What is the recommended treatment for constipation in children?

Treatment of Constipation in Children

The recommended treatment for constipation in children involves initial disimpaction with oral laxatives (preferably polyethylene glycol) followed by a maintenance phase of ongoing bowel management including increased water and fiber intake, along with osmotic laxative treatment. 1, 2

Initial Assessment

When evaluating a child with constipation, consider:

• Frequency and consistency of bowel movements
• Presence of pain during defecation
• Withholding behaviors
• Soiling/encopresis
• Duration of symptoms
• Red flags for organic causes:
  • Delayed passage of meconium (>48 hours after birth)
  • Failure to thrive
  • Abdominal distension
  • Perianal fistula
  • Abnormal position of anus
  • Absent anal or cremasteric reflex
  • Decreased lower extremity strength/tone/reflexes

Treatment Algorithm

Step 1: Disimpaction

For children with fecal impaction:

• Oral polyethylene glycol (PEG) is the first-line treatment due to effectiveness and tolerability 2
• Lactulose may be used as an alternative:
  • Infants: 2.5-10 mL daily in divided doses
  • Older children: 40-90 mL total daily dose 3
  • Reduce dose if diarrhea occurs

Step 2: Maintenance Therapy

1. Dietary Modifications:

   • Increase water intake
   • Add fiber-rich foods (fruits, vegetables, whole grains)
   • Consider trial of withholding cow's milk if suspected as contributing factor 4

2. Behavioral Interventions:

   • Establish regular toileting routine (after meals)
   • Proper toilet posture with buttock and foot support 1
   • Use reward systems for successful bowel movements
   • Address any anxiety around toileting

3. Maintenance Medications:

   • Polyethylene glycol (PEG) - first-line maintenance therapy
   • Alternatives: lactulose, milk of magnesia, mineral oil 4, 2
   • Adjust dose to achieve 2-3 soft stools daily

Step 3: Follow-up and Monitoring

• Regular follow-up to assess response to treatment
• Maintenance therapy may need to be continued for months to years 4
• Gradually taper medication once regular bowel pattern is established

Special Considerations

• Toilet Posture: Ensure proper positioning with buttock support, foot support, and comfortable hip abduction to enable relaxed voiding 1

• Constipation-Urinary Symptom Connection: Constipation can contribute to urinary symptoms including UTIs, daytime wetting, and enuresis 1

• Duration of Treatment: Treatment may need to be maintained for many months before the child regains bowel motility and rectal perception 1

• Parental Education: Parents often discontinue treatment too soon; education about the chronic nature of functional constipation is essential 1

Common Pitfalls to Avoid

1. Premature discontinuation of treatment: Maintenance therapy is often required for extended periods to prevent relapse 1, 4

2. Inadequate disimpaction: Complete disimpaction must occur before maintenance therapy can be effective

3. Overlooking behavioral components: Addressing anxiety, fear, or withholding behaviors is crucial for successful treatment 5

4. Ignoring the constipation-enuresis connection: Treating constipation can improve urinary symptoms 1

5. Relying solely on medications: A comprehensive approach including diet, behavior modification, and medication yields better outcomes

Despite appropriate treatment, only 50-70% of children with functional constipation demonstrate long-term improvement, highlighting the importance of consistent management and follow-up 4.