What is the initial treatment for constipation in children?

Initial Treatment for Constipation in Children

The initial treatment for constipation in children should include increasing fluid intake, dietary fiber, and using specific fruit juices such as prune, pear, and apple juices that contain sorbitol and other carbohydrates to help increase the frequency and water content of stools. 1

Assessment and Diagnosis

• Evaluate for:
  • Frequency and consistency of bowel movements
  • Presence of abdominal pain
  • Dietary habits (especially fiber and fluid intake)
  • Toilet training status
  • Presence of fecal impaction (check via physical exam)

First-Line Treatment Approach

Dietary Modifications

1. Increase fluid intake:

   • Essential for preventing dehydration which can worsen constipation 2
   • Aim for age-appropriate water intake throughout the day

2. Increase dietary fiber:

   • Studies show that 71% of constipated children have inadequate fiber intake 3, 4
   • Recommended daily fiber intake: Age (in years) + 5 grams 4
   • Good sources: Whole grains, fruits, vegetables, legumes

3. Fruit juices:

   • Prune, pear, and apple juices contain sorbitol and carbohydrates that create an osmotic effect 1
   • Dosing: 10 mL/kg body weight 1
   • The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition recommends these juices specifically for constipation in infants 1

4. Physical activity:

   • Regular exercise helps stimulate bowel movements 1
   • Encourage age-appropriate physical activity daily

Medication Options (if dietary measures insufficient)

For mild to moderate constipation:

1. Osmotic laxatives:

   • Polyethylene glycol (PEG):

     • First-line medication for children over 17 years: 17g dissolved in 4-8 oz of beverage once daily 5
     • For children under 16 years: consult physician for appropriate dosing 5

   • Lactulose:

     • Pediatric dosing: 6
       • Infants: 2.5-10 mL daily in divided doses
       • Older children/adolescents: 40-90 mL total daily dose
     • Reduce dose if diarrhea occurs

2. Stimulant laxatives (for more severe cases):

   • Bisacodyl: 10-15 mg daily to TID with goal of one non-forced bowel movement every 1-2 days 1

Management of Complications

• For impaction:
  • Glycerine suppository or mineral oil retention enema 1
  • Manual disimpaction may be necessary (with pre-medication for pain/anxiety) 1
  • Consider adding other laxatives such as:
    • Bisacodyl suppository (one rectally daily-BID)
    • Polyethylene glycol (1 capful/8 oz water BID)
    • Lactulose (30-60 mL BID-QID)
    • Sorbitol (30 mL every 2 hours × 3, then as needed)
    • Magnesium hydroxide (30-60 mL daily-BID)

Special Considerations

• Chronic constipation is a common lifelong problem requiring aggressive treatment 1
• Complications if untreated include rectal prolapse, hemorrhoids, and intestinal perforation 1
• Fiber supplementation like glucomannan (100 mg/kg daily, max 5g/day) has shown benefit even in children already on laxatives 3
• Monitoring response: Goal is 1 non-forced bowel movement every 1-2 days 1

Common Pitfalls to Avoid

1. Inadequate fiber intake: Most families struggle to achieve recommended fiber levels without intensive dietary counseling 4
2. Insufficient fluid intake: Mild dehydration is a significant risk factor for constipation 2
3. Delayed treatment: Chronic constipation becomes more difficult to treat over time
4. Overreliance on laxatives: Dietary modifications should always accompany medication
5. Discontinuing treatment too early: Maintenance therapy is often needed to prevent recurrence

By following this approach, most cases of childhood constipation can be effectively managed, improving quality of life and preventing complications associated with chronic constipation.