What Sets Polyethylene Glycol Apart in Winning Patient Acceptance

Chronic constipation, often overlooked as a gastrointestinal disorder in children, is a surprisingly prevalent concern with far-reaching consequences.^{1, 2} Almost 85%–95% of cases of constipation are functional in children.³ Research indicates that constipation can make its unwelcome debut in the first year of life in a substantial percentage of young ones, ranging from almost 17%–40% of cases.¹But perhaps the most striking revelation is that for one-third of those affected, the symptoms of childhood constipation persist stubbornly into adulthood even after initial treatment.¹ Prompt diagnosis and effective management are crucial factors to relieve associated symptoms and prevent complications.⁴

While numerous treatment choices are available for the management of functional constipation in children, there remains a substantial unmet medical need for achieving complete, long-term, and sustainable relief from symptoms.⁵

The use of osmotic laxatives alongside toilet training plays a key role in effectively addressing childhood functional constipation, particularly when stool-withholding behavior stands out as a primary contributing factor.⁶ Though there are several effective medications for the long-term management of pediatric constipation, such as milk of magnesia, lactulose, and mineral oil, these treatments may face challenges in terms of patient acceptance and compliance. This is often attributed to either their unappealing taste or the associated adverse effects, such as abdominal pain, flatulence, and anal leakage.⁷

The primary contributors to treatment failure are children’s compliance with medication and parental worries regarding the prolonged use of laxatives.⁶ Therefore, there is a dire need to seek out an optimal laxative option that is both safe and effective, while also being acceptable to children for long-term use.⁷

Polyethylene glycol (PEG) and lactulose are the most widely prescribed drugs for the management of pediatric functional constipation.⁸Major national and international guidelines—The European Society for Pediatric Gastroenterology Hepatology and Nutrition; North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines; and the Indian Society of Pediatric Gastroenterology Hepatology and Nutrition—recommend PEG as the laxative of choice for short and long-treatment of functional constipation in both adult and pediatric population.^3,8,9

PEG is a water-soluble polymer that remains unaltered in the gastrointestinal tract. It establishes an osmotic gradient within the lumen of the colon leading to fluid retention, ultimately resulting in the softening and loosening of stools.³A key advantage of PEG, as opposed to other osmotic agents, such as lactulose, lies in the fact that it is not absorbed or metabolized by human intestinal enzymes and colonic bacteria. Also, PEG is associated with significantly fewer occurrences of side effects, such as abdominal pain and nausea, when compared to other laxatives. Moreover, while the effectiveness of lactulose diminishes with prolonged use due to alterations in the gut flora, PEG continues to remain effective during the long term.

A prospective observational study including a total of 83 children with functional constipation demonstrated that 90% of children were compliant with long-term PEG therapy and almost 93% of children preferred taking daily PEG solution.⁷The distinct characteristics that help increase compliance are:^7,13   

• It is a tasteless and odorless powder
• It is electrolyte-free
• It can be mixed in a beverage of the patient’s choice, such as water, juice, or milk.
• Eighty-four percent of caretakers reported a noticeable improvement in bowel pattern

In conclusion, beyond effectiveness and symptom relief, the selection of a laxative also hinges on other factors, such as taste, ease of use, and patient adherence, all of which can significantly influence treatment outcomes.¹⁰ The above-stated attributes of PEG make it an ideal choice for the management of pediatric functional constipation.

References:

1. Poddar U. Approach to constipation in children. Indian Pediatr. 2016;53(4):319–327.
2. Levy EI, Lemmens R, Vandenplas Y, et al. Functional constipation in children: Challenges and solutions. Pediatric Health Med Ther. 2017;8:19–27.
3. Dheivamani N, Thomas W, Bannerjii R, et al. Efficacy of polyethylene glycol 3350 as compared to lactulose in treatment of ROME IV criteria-defined pediatric functional constipation: A randomized controlled trial. Indian J Gastroenterol. 2021;40(2):227–233.
4. Shatnawi MS, Alrwalah MM, Ghanma AM, et al. Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study. Sudan J Paediatr. 2019;19(1):31–36.
5. Sood M, Lichtlen P, Perez MC. Unmet needs in pediatric functional constipation. Clin Pediatr (Phila). 2018;57(13):1489–1495. 
6. Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World J Gastroenterol. 2023;29(8):1261–1288.
7. Pashankar DS, Loening-Baucke V, Bishop WP. Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children. Arch Pediatr Adolesc Med. 2003;157(7):661–664.
8. Jarzebicka D, Sieczkowska-Golub J, Kierkus J, et al. PEG 3350 versus lactulose for treatment of functional constipation in children: Randomized study. J Pediatr Gastroenterol Nutr. 2019;68(3):318–324.
9. Mínguez M, López Higueras A, Júdez J. Use of polyethylene glycol in functional constipation and fecal impaction. Rev Esp Enferm Dig. 2016;108(12):790–806.
10. Savino F, Viola S, Erasmo M, et al. Efficacy and tolerability of PEG-only laxative on faecal impaction and chronic constipation in children. A controlled double blind randomized study vs a standard PEG-electrolyte laxative. BMC Pediatr. 2012;12:178.
11. Voskuijl W, de Lorijn F, Verwijs W, et al. PEG 3350 (Transipeg) versus lactulose in the treatment of childhood functional constipation: A double-blind, randomised, controlled, multicentre trial. Gut. 2004;53(11):1590–1594.
12. Mathew JL. Polyethylene glycol vs. lactulose in infants and children with functional constipation: Evidence-based medicine viewpoint. Indian Pediatr. 2019;56(5):415–418.
13. Alper A, Pashankar DS. Polyethylene glycol: A game-changer laxative for children. J Pediatr Gastroenterol Nutr. 2013;57(2):134–140.