Columbus, OH — April 2018
Children with constipation who are considered to have failed medical management are often referred to the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s Hospital for surgery. One of the center’s first steps is putting those patients on a senna-based laxative.
More often than not, that solves the issue and makes surgery unnecessary, says Marc Levitt, MD, the center’s surgical director and chief of the Section for Colorectal and Pelvic Reconstruction Surgery at Nationwide Children’s.
So why do some pediatricians and gastroenterologists resist senna? Why is it not part of the typical medical management strategy?
A misperception of side effects and tolerance may be to blame, say Dr. Levitt and his colleagues. To remedy that, the center has published a review of studies on sennosides – along with an analysis of their use at the Center for Colorectal and Pelvic Reconstruction -- demonstrating that they are safe and effective for long-term use in children. The study appears in the Journal of Pediatric Surgery.
“The safety profile of senna is as good as or better than many common medications a person would be on, including over-the-counter medications routinely given to very young children, and tolerance does not appear to be a concern,” says Dr. Levitt, who is also a professor of Surgery at The Ohio State University College of Medicine. “We hope this paper will make physicians more comfortable in using senna-based laxatives, and that they will be more widely used.”
The authors examined the records of 640 patients treated with senna-based laxatives at the Center for Colorectal and Pelvic Reconstruction from April 2014 to April 2017. More than 84 percent, including some patients taking the laxatives for more than two years, experienced no side effects. Approximately 13 percent experienced abdominal pain/cramps or diarrhea, almost half of which resolved spontaneously within two weeks.
Change in laxative type (sometimes to another stimulant laxative) or to rectal enema resulted in resolution of most other side effects.
The authors also found perineal blisters or severe perineal rash in 2.2 percent of the center cohort, a side effect also noted in other studies. All of those patients had a long period of stool-to-skin contact because they were diapered or wearing training underwear overnight. This side effect potentially could be mitigated by timing senna administration so that bowel movements would be less likely to occur during sleep, and by applying a “barrier cream” to the skin of children who take senna while diapered. It may also be necessary to change laxative type.
The overall findings of the study, however, may lead to a change in practice for clinicians, says Dr. Levitt. Many physicians consider using a polyethylene glycol (PEG) such as Miralax first because of a belief that it is gentler. PEGs result in softer stool, but they do not stimulate bowel movements the way senna does.
Senna is often more effective than PEG. This study shows that it is safe as well.
“A physician should consider senna as the first line medication,” says Dr. Levitt.
Vilanova-Sanchez A, Gasior AC, Toocheck N, Weaver L, Wood RJ, Reck CA, Wagner A, Hoover E, Gagnon R, Jaggers J, Maloof T, Nash O, Williams C, Levitt MA. Are Senna based laxatives safe when used as long term treatment for constipation in children? Journal of Pediatric Surgery. 2018 Jan 31. [Epub ahead of print]