What is the best management for a 12-year-old female with constipation?

Management of Constipation in a 12-Year-Old Female

The best management for a 12-year-old female with constipation is a combination of polyethylene glycol (PEG) 17g daily mixed in 8 ounces of water as first-line therapy, with lifestyle modifications including increased dietary fiber, adequate fluid intake, and regular physical activity. 1, 2

Initial Assessment and First-Line Treatment

First-Line Pharmacologic Therapy:

• Polyethylene glycol (PEG) 17g daily mixed in 8 ounces of water 1
  • PEG is recommended with moderate certainty of evidence
  • Well-tolerated with good safety profile
  • Response to PEG has been shown to be durable over 6 months 1
  • Side effects may include abdominal distension, loose stool, flatulence, and nausea

Lifestyle Modifications (to be implemented concurrently):

• Dietary fiber:

  • Gradually increase fiber intake to approximately 30g/day through fruits, vegetables, and whole grains 2
  • For supplementation, psyllium can be considered (1/2 packet in 8 oz of liquid, up to 3 times daily for ages 6-11) 3
  • Start with 1 dose per day and gradually increase to avoid bloating 3

• Fluid intake:

  • Ensure adequate fluid intake, particularly water 2
  • Each dose of fiber supplement should be taken with at least 8 ounces of water 3

• Physical activity:

  • Regular moderate exercise as tolerated 1
  • Increase activity and mobility within patient limits 2

• Toileting habits:

  • Optimize toileting position (use footstool to assist with defecation) 2
  • Attempt defecation 30 minutes after meals to utilize the gastrocolic reflex 2
  • Ensure privacy and comfort for normal defecation 2

Second-Line Therapy (If Inadequate Response After 2-3 Days)

1. Increase the dose of PEG or

2. Add a stimulant laxative:

   • Bisacodyl 10-15 mg, 2-3 times daily 1, 2
   • Senna 8.6-17.2mg at bedtime 2
   • Goal: one non-forced bowel movement every 1-2 days 1

3. If impaction is present:

   • Glycerin suppositories may be administered 1
   • Manual disimpaction may be performed if necessary 2

Third-Line Therapy (For Persistent Constipation)

If constipation persists despite the above measures:

• Consider adding other laxatives such as:
  • Rectal bisacodyl once daily
  • Lactulose
  • Magnesium hydroxide
  • Magnesium citrate 1

Special Considerations

• Avoid bulk laxatives alone for severe constipation as they may be ineffective and potentially worsen symptoms if fluid intake is inadequate 2
• Rule out other causes of constipation such as hypothyroidism, hypercalcemia, medications, or defecatory disorders 1
• Assess for alarm features that would warrant further investigation:
  • Blood in stools
  • Weight loss
  • Anemia
  • Family history of inflammatory bowel disease or colon cancer 1

When to Consider Referral

Consider referral to a pediatric gastroenterologist if:

• Constipation persists despite adequate trial of the above therapies
• Symptoms worsen or new concerning symptoms develop
• Constipation is accompanied by poor growth or weight loss
• There is suspicion for an underlying anatomic, metabolic, or neurologic condition 4

Important Caveats

• Constipation in adolescents can significantly impact quality of life and should be addressed promptly 4
• Ensure adequate follow-up to monitor response to therapy and adjust treatment as needed
• Patient and family education about proper diet, fluid intake, and toileting habits is essential for long-term management