What are the treatment options for constipation in children?

Treatment Options for Constipation in Children

The first-line treatment for constipation in children includes dietary modifications with increased fiber and fluids, behavioral interventions, and osmotic laxatives such as polyethylene glycol (PEG) or lactulose when needed. 1, 2

Initial Assessment and Non-Pharmacological Management

• Evaluate feeding history, including type of feeding (breast milk vs. formula) and any recent changes, as these can significantly impact bowel patterns 1
• For infants under 1 year, fruit juices containing sorbitol (prune, pear, and apple juices) are recommended as first-line dietary intervention in small amounts (10 mL/kg body weight) 1
• Ensure adequate fluid intake to maintain proper stool consistency 1
• Maintain correct toilet posture with buttock support, foot support, and comfortable hip abduction to enable relaxed voiding 3
• Implement a regular toileting schedule with dedicated time for bowel movements, particularly after meals to take advantage of the gastrocolic reflex 3, 2

Pharmacological Management

For Infants:

• For breastfed infants, continue nursing on demand while addressing constipation 1
• Small amounts of fruit juices containing sorbitol (prune, pear, apple) can be effective for mild constipation 1
• Lactulose may be used if dietary modifications are insufficient, with recommended initial daily oral doses in infants of 2.5 mL to 10 mL in divided doses 1, 4
• If diarrhea occurs with lactulose, reduce the dose immediately or discontinue if diarrhea persists 4

For Older Children:

• Polyethylene glycol (PEG) is the preferred first-line osmotic laxative due to its effectiveness and tolerability 2
• For children over 17 years: one packet of PEG powder (17g) dissolved in 4-8 ounces of beverage once daily 5
• For children 16 years and under: consult a doctor for appropriate PEG dosing 5
• Alternative osmotic laxatives include lactulose (40-90 mL total daily dose for older children and adolescents) 4, 2
• Stimulant laxatives can be added if there is no improvement with osmotic laxatives alone 6

Treatment Algorithm

1. Initial Phase - Disimpaction (if needed):

   • Clear any fecal impaction before maintenance therapy 2
   • Oral or rectal medications may be used for disimpaction 2

2. Maintenance Phase:

   • Dietary modifications: increased fiber, adequate fluids 1, 2
   • Regular toileting schedule 3
   • Osmotic laxatives (PEG or lactulose) 4, 5, 2
   • Add stimulant laxatives if needed 6

3. Long-term Management:

   • Continue maintenance therapy for several months as relapse is common (50-70% of children may experience relapse) 2
   • Gradually taper medications once regular bowel habits are established 2

Special Considerations

• Avoid excessive juice consumption as it may lead to diarrhea, flatulence, abdominal pain, and poor weight gain 1
• Consider maternal diet modification if infant shows signs of milk protein allergy (which can mimic constipation symptoms) 1
• For persistent constipation not responding to standard treatment, consider referral to a pediatric gastroenterologist to rule out organic causes 7, 6
• Be alert for red flags that may indicate serious organic causes of constipation, such as Hirschsprung's disease, spinal cord abnormality, hypothyroidism, or congenital anorectal malformation 2
• Despite appropriate treatment, only 50-70% of children with functional constipation demonstrate long-term improvement 2

Parent Education

• Educate families about normal bowel patterns in children of different ages 1
• Explain the importance of consistent adherence to the treatment plan 8
• Regular follow-up is essential for effective management of this potentially chronic problem 8
• Reassure parents that with proper management, most children will eventually overcome constipation 2