What is the recommended treatment for constipation in children?

Treatment of Constipation in Children

The recommended treatment for constipation in children includes increasing fluid intake, dietary fiber, physical activity, and using appropriate laxatives such as polyethylene glycol, lactulose, or sorbitol-containing juices when necessary. 1

Initial Non-Pharmacological Approaches

• Increase fluid intake to maintain proper hydration, as dehydration is a significant risk factor for constipation 2
• Increase dietary fiber intake through age-appropriate foods:
  • For children over 2 years: aim for "age + 5" grams of fiber per day 3, 4
  • Recommended high-fiber foods include fruits, vegetables, whole grains, and legumes 1
• Encourage regular physical activity appropriate to the child's age 1
• Consider fruit juices containing sorbitol (prune, pear, and apple juices) to help increase stool frequency and water content in infants with constipation 1

Dietary Recommendations

• For infants: continue breast-feeding on demand or use full-strength formula 1
• For older children:
  • Maintain regular diet with emphasis on high-fiber foods 1
  • Include starches (rice, potatoes, noodles), cereals, yogurt, fruits, and vegetables 1
  • The "BRAT" diet (bananas, rice, applesauce, toast) can be helpful as part of the dietary management 1
  • Avoid foods high in simple sugars and fats, which can worsen constipation 1

Pharmacological Management

When non-pharmacological approaches are insufficient:

• First-line laxative therapy:

  • Polyethylene glycol (1 capful/8 oz water BID) 1
  • Lactulose (30-60 mL BID-QID for older children; for infants: 2.5-10 mL in divided doses) 1, 5
  • Sorbitol (30 mL every 2 hours × 3, then as needed) 1

• For more severe cases:

  • Bisacodyl (10-15 mg daily to TID) with a goal of one non-forced bowel movement every 1-2 days 1
  • Bisacodyl suppositories (one rectally daily-BID) for more immediate relief 1
  • Glycerin suppositories with or without mineral oil retention enemas for impaction 1

Management Algorithm

1. Assessment phase:

   • Rule out impaction, especially if diarrhea accompanies constipation (overflow around impaction) 1
   • Rule out obstruction through physical exam and, if needed, abdominal imaging 1
   • Identify and treat other causes (medications, metabolic disorders) 1

2. Initial treatment phase:

   • If impaction is present: perform manual disimpaction following pre-medication with analgesic/anxiolytic 1
   • Start dietary modifications (increased fluids, fiber) 1
   • Begin appropriate laxative therapy based on age and severity 1

3. Maintenance phase:

   • Continue dietary modifications with emphasis on adequate fiber intake 4, 6
   • Adjust laxative dosing to achieve regular bowel movements 1
   • Gradually taper medications as bowel habits normalize 1

Special Considerations

• Fiber supplements such as glucomannan (100 mg/kg body weight daily, max 5 g/day) can be beneficial for children who don't respond to dietary changes alone 7
• Children with constipation often consume less than one-fourth of the recommended fiber intake, highlighting the need for intensive dietary counseling 3
• Dietary fiber intake should be increased gradually to prevent bloating and gas 6
• Ensure adequate fluid intake when increasing fiber to prevent worsening of constipation 2

Common Pitfalls to Avoid

• Failing to maintain adequate hydration when increasing fiber intake 2
• Relying solely on dietary changes without addressing impaction if present 1
• Not providing sufficient education to families about appropriate fiber-rich foods 3
• Discontinuing treatment too early, as maintenance therapy may be needed for months 3
• Using stimulant laxatives as first-line therapy instead of osmotic agents 1