What are the treatment options for constipation in children?

Treatment Options for Constipation in Children

For children with constipation, a stepwise approach starting with dietary modifications, followed by osmotic laxatives such as polyethylene glycol, is the most effective treatment strategy. 1, 2, 3

First-Line Interventions

Dietary Modifications

• Increase fluid intake - Essential for proper stool consistency
• Increase dietary fiber through:
  • Whole fruits and vegetables
  • Fruit juices containing sorbitol (prune, pear, and apple juices) - particularly effective for infants with constipation 1
  • Recommended fiber intake: Age + 5 grams per day 4
• Regular meal schedule to promote regular bowel habits

Behavioral Approaches

• Establish regular toilet sitting times (typically after meals)
• Create a relaxed, unhurried bathroom environment
• Use positive reinforcement for successful bowel movements

Second-Line Interventions (If Dietary Changes Are Insufficient)

Osmotic Laxatives

• Polyethylene glycol (PEG) - First choice medication 2, 3
  • Dosing: For children over 17 years: 17g dissolved in 4-8 oz of beverage once daily
  • For children under 16 years: consult physician for appropriate dosing
  • Typically produces bowel movement within 1-3 days
  • Do not use for more than 7 days without medical supervision

Stool Softeners

• Docusate sodium 5
  • Works within 12-72 hours
  • Useful for prevention of dry, hard stools
  • Can be used alongside osmotic laxatives

Special Considerations

For Infants

• Fruit juices containing sorbitol (prune, pear, apple) at appropriate amounts (10 mL/kg body weight) can help increase stool frequency and water content 1
• The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition recommends these juices specifically for infants with constipation 1

For Chronic Constipation

• Fiber supplements like glucomannan (100 mg/kg/day, max 5g/day) have shown significant benefits 6
  • 45% of children treated with fiber showed improvement versus 13% with placebo
  • Particularly effective for children with constipation without encopresis (69% success rate)
  • Can be beneficial even for children already on laxatives

For Severe Constipation

• Disimpaction may be necessary before maintenance therapy
• After disimpaction, maintenance therapy with osmotic laxatives and dietary modifications is essential to prevent recurrence

Common Pitfalls and Cautions

• Most families struggle to achieve adequate fiber intake without specific guidance - only half of health-conscious families meet recommendations 4
• Children with constipation typically consume less than one-fourth of recommended fiber 4
• Intensive and ongoing dietary counseling is often necessary for successful implementation of high-fiber diets
• Avoid antimotility agents in children under 18 years
• For children with Williams syndrome or other conditions, chronic constipation requires aggressive treatment to prevent complications like rectal prolapse, hemorrhoids, and intestinal perforation 1

When to Refer

• Persistent constipation despite appropriate first-line therapy
• Signs of organic causes (failure to thrive, delayed growth, blood in stool)
• Severe abdominal distention or vomiting suggesting obstruction
• Neurological symptoms or abnormal physical findings

By following this stepwise approach and addressing both dietary and behavioral factors, most cases of pediatric constipation can be effectively managed.