What is the best approach to manage pediatric constipation?

Management of Pediatric Constipation

Polyethylene glycol (PEG) is the first-line treatment for pediatric constipation due to its higher success rate and fewer side effects compared to other laxatives. 1

Diagnosis and Assessment

Proper diagnosis is essential before initiating treatment:

• Determine if true constipation exists by checking for:

  • Hard stool consistency
  • Signs of discomfort during defecation
  • Abdominal distension 2

• Be aware of normal variations:

  • Breastfed infants may have infrequent but soft stools
  • Straining and facial redness during defecation can be normal in infants due to immature abdominal muscles 2

• Watch for red flags suggesting organic causes (5% of cases):

  • Delayed passage of meconium (>48 hours after birth)
  • Failure to thrive
  • Abdominal distension
  • Abnormal positioning of anus
  • Neurological abnormalities 3, 4

Treatment Algorithm

Step 1: Disimpaction (if needed)

• For significant fecal impaction, disimpaction must occur before maintenance therapy
• Options:
  • Oral PEG 3350: Most effective and well-tolerated 3
  • Rectal medications for severe cases

Step 2: Non-pharmacological Management

For breastfed infants:

• Continue breastfeeding on demand
• If constipation persists, consider 2-4 week trial of maternal exclusion diet (restricting at least milk and egg) 2

For formula-fed infants:

• Consider switching to lactose-free or lactose-reduced formula
• Full-strength, lactose-free formulas can be safely introduced 2
• Avoid formulas high in simple sugars 2

For older infants and children:

• Ensure adequate fluid intake appropriate for age and weight
• For infants over 1 month, consider small amounts of pasteurized prune, pear, or apple juices (contain sorbitol) 2
• Increase dietary fiber for older children 5
• Establish regular toileting habits with proper positioning 6

Step 3: Pharmacological Management

First-line medication:

• PEG 3350: Most effective with fewer side effects 1
  • For children <6 years: 2.95g/sachet daily
  • For children ≥6 years: Start with 2 sachets/day
  • Adjust dose based on response
  • Do not use for more than 7 days without medical supervision 7

Alternative medications:

• Lactulose: 2.5-10 mL daily in divided doses for infants 2
  • Monitor for bloating and flatulence
• Milk of magnesia
• Mineral oil (for older children)
• Senna (stimulant laxative): Do not use for longer than one week unless directed by a doctor 8

Maintenance and Follow-up

• Maintenance therapy may be required for months to years as relapse is common (50-70% of children) 3
• Continue medications until regular bowel pattern is established for at least 1 month
• Gradually taper medications to prevent relapse
• Monitor for:
  • Signs of dehydration
  • Electrolyte imbalances
  • Excessive gas or abdominal distension 2

Important Considerations

• Stop medication and consult a doctor if:

  • Rectal bleeding occurs
  • Abdominal pain worsens
  • Diarrhea develops 7, 8

• Behavioral education improves response to treatment; biofeedback training does not 3

• For cow's milk protein allergy-related constipation:

  • Consider trial of milk protein elimination
  • May require specialized formula 2

• Refer to pediatric gastroenterologist if:

  • Treatment fails after 3-6 months
  • Red flag symptoms are present
  • Significant psychological issues accompany constipation 4