NHD Issue 150: CONSTIPATION

~50%

CONSTIPATION

CONDITIONS & DISORDERS

reduction in risk of future allergies1

Starts working as early as the first feeding2 Unlike soy, rice, and amino-acid–based formulas,

Constipation is a common digestive disorder and chronic NUTRAMIGEN LGG significantly reduced the risk of developing future allergies at 3 years, including *: constipation is thought to affect (on average) around 15% of the RhinoAllergic Asthma Eczema conjunctivitis urticariato determine constipation population.1 This article will focus on how and treat it appropriately.

1

Resilience assessed after 12 months 18%

Amino Acid Formula (AAF)

9 out of 10 infants experienced colic relief within 48 hours2

Amino Acid Formula (AAF)

24%

Soy Formula (SF)

Soy Formula (SF)

68%33%

Hydrolysed Rice Formula (HRF)

61%

Extensively Hydrolysed Casein Formula (EHCF)

Hydrolysed Rice Formula (HRF) 51% 44%

Extensively Hydrolysed Casein Formula (EHCF)

44%

Constipation can be classed into different months before diagnosis and symptoms types. Functional constipation is more should be present during the last three ~ 50% 3 specifically chronic constipation with months.

However, a clinic review reduction in future allergies reduction in risk by the BMJ states that they prefer a no cause and can include slow transit ~50% of future allergies 18% constipation, outlet delay constipation, or more inclusive method to diagnose 2 tonormal 4X more infants safely returned transit constipation. Slow transit chronic constipation, ie, any patient RhinoAllergic to cow’s milk in 12 months or less urticaria Asthma compared to other formulas constipation, as *it says on the tin, is conjunctivitis when experiencing consistentEczema difficulty with contents move slower than usual through defaecation.4 68% REDUCTION 61% REDUCTION 51% REDUCTION 44% REDUCTION the colon. Outlet delay constipation is ~ 50% affected by the pelvic floor muscles, WHY DOES IT OCCUR? either from pelvic floor dysfunction Constipation tends to affect the very (when the muscles contract during young, or older population and is more RhinoAllergic conjunctivitis urticarial Asthma 61% 44% defaecation) and/or anismus68% (where the 51%common in women thanEczema men.2 25.5% 44% external anal sphincter contracts instead It is30.5% often thought that a22% lack of fluid 68% 34% 61% 51% of relaxes during defaecation). Normal can contribute to constipation, due to transit constipation, meaning68%that 61% there 51% the44%physiology of the digestive system. are no delays in colonic transit or outlet, The RhinoAllergic colon receives approximately 1.5L conjunctivitis urticarial Asthma Eczema is the most common subgroup, but is the of liquid effluent daily from the small 68% 61% 51% least clearly defined.2 intestine, with44% 200ml to 400ml excreted Functional constipation can be in ~50% the stool. The functions of the colon Reduced by diagnosed by using the Rome IV are to absorb fluid and transport waste ~50% criteria, which states it must include to the rectum, where it is expelled or two or more of the following: stored until defaecation is convenient, • straining during more than oneas well as sodium and electrolytes being fourth (25%) of defaecations; actively reabsorbed. As a result of this, • lumpy or hard stools more than stools that remain in the colon longer one-fourth (25%) of defaecations; will become drier, which can lead to • sensation of incomplete evacuation pebble-like stools and impaction if a more than one-fourth (25%) of stool becomes too large and hard to defaecations; pass through the anal canal;5 it can slow • sensation of anorectal obstruction/ colonic transit and reduce stool output. blockage more than one-fourth However, interestingly, the evidence (25%) of defaecations; for increasing fluid in the diet to relieve • manual manoeuvres to facilitate constipation is lacking.6 Not drinking more than one fourth (25%) of enough fluid tends to be more common defaecations (eg, digital evacuation, in the elderly, perhaps as a habit or support of the pelvic floor); actively reducing fluid intake to control • fewer than three spontaneous continence. bowel movements per week.3 Mobility may also be a factor, as well as independent living, as studies have The Rome IV criteria also states that found that healthy, active individuals symptom onset should occur at least six living in the community are less likely

Extensively hydrolysed casein formula (eHCF)

Soy formula (SF)

Amino acid formula (AAF)

2–4X more infants returned to cow’s milk in ≥12 months

Nutramigen LGG

2 to 4X more infants safely returned to cow’s milk in 12 months or less ompared to other formulas3*

Nutramigen LGG

Infants who build resilience (%)

1

Rebecca Gasche Specialist Dietitian, Countess of Chester Hospital NHS Trust

1

Starts working as early as the first feeding2

Unlike soy, rice, and amino-acid–based formulas, NUTRAMIGEN LGG significantly reduced the risk of developing future allergies at 3 years, including1*:

3

9 out of 10 infants experienced colic relief within 48 hours2

Rhinoconjunctivitis

Allergic urticaria

Asthma

68%

61%

51%

Eczema

44%

†

% if infants rienced relief just 48 hours3

2× to 4× more infants safely returned to cow’s milk in 2 months or less, compared with other formulas3†

79%

†

†

†

reduction in future allergies1

2 to 4X more infants safely returned to cow’s milk in 12 months or less compared to other formulas3*

Rhinoconjunctivitis

Allergic urticaria

Asthma

Eczema

REDUCTION†

REDUCTION†

REDUCTION†

REDUCTION†

Allergic urticarial

Asthma

Eczema

Rhinoconjunctivitis

34%

Rhinoconjunctivitis

68%

30.5%

Allergic urticarial

61%

Asthma

51%

25.5%

22%

Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

Eczema

44%

Other

Other

Reduced by

REFERENCES Please visit: https://www. nhdmag.com/ references.html

www.NHDmag.com December 2019 / January 2020 - Issue 150

27

80

This material is for HCP use only.

79%

Nutramigen with LGG : shown to provide 44% long-term cost effectiveness to the NHS for the dietary 24% 18% management of cow’s milk protein allergy (CMPA) ®

60 40 20 0

A new health economics study shows the cost effectiveness of Nutramigen with Lactobacillus rhamnosus (LGG®) compared to an eHCF alone as first-line dietary management for IgE-mediated CMPA.

Resilience assessed after 12 months1

80

†

79%

60 40

44% 33%

20 0

24%

Nutramigen with LGG®

18%

Infants who built tolerance (%)

Starts working to relieve ~90% if infants For first line dietary management of The unique formula of Nutramigen with CMA related colic as experienced relief ® ® IgE-mediated CMPA, Nutramigen with LGG :early as LGG proven to deliver both short and the firstisbottle within just 48 79% hours long-term clinical outcomes. Resulting in 44% cost effectiveness due to: 80

3

60

3

40 20

24%

0

Improves clinical outcomes1

Fast symptom resolution with 99% proven average clinical efficacy3† Starts working to relieve CMA related colic as early as the first bottle3

Proven to help x4 more infants return to milk sooner2‡

Releases NHS resources1 e.g. Frees up NHS appointments

2

Incidence of allergic manifestations

Reduces NHS costs

Proven to reduce incidence of 1 or more future

by Starts allergic working as manifestations 9 out of 10 ~50% infants early as the first feeding2 experienced colic relief within 48 hours2

1

0.5 0.4

eHCF

eHCF with LGG®

0.463

0.1 0.0

The study estimated the total 5 year cost of initially feeding infants with eHCF with LGG® was less than that of an eHCF alone

£

497

savings per infant over 3 years1

Reductions in incidence: Starts working as

early as the first feeding2

0.3 0.2

2× to 4× more infants safely returned to cow’s milk in 12 months or less, compared with other formulas3† 9 out of 10 infants experienced colic relief within 48 hours2

d 68% rhinoconjunctivitis

0.235

Starts working as 9 out of 10 infants Allergic manifestations combined during 3 years early as the first feeding experienced colic relief within 48 hours

Nutramigen with LGG® can save the NHS, on average:

~90% exper within j

2

12

d 61% allergic urticaria d 51% asthma Starts working as early as the first feeding

d 44% eczema

9 out of 10 infants experienced colic relief within 48 hours

2 to 4X more infants safely returned to cow’s milk in 12 months or less compared to other formulas3*

£

907

savings per infant over 5 years1*

*Projected savings over 5 years †Calculated using data on allergic reactions after oral food challenge with an eHF from table 3 of Dupont et al. 2012, as judged by the Committee on Nutrition of the French Society of Paediatrics. ‡Versus an eHCF without LGG, or formulas based on soy or amino acids.

References 1. Guest JF, Singh H Curr Med Res Opin 2019; 24:1-9 2. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913 3. Dupont C et al. Br J Nutr. 2012;107:325–338. eHCF = Extensively hydrolysed casein formula IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply.

The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® is a registered trademark of Chr. Hansen A/S. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional.

Date of preparation: October 2019 RB-M-01339

For long-term, cost effective dietary management of CMPA

co

CONDITIONS & DISORDERS Table 1: Common drugs that can cause constipation6 Antihypertensive drugs, such as clonidine, calcium antagonists and ganglionic blockers, can be linked to constipation as they reduce smooth muscle contractility.

Analgesics, such as opiates and cannabinoids, are especially notorious for causing constipation.

Antidepressants, especially tricyclic antidepressants.

Anti-parkinson, antiepileptic and antipsychotic drugs are associated with constipation due to their anticholinergic and dopaminergic actions and should be avoided or combined with the regular use of laxatives.

Oral iron supplementation frequently causes constipation and, in patients in whom iron supplementation is necessary, intravenous supplementation of iron or the addition of a laxative may be options.

Antihistamines, antispasmodics and vinca alkaloids are associated with constipation as a side effect and should be replaced.

Table 2: The amount of fibre found in certain foods14 Food

Fibre per 100g

Fibre flake/Bran cereals

13-24.5g

Wholemeal bread (2 slices)

5g

Brown rice

0.8g

Wholemeal spaghetti

3.5g

Apple

1.8g

Banana

1.8g

Broccoli (boiled)

2.3g

Carrots (boiled)

2.5g

Almonds

7.4g

Peanuts

6.4g

Sunflower seeds

6g

Peas (boiled)

4.5g

Baked beans

3.7g

Chickpeas

4.3g

to experience functional constipation than those in hospitals or similar institutions.7,8 When looking at the older population, taking into consideration chewing difficulties/dentures, the number of high-fibre foods they are able to consume may be affected.

DIETARY FIBRE

A change in diet seen in western culture is thought to have some links with the prevalence of constipation and may be a causation factor.

The increase of food processing has resulted in a lower intake of fibre.

Dietary fibre can be described as a component of food that includes ‘all carbohydrates that are neither digested nor absorbed in the small 28

intestine and have a degree of polymerisation of three or more monomeric units, plus lignin’.9 In simpler terms, it is ‘roughage’ in our diet that helps to regulate our bowel movements. Diets high in fibre have been linked to reducing the risk of diabetes and bowel cancer, as well as helping to lower cholesterol.

Historically, fibre has been broken down into insoluble and soluble, depending on the water solubility of the fibre. Insoluble fibre is roughage, as it isn’t digested and adds bulk to our stools.

Insoluble fibre consists of the structural fibres, for example cellulose, lignin and hemicelluloses, and can be found in wholegrains, wheat bran and the skins/seeds/piths of fruits and vegetables.

Soluble fibre helps draw water into our stools, as

www.NHDmag.com December 2019 / January 2020 - Issue 150

CONDITIONS & DISORDERS

Both soluble and insoluble fibre sources can help with constipation.

Table 3: Tips to help increase fibre in the diet

HOW TO TREAT IT

Add nuts/seeds to cereals or soups Snack on fruit/vegetables with the skins on (apples, carrots) Choose wholegrain carbohydrates Increase fibre intake gradually and ensure adequate fluids – set an alarm or use a bottle with markings on to track fluid intake throughout the day Additional beans/pulses in stews, soups Include a high-fibre breakfast cereal Include an extra portion of vegetables with main meals

well as binding to substances such as cholesterol and glucose, slowing their absorption. The natural geI-forming fibres are pectin, gums, mucilages and some hemicelluloses, and are largely found in oats, beans, pulses and the inner flesh of fruits and vegetables.2 The terms ‘insoluble’ and ‘soluble’ have, however, been discouraged in the clinical setting, with the argument that all fibrous foods contain a mixture of both these types of fibre.

Pharmaceuticals also play a role in the risk of constipation, as it is a common side effect of many drugs (see Table 1).

Many diseases, in particular neurological diseases, may contribute to constipation. These include diseases that involve the nervous system, such as diabetes mellitus and autonomic neuropathy and neurogenic bowel dysfunction in diseases such as spinal cord injury, multiple sclerosis and Parkinson’s disease.

A multifactural approach is important when treating constipation; as we can see from the causes, it is often not a ‘one size fits all’.

Fibre The Scientific Advisory Committee on Nutrition (SACN) released a report in 2015 which advised that the population should be aiming for 30g fibre/day.10 However, it is estimated that the UK population consumes around 17.2g/day of fibre for women, and 20.1g/day for men.11 Both soluble and insoluble fibre sources can help with constipation. Soluble fibre helps to increase faecal bulk, which can stimulate colonic transit, as well as producing greater bacterial growth (particularly when found in oat bran).

Insoluble fibre provides more slowly fermentable polysaccharides, which helps to maintain the microbiomes during the transit through the colon. Foods such as prunes and kiwis have been shown to help improve constipation, likely due to the combination of different fibres that the fruits contain.12,13 When increasing dietary fibre, it is important to do this gradually and alongside increasing fluids. Increasing fibre too quickly into a diet may result in more gastrointestinal symptoms. The response should be monitored, as it may take a number of days or weeks before the effects take place.

Probiotics Probiotics may also have a role in relieving constipation. Some studies have identified that certain strains of probiotics may have

www.NHDmag.com December 2019 / January 2020 - Issue 150

29

This material is for healthcare professionals only

NUTRAMIGEN WITH LGG : ®

PROVEN EFFICACY AT EVERY STEP* 1

NOW rapidly relieve cow’s milk allergy symptoms as quickly as 48 hours 2–4

TOMORROW successfully accelerate return to cow’s milk after 12 months of use**5

IN THE FUTURE reduce the risk of future allergic manifestations by ~50%†6

*For the management of cow’s milk allergy **vs. eHCF without LGG®, rice, soy or amino acids (p<0.001) † During a period of 3 years vs. eHCF without LGG® (p<0.001)

TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY

References: 1. Dupont C et al. Br J Nutr 2012; 107:325–338. 2. Lothe L et al. Pediatrics 1989; 83:262–266. 3. Baldassarre ME et al. J Pediatr 2010; 156:397–401.

4. Nermes M et al. Clin Exp Allergy 2011; 41:370–377. 5. Canani RB et al. J Pediatr 2013; 163:771–777. 6. Canani RB et al. J Allergy Clin Immunol 2017; 139:1906–1913.

Nutramigen with LGG ® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG ® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional.

IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated.

Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be under medical supervision. Trademark of Mead Johnson & Company LGG © 2019 Mead Johnson & Company, LCC. All rights reserved. LGG ® and the LGG ® logo are registered trademark of Chr. Hansen A/S. Date of Preparation: September 2019 (RB-M-00424)

CONDITIONS & DISORDERS beneficial effects. These include lactobacillus casei, Escherichia coli and Bifidobacterium lactis, which all increase stool frequency and improved consistency, and Bifidobacterium animalis, which reduces colonic transit time.15-18 However, as most studies look at probiotics and GI health, evidence is limited and, therefore, recommendations should be made on an individual basis.

Medication As well as being the cause of some constipation, medications can help to relieve it. The NICE guidance advises the following on treating both short-term and chronic constipation:19 • Offer drug treatment with oral laxatives using a stepped approach. Adjust the dose, choice and combination of laxatives used, depending on the person’s symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference.

• Initial treatment should be with a bulkforming laxative such as ispaghula.

• If stools remain hard or difficult to pass, add or switch to an osmotic laxative, such as a macrogol.

• If a macrogol is ineffective, or not tolerated, offer treatment with lactulose second line.

• If stools are soft but difficult to pass, or there is a sensation of inadequate emptying, add a stimulant laxative.

• If faecal loading/impaction is apparent, suppositories may be used.

FURTHER RECOMMENDATIONS

NICE also recommends increasing dietary fibre and fluids (especially if dehydrated), establishing a good ‘toilet routine’ and increasing activity and exercise levels, if needed. Helpful toileting routines include the following:19 • Establish a regular, unhurried toilet routine, giving time to ensure that defaecation is complete.

• Advise on responding immediately to the sensation of needing to defaecate.

• Ensure that people with limited mobility have appropriate help to access the toilet with adequate privacy.

• Ensure the person has access to supported seating if they are unsteady on the toilet.

CONCLUSION

Constipation tends to affect the very young and the elderly and is more common in women than men. Dietary fibre plays a large role in helping with the symptoms of constipation, but when increasing dietary fibre, it is important to introduce foods gradually, making sure that hydration is increased alongside. Whilst some medications can cause constipation, drug treatment (supported by NICE19) can help in the short-term, as well as for the symptoms of chronic constipation.

Coming in the February 2020 issue View it online at www.NHDmag.com

NETWORK HEALTH DIGEST

• Nutrition support in oncology

• Obesity and energy metabolism

• ONS and eating disorders • Diet and fertility

• Diet trends 2020

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Click here to read the Dec/Jan issue Articles include: • Weaning preterm babies

• Nasogastric tube feeding • Fussy eating in toddlers • Constipation and treatment • Popular liquid diets

• Plant-based diets • Care caterers in social care • Follow-on formula new regulations