What is the management of constipation in a 4-year-old child?

From the Guidelines

Management of constipation in a 4-year-old child should begin with dietary changes, including the use of certain fruit juices such as prune, pear, and apple juices, which contain sorbitol and other carbohydrates that can help increase the frequency and water content of stools, as recommended by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition constipation guideline 1. The first step in managing constipation in a child is to increase fiber in the child's diet by offering fruits, vegetables, and whole grains.

• Ensure the child drinks plenty of water throughout the day, aiming for at least 8-10 glasses of water.
• Create a regular toileting schedule, having the child sit on the toilet for 5-10 minutes after meals.
• For medication, polyethylene glycol (Miralax) is the first-line treatment, given at a starting dose of 0.5-1 g/kg/day mixed in 4-8 ounces of liquid, as recommended by recent guidelines 1. This can be used daily for several months to maintain soft stools.
• If impaction is present, a higher dose (1-1.5 g/kg/day) may be needed for 3-5 days for disimpaction. Alternatively, lactulose (1-2 mL/kg/day) or mineral oil (1-3 mL/kg/day) can be used.
• Avoid stimulant laxatives for long-term use, as they can lead to dependence and decreased bowel function. Constipation in children often becomes chronic because inadequate treatment leads to painful defecation, causing the child to withhold stool, which worsens the problem. Successful management requires addressing both the physical and behavioral aspects of constipation, with treatment typically needed for several months to prevent relapse, and initial education and trial of noninvasive methods on initial presentation is crucial 1.

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

For a 4-year-old child, the recommended initial daily oral dose of lactulose is 40 mL to 90 mL in divided doses, with the goal of producing 2 or 3 soft stools daily.

• The dose may need to be adjusted based on the child's response to the medication.
• If the initial dose causes diarrhea, the dose should be reduced immediately.
• If diarrhea persists, lactulose should be discontinued 2

From the Research

Management of Constipation in a 4-year-old Child

Definition and Evaluation

• Constipation can be defined as less than three bowel movements per week 3
• The history and physical examination should be evaluated for stool size, frequency, and straining and discomfort on defecation 3
• The influence of age, gender, and society should also be considered 3

Dietary Approach

• A dietary approach of increased dietary fiber intake can be used as a therapeutic trial if hard or small stools are part of the initial evaluation 3
• It is recommended that children older than 2 years of age increase dietary fiber intake to an amount equal to or greater than their age + 5 g/day 4
• Dietary fiber intake should be increased gradually in childhood by increasing consumption of a variety of fruits, vegetables, legumes, cereals, and other whole-grain products 4

Pharmacologic Therapy

• Polyethylene glycol (PEG) is a commonly used laxative in children and has been shown to be effective and safe for the long-term treatment of constipation 5, 6, 7
• PEG is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability 7
• PEG can be used to treat fecal impaction and is as efficacious as enemas in this condition 7

Behavioral Changes

• Behavioral changes such as laxation and toilet-training programs can be useful in the management of constipation in children 3, 6
• Education is equally important as medical therapy and should include counseling families to recognize withholding behaviors and to use behavior interventions, such as regular toileting and reward systems 6