What are the recommended laxatives for treating constipation in children?

Recommended Laxatives for Treating Constipation in Children

For children with constipation, polyethylene glycol (PEG) is the first-line laxative treatment due to its efficacy, safety profile, and strong evidence base. 1, 2, 3

First-Line Treatment Options

Polyethylene glycol (PEG)

• Dosing: For children under 16 years, dosing should be determined by a doctor 4
• Advantages: Well-tolerated, effective, strong evidence base
• Administration: Dissolve in 4-8 ounces of beverage (can be given cold, hot, or room temperature)
• Mechanism: Osmotic laxative that increases water in the colon

Dietary and Lifestyle Modifications (to accompany medication)

• Increase fluid intake to at least 8 glasses of water daily (appropriate for age) 5
• Gradually increase dietary fiber to age-appropriate levels 6, 7
• Increase physical activity within the child's capabilities 6

Second-Line Treatment Options

Stimulant Laxatives

• Senna
  • For ages 2-6 years: ½ to ¾ teaspoon (2.5-3.75 mL) once daily, maximum ¾ teaspoon once daily
  • For ages 6-12 years: 1-1½ teaspoons (5-7.5 mL) once daily, maximum 1½ teaspoons twice daily
  • For ages 12+ years: 2-3 teaspoons (10-15 mL) once daily, maximum 3 teaspoons twice daily 8

Other Osmotic Laxatives

• Lactulose: Conditionally recommended when PEG is not effective or available 6, 2
• Magnesium oxide/Milk of magnesia: Conditionally recommended as alternative 6, 2

Treatment Algorithm for Pediatric Constipation

1. Initial Assessment:

   • Rule out red flags: rectal bleeding, weight loss, change in stool caliber, worsening abdominal pain 9
   • Evaluate for impaction through physical examination 6

2. If Impaction Present:

   • Disimpaction using oral PEG or rectal approaches (glycerin suppository or mineral oil enema) 6, 2

3. Maintenance Treatment:

   • Start with PEG as first-line therapy 1, 2, 3
   • If insufficient response after 2-4 weeks, add stimulant laxative (senna) 6, 9
   • Goal: 1 non-forced bowel movement every 1-2 days 9

4. For Refractory Cases:

   • Consider combination therapy with PEG plus stimulant laxative 9
   • Evaluate for underlying conditions if persistent despite adequate therapy 2

Important Considerations

• Duration of Treatment: Maintenance medications may be required for months to years as relapse is common (50-70% of children) 2
• Avoid: Bulk-forming laxatives in severe constipation as they may worsen obstruction 9
• Monitor: Reassess treatment efficacy within 2-4 weeks of initiating therapy 9
• Special Populations: For children with Williams syndrome or other specific conditions, aggressive treatment of constipation is essential to prevent complications like rectal prolapse, hemorrhoids, and intestinal perforation 6

Potential Complications if Untreated

• Rectal prolapse
• Hemorrhoids
• Intestinal perforation
• Diverticulitis (especially in adolescents) 6
• Chronic abdominal pain
• Fecal incontinence affecting quality of life 3

Remember that chronic constipation in children is often functional rather than organic, but persistent symptoms despite appropriate treatment warrant further investigation for underlying conditions.