Role of Laxatives in Managing Constipation in Children
Polyethylene glycol (PEG) is the first-line laxative treatment for constipation in children due to its superior efficacy, safety profile, and tolerability compared to other laxative options. 1, 2
First-Line Treatment Options
- PEG is the preferred osmotic laxative for childhood constipation, generally producing a bowel movement within 1-3 days 3
- PEG has been shown to be safe and effective even in children younger than 18 months at a maintenance dose of approximately 0.78 g/kg/day 4
- PEG works by drawing water into the intestinal lumen, softening stool and stimulating bowel movements 5
- Management of constipation is particularly important in children with dysfunctional voiding, as constipation treatment has been shown to decrease urinary tract infections and improve outcomes 5
Treatment Algorithm for Childhood Constipation
- Initial management should include disimpaction if needed, followed by maintenance therapy with PEG 1, 2
- For children with mild to moderate constipation, PEG at 0.6-0.8 g/kg/day is typically effective 4, 6
- If PEG is unavailable or poorly tolerated, lactulose is the recommended alternative, though it is less effective than PEG 7
- Liquid paraffin (mineral oil) has shown efficacy compared to lactulose but should be used with caution in infants due to risk of aspiration 7
- Stimulant laxatives (senna, bisacodyl) may be added if there is inadequate response to osmotic laxatives alone 5, 2
Important Considerations and Pitfalls
- Bulk-forming laxatives like psyllium are not recommended for constipation management in children as they are unlikely to control constipation effectively 7
- Docusate sodium (stool softener) lacks experimental evidence supporting its use in pediatric constipation management and is not recommended 7
- Constipation treatment may need to be maintained for many months before the child regains normal bowel motility and rectal perception 5
- A common clinical observation is that parents often discontinue treatment too soon, leading to relapse 5
- Despite improvement with laxatives, 40-50% of children with constipation experience at least one relapse within 5 years 2
Special Populations and Considerations
- For infants with normal or frequent bowel movements, clear liquids for 24 hours with a normal saline enema (10 mL/kg) may be sufficient 5
- For older children requiring bowel preparation for procedures, PEG-3350 at 1.5 g/kg/day for 4 days before the procedure (with clear liquid diet on the fourth day) has been effective 5
- Sodium phosphate preparations should be avoided in children younger than 12 years due to risk of adverse effects 5
- When treating constipation associated with opioid use, PEG with adequate fluid intake is recommended as a prophylactic bowel regimen 5
Monitoring and Follow-up
- The goal of therapy is one non-forced bowel movement every 1-2 days 5
- Regular follow-up is essential to sustain motivation and improve outcomes 5
- Keeping a calendar of dry and wet nights (for children with enuresis) and bowel movements provides a baseline to judge treatment effect 5
- Treatment should be continued until the child establishes regular bowel habits, which may take several months 5, 8