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Letter to the editor

Editor, – It was pleasing to see the article 'Managing constipation in children' (Aust Prescr2002;25:85-7) as it is such a common problem. It was particularly pleasing to see the prominence given to the emotional aspects.

However, the article needs several comments. The first is the strong recommendation for oral bowel cleansing solutions and rectal medications. Oral cleansing solutions have significant risks in the presence of faecal impaction. Rectal medications frequently interfere with emotional management.

The article deals with stimulant aperients in the same paragraph as stool softeners. The two have very different indications. Stimulants such as senna and phenolphthalein often cause significant pain or incontinence due to increased muscle activity. Furthermore, their long-term use damages the intramural ganglion cells of the colon.

Stool softening agents are usually all that is needed for children with constipation unless there is an underlying organic cause. The vast majority of children who have no abnormality of the colon (albeit with a secondary fissure) require nothing more than stool softening. Dietary means alone are rarely enough in the first instance, but are important in long-term management. Paraffin oil, either plain or as an emulsion, is the only agent that will soften inspissated faeces. It is not absorbed so is safe to give in large doses and for prolonged periods. It takes 5-10 days to soften old hard faeces, but it will eventually do so and thereby avoid any anal manipulations or general anaesthetic to perform manual evacuation. It has a reputation for interfering with absorption of fat-soluble vitamins, but I am unable to find a reliable reference for this.

Apart from a small number of children with an organic cause or very resistant constipation, the majority of constipated children have a totally normal colon, so once sensation and motility are restored by getting rid of accumulated faeces, they will defecate quite satisfactorily if the stool is soft.

Hugh Martin
Paediatric Surgeon
The Children's Hospital at Westmead
Westmead, NSW