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Re: Bisacodyl in chronic constipation

Dear Editor

Sharif et al recommend bisacodyl (Dulcolax) by mouth to achieve disimpaction in children with chronic constipation [1]. Bisacodyl comes as enteric-coated tablets which should not be crushed or chewed and I am not aware that there is a liquid preparation. The majority of children with stool-withholding chronic consipation are toddlers who will not take tablets. How do the authors get round that problem? Using suppositories is never a good idea in children with this problem or indeed any problem!

References

Send letter to journal:
Re: Re: Bisacodyl in chronic constipation

Dear Editor,

In response to Dr. Tawfik's query, we use bisacodyl(dulcolax) by mouth. The enteric coated tablets appear to work well, even if crushed. Karen O'Driscoll -GI Clinical Nurse Specialist- finds that whole tablets can be effectively disguised in garden peas!

We wholeheartedly agree with Dr.Tawfik that suppositories are particularly to be avoided in this group. We reserve any form of per- rectal disimpaction treatment for only the most recalcitrant problems, and then usually in an in-patient setting with sedation.

In fact, we believe that rectal examinations for the purposes of assessment should also be avoided. When the history and clinical examination does not give a definite diagnosis of suspected functional constipation, an abdominal x-ray is appropriate and preferable to the potential traumatisation asssociated with digital examination.

Dr Bourke

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Re: The Role of Liquid Paraffin in the Treatment of Constipation

Dear Editor

We read with interest the article by Sheriff et al on "Liquid Paraffin: a reappraisal of its role in the treatment of constipation." which appeared in your journal. Besides the important facts projected in it, we like to strengthen the article by putting forth our views and additional points for the benefit of the readers.

The authors have concluded that concerns regarding the development of fat soluble vitamins deficiency in those administered liquid paraffin are unfounded. However, it has been reported that if liquid paraffin is taken within two hours of a meal, it impairs absorption of fat soluble vitamins (A,D,E,K) [1]. The Food and Drug Administration Act (FDA) in fact requires the following warning on all non prescpition preparations containers of liquid paraffin "Do not take with meals". Hence, it is prudent to advise the patients to take liquid paraffin either three hours before or after the meals. Additionally, the approved FDA label also insists that pregnant women must not use liquid paraffin since the hemorrhage disease of the newborn may result from hypovitaminosis K.

The authors contention that liquid paraffin medication is free from carcinogenicity in dogs or rodents can be disputed since carcinogenicity in some species of mice. Researches believe that it could indirectly induce cancer in man through the production of pulmonary fibrosis [2,3,4]. However, extrapolation of these animal data to human beings is difficult.

The authors have mentioned that liquid paraffin has an established track record as an effective treatment modality for childhood constipation. However, they have also pointed out that there have been a number of case reports of lipoid pneumonia developing in association with liquid paraffin ingestion. We suggest the following instructions to the patients which might possibly help to minimize this complication to a larger extent.

1. Patients must be upright while taking liquid paraffin.
2. Patients must be able to raise the top half of the trunk to approximately to a 70 angle.
3. Patients who are confined to bed or who remain in prone, side-lying or supine position must not use it.
4. Liquid paraffin should be taken 30-60 min prior to bedtime so that it moves into intestine when the patient is lying down thus avoiding the possibility of being aspirated. They also should make sure that it is taken three hours before or after meals.
5. As concurrent administration of stools softeners (docusate) with liquid paraffin can result in systemic lipid granulomatous [5], patients should be advised not to take docusate if they are presently taking liquid paraffin.

Finally, this article examined the theoretical possibility of aspiration and the authors suggested that most children less than 12 months old are treated with lactulose in place of liquid paraffin. We would like to point out that care should be taken while using lactose in children with lactulose intolerance because of the presence of some free lactose present in the lactulose. Further, unlike liquid paraffin, lactulose takes about 2-3 days to exert its laxative action. We suggest that, in contrast to lactulose, magnesium salts (hydrochloride or sulphate) is inexpensive and useful when rapid bowel evacuation is required [6]. However, in high doses they must be used with caution and their regular use must be avoided.

Thulasimani M
Department of Paediatrics
Community Health Center
Mannadipet
Pondicherry-605 006
India

Ramaswamy S
Department of Clinical Pharmacology
Jawaharlal Institute of Postgraduate Medical Education & Research
Pondicherry-605 006.
INDIA

References
(1) Donatelle EP. Constipation: Pathophysilogy and treatment. Am Fam Physician 42: 1335; 1990
(2) Wald A Constipation and facal incontinence in the elderly. Gastroenterol Clin North Am 19: 405; 1990
(3) Rousseau p . Treatment of constipation in the elderly. Post grad Med. 83: 339; 1988.
(4) Granella M, Clonfera E., The mutagenic activity and polycyclic aromatic hydrocarbon content of mineral oils. Int Arch Occup Environ Health 91:149; 1991.
(5) Randell RA Nasal cancer and mineral oil (Letter). Lancet 335: 56; 1990.
(6) Luscombe DK Constipation and diarrhoea, In. Clinical Pharmacy and therapeutics ( Eds) Walker A & Edward C, Churchill Livingstone, London,pp169-80,1999.

Send letter to journal:
Re: Re: The Role of Liquid Paraffin in the Treatment of Constipation

Dear Editor

We are most grateful to Drs Thulasimani and Ramaswamy for the interest that they have shown in our paper on liquid paraffin use in children. Some of the points raised in this letter underline our inability to draw firm conclusions on which to base recommendations regarding liquid paraffin therapy because of a lack of evidence.

For example, fat soluble vitamin malabsorption remains a theoretical possiblity if liquid paraffin is taken near meals (indeed, by convention, we recommend night-time liquid paraffin dosing on account of this). Nonetheless, there is a lack of data to support this concern.

Concerns regarding carcinogenicity and granuloma formation underlie much of the suspicion with which liquid paraffin is viewed in some quarters. However, as we have pointed out, there is no direct evidence for liquid paraffin-induced carcinogenicity in humans, despite prolonged use.

Lipoid pneumonia is a definite concern with liquid paraffin use. However, normal gastrointestinal motility in children without airway protection problems should ensure passage of liquid paraffin from the stomach, regardless of the patient's position.

Finally, congenital hypolactasia (exceedingly rare among young children in our population) in theory should augment the effect of lactulose, which acts in the manner of a non-absorbable sugar to induce its laxative effect.