What are the treatment options for pediatric constipation?

Treatment Options for Pediatric Constipation

The first-line treatment for pediatric constipation is polyethylene glycol (PEG), which is strongly recommended due to its efficacy and safety profile, with dosing adjusted based on age and severity of constipation. 1, 2

Initial Assessment and Non-Pharmacological Approaches

• Constipation in children is usually functional without an organic cause, but assessment should rule out impaction, obstruction, and other treatable causes such as hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 3, 1
• Increasing fluid intake and dietary fiber through age-appropriate foods (fruits, vegetables, whole grains, legumes) helps manage constipation 1
• Regular physical activity appropriate to the child's age is recommended to improve bowel motility 1
• Fruit juices containing sorbitol (prune, pear, apple) can help increase stool frequency and water content, particularly in infants 1
• Correct toilet posture is essential - children need secure seating with buttock support, foot support, and comfortable hip abduction to enable relaxed voiding 3

Pharmacological Management Algorithm

Step 1: Disimpaction (if needed)

• For fecal impaction, glycerin suppositories may be administered or manual disimpaction performed 3
• Phosphate enemas can be used for initial disimpaction if rectal impaction is present 4

Step 2: Maintenance Treatment

• First-line: Polyethylene glycol (PEG) - most effective laxative for children 1, 2

  • For children under 16 years: dosing should be determined by a doctor 5
  • For children 17 years and older: one packet (17g) dissolved in 4-8 ounces of beverage once daily 5

• Second-line options:

  • Lactulose or sorbitol-containing juices 1
  • Bisacodyl (for more severe cases):
    • Children 6-11 years: 1/2 suppository once daily 6
    • Children 12 years and older: 1 suppository once daily 6
    • Children under 6 years: consult a doctor 6

• For opioid-induced constipation: stimulant laxatives with or without stool softeners 3

Step 3: Weaning

• Gradually taper medications as bowel habits normalize 1
• Maintenance phase may need to continue for many months before the child regains normal bowel motility and rectal perception 3

Special Considerations

• Constipation management should be aggressive, as it can impact other conditions - it has been shown to decrease urinary tract infections and reduce the need for intervention in patients with vesicoureteral reflux 3
• Fiber supplements like glucomannan (100 mg/kg body weight daily, max 5g/day) can be beneficial, particularly for children with constipation without encopresis (69% success rate vs. 28% for those with encopresis) 4
• Recent research shows increasing dietary fiber and fluid intake above usual daily recommendations provides no additional benefits for treating constipation 2
• A combination of fiber mixture and lactulose gives comparable results in treating childhood constipation, though lactulose produces softer stools 7

Common Pitfalls to Avoid

• Premature discontinuation of treatment - parents often cease treatment too soon before the child regains bowel motility and rectal perception 3
• Relying solely on dietary changes without addressing impaction if present can worsen constipation 1
• Using stimulant laxatives as first-line therapy instead of osmotic agents like PEG is not recommended 1
• Failing to provide adequate follow-up - frequent follow-up visits are essential for successful treatment 2
• Neglecting to educate caregivers about the potentially chronic course of functional constipation, frequent relapses, and the possibility of prolonged therapy 2