What is the best treatment for constipation in a 16-month-old child?

Management of Constipation in a 16-Month-Old Child

For constipation in a 16-month-old child, dietary modifications including prune juice, pear juice, or apple juice (10 mL/kg body weight), along with increased fluid intake and high-fiber fruits are the first-line treatment, with osmotic laxatives such as polyethylene glycol being the preferred pharmacological intervention if dietary measures are insufficient. 1

Initial Assessment

• Check for:
  • Bowel movement frequency and consistency
  • Signs of abdominal pain or discomfort
  • Adequate fluid intake and output
  • Presence of abdominal distension or vomiting
  • Poor feeding or failure to thrive
  • Delayed passage of meconium at birth (history)
  • Abnormal anal position or structure

First-Line Management: Dietary Modifications

For All Infants

• Ensure adequate hydration appropriate for age
• For infants over 6 months, offer small amounts of water 1

For Breastfed Infants

• Continue nursing on demand
• Consider a 2-4 week trial of maternal exclusion diet (restricting milk and egg) if symptoms persist 1

For Formula-Fed Infants

• Consider switching to lactose-free formula if symptoms persist 1
• Avoid rice cereal which can worsen constipation 1

For Infants on Solids

• Introduce high-fiber fruits, especially pureed prunes and pears 1
• Temporarily discontinue rice cereal if currently using 1
• Offer fruit juices containing sorbitol (prune, pear, apple juice) at 10 mL/kg body weight 1
• Avoid foods high in simple sugars and fats 1

Second-Line Management: Pharmacological Interventions

If dietary modifications fail to resolve constipation after 1-2 weeks, consider:

Disimpaction (if needed)

• Glycerin suppository to stimulate bowel movement 2, 1
• If unsuccessful, consider small volume mineral oil retention enema 2, 1

Maintenance Therapy

1. Polyethylene glycol (PEG) - First choice due to efficacy and tolerability 3, 4, 5

   • Dosing should be adjusted to achieve 1-2 soft stools daily

2. Alternative osmotic laxatives if PEG is unavailable:

   • Lactulose: For infants, initial daily oral dose of 2.5-10 mL in divided doses 6
   • Milk of magnesia 4
   • Sorbitol 4

Monitoring and Follow-Up

• Track bowel movement frequency and consistency
• Regular follow-up to monitor growth and nutrition
• Adjust treatment as needed to maintain 1-2 soft stools daily
• Be prepared for potentially long-term management as functional constipation often requires prolonged support 4, 7

Common Pitfalls to Avoid

1. Undertreating the condition - Studies show nearly 40% of children remain symptomatic after 2 months due to undertreatment 8
2. Stopping treatment too early - Functional constipation often requires prolonged management to prevent relapse 4, 7
3. Not addressing potential disimpaction - Children who undergo colonic evacuation followed by daily laxative therapy show better outcomes 8
4. Fixed dosing without adjustment - Laxative doses should be titrated to achieve 1-2 soft stools daily, not kept at a fixed dose 8
5. Overlooking the importance of education - Family education is instrumental in improving functional constipation outcomes 1, 4

When to Refer to a Specialist

• If symptoms persist despite appropriate management
• If there are red flags suggesting an organic cause (Hirschsprung's disease, spinal cord abnormality, hypothyroidism, etc.) 4
• For feeding difficulties, gastroesophageal reflux, and poor growth 2

Remember that functional constipation in infants often requires patience and consistent management, with only 50-70% of children showing long-term improvement despite appropriate treatment 4.