What is the management of constipation in a 7-year-old child with abdominal X-ray (abdominal radiograph) showing moderate to marked fecal loading?

From the Guidelines

For a 7-year-old with moderate to marked fecal loading on abdominal X-ray, I recommend a two-phase approach: initial disimpaction followed by maintenance therapy. Begin disimpaction with polyethylene glycol (PEG 3350, Miralax) at a higher dose of 1-1.5 g/kg/day divided twice daily for 3-7 days until the impaction resolves, as suggested by 1. Alternatively, you can use sodium phosphate enemas (one pediatric enema daily for 2-3 days) or mineral oil enemas (30-60 ml daily for 2-3 days) if oral medication isn't tolerated. After disimpaction, transition to maintenance therapy with PEG 3350 at 0.4-0.8 g/kg/day for at least 2-3 months. Some key points to consider in the management of constipation include:

• Dietary modifications are essential: increase fiber intake to 5 grams plus the child's age in years (so 12 grams for a 7-year-old) 1
• Ensure adequate hydration with 5-6 cups of water daily
• Incorporate fruits, vegetables, and whole grains
• Establish regular toilet habits with scheduled sitting times for 5-10 minutes after meals, using proper positioning with feet supported
• Regular follow-up is important to monitor progress and adjust treatment as needed It's also important to note that digital fragmentation of the stool, followed by enema (water or oil retention) or suppository to facilitate its passage through the anal canal, may be useful in some cases, as reported in 1. However, the treatment of a distal faecal impaction has not been the subject of clinical trials, and practice reports the utility of these methods. In the case of proximal faecal impaction and in the absence of complete bowel obstruction, lavage with PEG solutions containing electrolytes may help to soften or wash out stool, as mentioned in 1. Overall, the goal of treatment is to address the current impaction while preventing recurrence by softening stool, promoting regular bowel movements, and establishing healthy bathroom habits.

From the FDA Drug Label

USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days For a 7-year-old with moderate to marked fecal loading, polyethylene glycol (PO) may be considered for the management of constipation.

• The drug is indicated for relieving occasional constipation.
• It generally produces a bowel movement in 1 to 3 days. However, the label does not provide specific guidance for managing moderate to marked fecal loading in a pediatric patient. Given the potential for polyethylene glycol (PO) to help relieve constipation, it may be a reasonable option, but caution should be exercised and medical supervision is recommended 2.

From the Research

Management of Constipation

The management of constipation in a 7-year-old with an X-ray showing moderate to marked fecal loading can be approached through various methods.

• Disimpaction using oral or rectal medication is often the first step, as seen in 3.
• Polyethylene glycol is effective and well-tolerated for disimpaction, as noted in 4 and 3.
• After disimpaction, a maintenance program may be required for months to years, as relapse of functional constipation is common, as stated in 3.
• Maintenance medications include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol, as listed in 3.

Treatment Options

Treatment options for constipation in children include:

• Polyethylene glycol-based solutions, which have become the mainstay of therapy, as mentioned in 5.
• Other osmotic or stimulant laxatives, such as senna, which can be effective in certain cases, as seen in 6.
• An increase in dietary fiber may improve the likelihood that laxatives can be discontinued in the future, as suggested in 5.
• Education and counseling on recognizing withholding behaviors, using behavior interventions, and expecting a chronic course with prolonged therapy are equally important as medical therapy, as emphasized in 5.

Considerations

When managing constipation in children, it is essential to:

• Be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease or spinal cord abnormality, as noted in 3 and 5.
• Consider referral to a subspecialist if there is concern for organic disease or if the constipation persists despite adequate therapy, as recommended in 5.