What is the treatment for a child with constipation who has difficulty passing stools?

Treatment for Childhood Constipation

Polyethylene glycol (PEG) is the first-line maintenance therapy for children with constipation, with a typical starting dose of 0.4-0.8 g/kg/day, adjusted to achieve 2-3 soft stools daily. 1

Initial Assessment and Management

Diagnosis

• Perform a perineal inspection to check for:
  • Fissures, skin tags, redness, and soiling 1
• Digital rectal examination to assess:
  • Presence of stool in rectum/fecal impaction
  • Sphincter tone
  • Anal fissures or tenderness
  • Rectal vault size 1

Treatment Algorithm

1. For Fecal Impaction (Initial Phase)

   • Initial disimpaction with oral PEG is preferred 1
   • For severe impaction, consider:
     • Glycerine suppository with or without mineral oil retention enema
     • Manual disimpaction (only if necessary, with appropriate pain management) 1

2. Maintenance Phase

   • First-line medication: Polyethylene glycol (PEG) 0.4-0.8 g/kg/day 1
   • Alternative medications if PEG is unavailable or not tolerated:
     • Lactulose
     • Milk of magnesia
     • Mineral oil 1

3. Dietary Modifications

   • Increase water intake
   • Add fiber-rich foods (fruits, vegetables, whole grains)
   • Consider fiber supplements for mild constipation 1

4. Behavioral Interventions

   • Establish proper toilet posture:
     • Buttock support
     • Foot support
     • Comfortable hip abduction 1
   • Implement regular toileting routine:
     • Schedule 5-10 minutes after meals
     • Use reward systems for successful bowel movements 1

Special Considerations

Duration of Treatment

• Maintenance therapy is often required for extended periods
• Premature discontinuation of treatment is a common pitfall leading to relapse 1
• Parental education about the chronic nature of functional constipation is essential 1

Connection with Urinary Issues

• Constipation can contribute to:
  • Urinary tract infections
  • Daytime wetting
  • Enuresis 1
• Treating constipation often improves these urinary symptoms 1

Common Pitfalls to Avoid

1. Discontinuing treatment too soon

   • Maintenance therapy should continue until regular bowel habits are established for several months 1

2. Ignoring the constipation-enuresis connection

   • Always assess for constipation when evaluating children with urinary symptoms 1

3. Inadequate disimpaction before maintenance therapy

   • Complete disimpaction is necessary before maintenance therapy can be effective 1

4. Insufficient dosing of laxatives

   • PEG dosing should be adjusted to achieve 2-3 soft stools daily 1

5. Lack of follow-up

   • Close monitoring is essential to adjust treatment and prevent relapse 1

By following this comprehensive approach to managing childhood constipation, focusing on proper disimpaction, maintenance therapy with PEG, dietary modifications, and behavioral interventions, most children will experience significant improvement in their symptoms and quality of life.