What is the recommended treatment for pediatric constipation?

Treatment of Pediatric Constipation

The recommended first-line treatment for pediatric constipation includes increasing water and fiber in the diet followed by osmotic laxative therapy, with polyethylene glycol (PEG) being the preferred agent for children over 6 months of age and lactulose for infants under 6 months. 1

Initial Assessment and Management

• Constipation is a common lifelong problem in children that must be aggressively treated to prevent complications such as rectal prolapse, hemorrhoids, and intestinal perforation 1
• Initial evaluation should focus on identifying whether constipation is functional (90-95% of cases) or organic in nature 2
• Treatment should begin promptly to avoid psychosocial and digestive consequences 3

Treatment Algorithm

For Infants (Under 6 Months)

• Lactulose-based medications are authorized and effective for this age group 3
• Initial daily dose in infants is 2.5 mL to 10 mL in divided doses 4
• If the initial dose causes diarrhea, the dose should be reduced immediately 4

For Children Over 6 Months

• Polyethylene glycol (PEG) is the preferred treatment 3
• For children 6 months to 16 years: dosing should be determined by a doctor 5
• For children 17 years and older: one packet of powder (17 g) dissolved in 4-8 ounces of beverage once daily 5

For Fecal Impaction

• Initial disimpaction is critical before maintenance therapy can be effective 3
• Options include:
  • High-dose PEG for the first few days 3
  • Repeated phosphate enemas (for severe cases) 3

Comprehensive Management Approach

• Dietary Modifications:

  • Increase water intake 1
  • Increase dietary fiber 1
  • Avoid foods high in simple sugars and fats 1

• Behavioral Interventions:

  • Establish proper toilet posture with buttock support, foot support, and comfortable hip abduction 1
  • Implement a regular toileting program 1
  • Educate child and family about the importance of maintaining treatment long-term 1

• Medication Management:

  • Use sufficient doses for an adequate duration (often several months) 3
  • Monitor response and adjust dosing as needed 3
  • Be prepared to restart medication promptly if symptoms recur 2

Important Considerations and Pitfalls

• Common Pitfalls:

  • Premature discontinuation of treatment is common and leads to relapse 1
  • Parents often stop treatment too soon before the child regains bowel motility and rectal perception 1
  • Hyperosmotic mineral water, diet changes alone, and endoanal medications are not sufficient treatments for established constipation 3

• When to Refer:

  • Persistent constipation despite adequate therapy 2
  • Signs of organic disease 2
  • Constipation associated with neurological disorders 6
  • Suspected enteric neuromuscular disorders 6

• Long-term Outcomes:

  • Approximately 70% of children respond to medical therapies and behavioral modifications within 2 years 6
  • About 30% of children continue to have symptoms beyond puberty 7
  • Long-term follow-up is essential to monitor progress and adjust treatment as needed 2