What are the treatment guidelines for pediatric constipation (Gastrointestinal Motility Disorder)?

From the Guidelines

Treatment guidelines for pediatric constipation should prioritize a stepwise approach, starting with education, dietary modifications, and behavioral interventions, before considering medication management, with a focus on increasing fluid intake and fiber supplementation, as recommended by the most recent guidelines 1. The approach to treating pediatric constipation involves a combination of lifestyle modifications and, when necessary, medication.

• Key components of the initial approach include:
  • Education on normal bowel patterns and the importance of regular toileting habits
  • Dietary changes to increase fluid intake, particularly water, and add more fiber through fruits, vegetables, and whole grains
  • Encouraging children to sit on the toilet for 5-10 minutes after meals to take advantage of the gastrocolic reflex
• For medication management, osmotic laxatives like polyethylene glycol (PEG 3350, Miralax) are considered first-line at a dose of 0.5-1.5 g/kg/day divided once or twice daily 1.
• Alternatives include lactulose (1-2 mL/kg/day) or milk of magnesia (1-3 mL/kg/day), with higher doses of PEG (1-1.5 g/kg/day for 3-6 days) or rectal therapies like glycerin or bisacodyl suppositories considered for impaction.
• The importance of managing constipation is also highlighted in the context of treating dysfunctional voiding in children, where aggressive management of constipation is crucial 1.
• Treatment should continue for at least 2-3 months after regular bowel movements are established to prevent relapse, allowing the stretched rectum time to regain normal tone and sensation.
• It's also important to note that fiber supplements, particularly psyllium, can be effective as first-line therapy for chronic idiopathic constipation, especially in individuals with low dietary fiber intake 1.
• Adequate hydration should be encouraged with the use of fiber, and parents should be aware of potential side effects like flatulence.
• A comprehensive approach addressing both physiological and behavioral aspects of constipation is essential for effective management in children.

From the FDA Drug Label

Pediatric: Very little information on the use of lactulose in young children and adolescents has been recorded. As with adults, the subjective goal in proper treatment is to produce 2 or 3 soft stools daily. On the basis of information available, the recommended initial daily oral dose in infants is 2. 5 mL to 10 mL in divided doses. For older children and adolescents the total daily dose is 40 mL to 90 mL. If the initial dose causes diarrhea, the dose should be reduced immediately. If diarrhea persists, lactulose should be discontinued children 16 years of age or under: ask a doctor

The treatment guidelines for pediatric constipation are as follows:

• For infants, the recommended initial daily oral dose of lactulose is 2.5 mL to 10 mL in divided doses 2.
• For older children and adolescents, the total daily dose of lactulose is 40 mL to 90 mL 2.
• For children 16 years of age or under, it is recommended to ask a doctor before using polyethylene glycol 3.
• The goal of treatment is to produce 2 or 3 soft stools daily 2.
• If the initial dose causes diarrhea, the dose should be reduced immediately. If diarrhea persists, lactulose should be discontinued 2.

From the Research

Treatment Guidelines for Pediatric Constipation

• The treatment of pediatric constipation often involves the use of over-the-counter laxatives, with osmotic laxatives such as polyethylene glycol 3350 (PEG 3350) and lactulose being the most effective and safe therapies for both long and short term treatment 4.
• Stimulant laxatives, like Senna and Bisacodyl, probiotics, fiber preparations, enemas, and suppositories can be used as adjunct therapies in specific clinical scenarios 4.
• The rule for treatment is a sufficient dose for a long time, and in case of fecal impaction with or without fecal incontinence, the first stage is fecal disimpaction, using a high dose of PEG the first few days, or repeated phosphate enemas 5.
• Education regarding the adaptation of toilets and a daily bowel movement should restore colic motility and avoid relapses when the treatment is discontinued 5.

Comparison of Treatment Options

• A meta-analysis comparing polyethylene glycol (PEG) with lactulose showed that PEG was more effective in increasing the number of stools per week, and patients who received PEG were less likely to require additional laxative therapies 6, 7.
• PEG 3350 was found to be more effective and cause fewer side effects than lactulose in the treatment of constipation in infants and children 8.
• Liquid paraffin (mineral oil) was also found to be effective and well tolerated, with a significant increase in the number of stools per week compared to lactulose 7.

Safety and Efficacy

• PEG-based laxatives are effective and safe for chronic constipation and for resolving fecal impaction in children, with acceptable treatment-related adverse events 6.
• The most common adverse events associated with PEG and lactulose include flatulence, abdominal pain, nausea, diarrhea, and headache 7.
• PEG appears to be safe and well tolerated, with no serious adverse events reported in the majority of studies 6, 7.