What is the approach to managing constipation in children?

Management of Constipation in Children

The management of constipation in children should follow a stepwise approach including dietary modifications, behavioral interventions, and pharmacological treatments, with polyethylene glycol (PEG) as the first-line medication due to its efficacy and safety profile.

Initial Assessment and Non-Pharmacological Management

Dietary Modifications

• Increase fluid intake: Dehydration is a risk factor for constipation; ensuring adequate hydration is essential 1
• Increase dietary fiber:
  • Recommended daily fiber intake: age + 5 grams 2, 3
  • Most constipated children consume less than 25% of recommended fiber 2
  • Incorporate whole grains, fruits, and vegetables
  • For infants with constipation: Prune, pear, and apple juices can help increase stool frequency and water content due to their sorbitol content 4

Behavioral Interventions

• Establish regular toilet sitting schedule (4 times daily, preferably after meals)
• Create a comfortable toilet environment
• Use positive reinforcement for successful bowel movements
• Address any toilet avoidance behaviors

Pharmacological Management

First-Line Treatment

• Polyethylene glycol (PEG):
  • Dosing for children 17 years and older: 17g dissolved in 4-8 ounces of beverage once daily 5
  • For children under 16 years: dosing should be determined by a physician 5
  • PEG works by drawing water into the intestinal lumen, softening stool and increasing bowel movement frequency

Second-Line Options

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

Disimpaction Phase

For children with significant fecal impaction:

1. Clear the impaction first (may require enemas or high-dose laxatives)
2. Follow with maintenance therapy to prevent recurrence

Special Considerations

For Infants

• Fruit juices containing sorbitol (prune, pear, apple) can be beneficial for constipation 4
• Juice should be limited to 10 mL/kg body weight to avoid malabsorption issues 4

For Children with Williams Syndrome

• Chronic constipation is a common lifelong problem requiring aggressive treatment
• Increase water and fiber intake first, then add osmotic laxatives
• Monitor for complications including rectal prolapse, hemorrhoids, and intestinal perforation 4

Long-Term Management

• Treatment typically involves three phases:

  1. Disimpaction (days to weeks)
  2. Laxative use (months)
  3. High-fiber diet (lifelong) 2

• Intensive and ongoing dietary counseling is crucial, as families often struggle to maintain high-fiber diets without proper guidance 2

• Regular follow-up to assess response to treatment and adjust management plan as needed

Monitoring for Complications

• Watch for signs of:
  • Rectal prolapse
  • Hemorrhoids
  • Intestinal perforation (particularly in children with Williams syndrome) 4
  • Diverticular disease (can occur at young age in adolescents with chronic constipation) 4

By following this structured approach to managing constipation in children, clinicians can effectively address this common pediatric problem and prevent long-term complications.