1. Treating resistant constipation in children :laxatives and transcutaneous electrical stimulation (TES)
Bridget R Southwell – Research Scientist, Fellow
Julie Jordan-Ely - Continence Nurse Specialist
1. Murdoch Children’s Research Institute, Melbourne, Australia
2. Department of Paediatrics, University of Melbourne, Victoria, Australia

2. Home-based transcutaneous electrical stimulation (TES)
YI Yik 1,2,3,4, KA Ismail 1,2, JM Hutson 1,2,3, BR Southwell 1,2.
1. Murdoch Children’s Research Institute, Melbourne, Australia
2. Department of Paediatrics, University of Melbourne, Victoria, Australia
3. Department of Urology, Royal Children’s Hospital, Melbourne, Australia
4. Department of General Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

3. Introduction Slow-transit constipation
motility is reduced in the whole colon
resistant to laxatives
Transcutaneous electrical stimulation (TES) using interferential current (IFC)
delivered across the skin with sticky electrodes.
used by physiotherapists to treat musculoskeletal pain and bladder incontinence.
We have previously trialled TES-IFC to treat chronic constipation in children

4. TES trials for constipation
Location
Stim Frequency
# of Pts
Clinician
Pilot 2003
Hospital
20 mins x3 /wk
1 mth- physio
8 P
Chase 2005
RCT
Clinic
46 P RCT
23 stim
Chase
Clarke 2009
Manometry
Clarke 2012
1st home
Home
1 h/ day - 1 mth
11 P
Ismail 2009
2nd home
1 h/ day - 6 mths
68 P
Yik 2012
Suburban Clinic –
Disimpaction, Educaton,
Laxatives, Diet (DELD)
1 hr/ day-
2-3 mths 60
A&P
Jordan-Ely
(2011)
Hospital Clinic
DELD
1 hr/ day mths
33 P
Dobson 2013
Total
214 P
STC Adult
1 hr/ day - 2 mths
20 A
Lynn 2011
IBS adult
clinic
15 min x 12
67 A RCT 33 stim
Coban 2012
home
1 hr/ day - 3 mths
11A
Queralto 2013
98 A
Child
Adult

5. Aim:
Determine if TES administered daily at home can improve defecation, soiling, abdominal pain and laxative use in STC children.
Added onto existing treatment
Clinician naive to electrical therapy

6. Patients STC was determined by radionuclear colonic transit study
62 patients (34 female, mean 7 yrs, 2-16 yrs)
Patient/parent trained to give stimulation at home

7. Methods
4 electrodes- 2 on front, 2 on back- at belly button

8. Stimulation parameters- beating current
Currents crossed, 4000 Hz, Hz- beat
1 hour daily for 3- 6 months- battery operated stimulator
Bowel diary: defecation, soiling, laxative use
Quality of life (PedsQL), colonic transit time (nuclear transit scintigraphy)

9. Results

11. Laxative use decreased or stopped
GENDER OUT

12. Urge to Defecate Increased
GENDER OUT

13. Summary
TES-IFC
is non-invasive using removable sticky pad electrodes and can be given at home by the patient or parent.
When added onto existing treatment in children with STC,
increased defecation into the normal range in ½
stopped soiling
laxative use stopped in ¼, reduced in ½
Increased urge to defecate
Clinician training was needed and took 6 patients.
SUMMARIZE TO 3 LINES ON HOME TES

14. Disimpaction with PEG and SP
Polyethylene glycol (PEG electrolytes) and sodium picosulphate (SP) are well-established treatments for constipation.
PEG - disimpaction in 92% of children
Candy DC, et al. J.Pediatric Gastroenterology Nutr :65-70
SP -treatment response in 83% of adults with chronic constipation
Wulkow R, et al. Int J Clin Pract :944-50
This study investigated the effect of combined PEG/SP to achieve bowel disimpaction in treatment-resistant pediatric patients presenting to a surgeon in a tertiary children’s hospital.

15. D.E.L.D. Disimpaction Education Laxatives Diet
– nurse-led treatment
Disimpaction PEG+E and Sodium Picosulphate (SP)
Education – Bristol Stool Scale (BSS), toilet timing, toilet posture, stress effects.
Laxatives - low level PEG+E & SP
Diet – food and water

16. METHODS Retrospective audit - 44 pts -4 month period
Poor response to medical treatment by clinicians (GPs, paediatricians, gastroenterologists) before referral to surgeon
Radionuclear colonic transit studies.
PEG + electrolytes (13.7g/ sachet), SP (0.5mg/drop)
Dosage:
- Day sachets PEG+E /15-20 drops SP
- Day sachets PEG+E /20 drops SP
- Day sachets PEG+E /10 drops SP
Instructions to administer at home over 3 days.
PEG+E dissolved in 125 ml water/sachet and mixed with an equal volume of juice,
drunk at 125 ml/60 min during the morning. SP added to any drink in evening.

17. Dose of laxatives Polyethylene Glycol +Electrolytes (PEG+E)
Sodium Picosulphate (SP)
Each sachet contains 13.7g PEG+E Each drop contains 0.5mg per drop SP

18. Stool output increased over 3 days
cups of stool
during day 2-3
mean +/- SEM :
(1 cup = 250ml)

19. Stool consistency targeted to BSS Type 4
Stool consistency improved
Hard Soft
Hard Soft
Stool consistency targeted to BSS Type 4

20. Stool volume increased
/wk to p/w

21. Soiling episodes decreased
4.5 ±0.5 to 1.1 ±0.3/week

22. Disimpaction also works in adults
Adults and children
Suburban clinic
Emergency Department-
Elderly
Aged-Care facility
Extreme Cases
Duchenes muscular dystrophy, palliative, faecaloma 12 cups
Hard faecaloma-

23. Summary- disimpaction
High-dose PEG+E / SP was effective in disimpaction for children with treatment-resistant chronic constipation presenting to a tertiary surgical clinic.
The combination of PEG+E and SP produced disimpaction in all patients without complication. This method could be useful for all patients with chronic constipation.

24. JA Jordan-Ely, KM Dobson, BR Southwell, JM Hutson
Transcutaneous electrical stimulation combined with disimpaction, education, laxatives, and diet
JA Jordan-Ely, KM Dobson, BR Southwell, JM Hutson

25. To determine if TES plus DELD is more effective than TES alone
Aim
To determine if TES plus DELD is more effective than TES alone

26. Methods
33 patients (17 males, 4-16 yrs) with STC
DELD
Daily diary
Start TES 1 hour/daily after DELD
2-3 months TES

27. DELD + TES is more effective than TES alone

28. DELD + TES increased BA more than TES alone
High-dose oral medication for disimpaction was well tolerated. All patients had successful disimpaction over 3 days (mean 6 cups of stool in total) and then continued with low dose of medication and TES therapy. All patients started with < 3 bowel actions/week. After 8-12 weeks of TES, 32/33(97%) increased to >3 BA/wk with 29 /33(88%) having 7 BA/wk. Median stool consistency improved from BSS score of 2 (range:1-7) to 4 (4-5) (p<0.0001). Median stool output improved from 1(0-2) to 7(2-10) cups/wk (p<0.0001). Soiling episodes decreased from 5 (0-7) to 0 (0-4) episodes/wk (p<0.0001). Patients were weaned off laxatives during TES, and off TES after 3 months and continued with daily defecation.

29. DELD +TES Soiling stopped completely
Stool consistency changed to BSS 4-5

30. DELD + TES 97% patients increased defecation to >3 BA /week
88% had daily BA
stool volume increased from 1 to 7 cups/pw
BSS shifted from Hard (type 2) to Soft (type 4) (p<0.0001)
Soiling episodes decreased from 5 to 0 per week

31. Advantages of DELD+ TES
Improvement in higher % patients (97 % vs. 50%)
More rapid response
Patients/families empowered
Significant improvement in QOL

32. Conclusion TES alone: improved 50% of patients (6 months).
DELD alone: improves BA but impaction recurs after months.
TES + DELD improves more patients faster
Combined DELD/TES most effective.

33. TES trials for constipation
Location
Stim Frequency
# of Pts
Clinician
Pilot 2003
Hospital
20 mins x3 /wk
1 mth- physio
8 P
Chase 2005
RCT
Clinic
46 P RCT
23 stim
Chase
Clarke 2009
Manometry
Clarke 2012
1st home
Home
1 h/ day - 1 mth
11 P
Ismail 2009
2nd home
1 h/ day - 6 mths
68 P
Yik 2012
Suburban Clinic –
Disimpaction, Educaton,
Laxatives, Diet (DELD)
1 hr/ day-
2-3 mths 60
A&P
Jordan-Ely
(2011)
Hospital Clinic
DELD
1 hr/ day mths
33 P
Dobson 2013
Total
214 P
STC Adult
1 hr/ day - 2 mths
20 A
Lynn 2011
IBS adult
clinic
15 min x 12
67 A RCT 33 stim
Coban 2012
home
1 hr/ day - 3 mths
11A
Queralto 2013
98 A
Child
Adult

34. Conclusion
Disimpaction with PEG + sodium picosulphate is effective in most children and adults with CC
TES is a non-invasive technique
Can be delivered at home
Increases defecation in treatment-resistant patients
Better with DELD
Promising for use in children and adults.