances (hypokalemia, uremia)
- Neurological disorders (spinal cord involvement)
- Depression
- Sedation
- Low fiber diet and poor fluid intake
Opioids induce constipation through many ways:
- Delay the gastric emptying secondary due to a tone increase of the pyloric sphincter
- Delay stool transit time through the small bowel (jejunum) due o an increase in non-propulsive contractions (leading to an increase in water and electrolytes absorption).
- Increased tone of the internal anal sphincter.
The constipation effect of opioids is immediate and dose related and unlike most other side effects patients never become tolerant to it(7).
Treatment:
Non pharmacological:
- Increased fluid intake or fiber in specific cases can be useful.
- Always the child’s privacy should be considered to provide comfort.
Pharmacological:
- Osmotic laxatives:
- produce osmotic effect in colon resulting in distention and promotion of peristalsis.
- Examples are Lactulose, Magnesium hydroxide and PEG 3350.
PEG 3350 (Polyethylene glycol) is well tolerated and commonly used.
Recommended dose:
1 gram/kg/day OD or divided in two doses. Max dose is 17grams /day.
- Colonic stimulants:
- used to promote peristalsis.
- Examples are Bisacodyl , Senna.
- Lubricants:
- produce soft stools and decrease water absorption from GI.
- Example is Mineral oil.
- Bulking agents:
- Absorb water in intestine to form viscous liquid that promotes peristalsis and reduces transit time.
- Example is Psyllium.
- Emollient stool softeners:
- Help to keep stools soft for an easy natural passage.
- Example is Docusate.
