What is the recommended treatment for pediatric constipation?

Management of Pediatric Constipation

The recommended first-line treatment for pediatric constipation is polyethylene glycol (PEG), which should be administered at an age-appropriate dose to achieve soft, painless bowel movements. 1, 2

Initial Assessment

• Evaluate for warning signs that may indicate an organic cause of constipation:
  • Delayed passage of meconium (>48 hours after birth) 3
  • Failure to thrive, abdominal distension, abnormal position of anus, absence of anal or cremasteric reflex 3

Treatment Algorithm

Step 1: Disimpaction (if needed)

• For fecal impaction, begin with high-dose PEG for the first few days or use phosphate enemas 4
• Complete disimpaction is necessary before beginning maintenance therapy 5

Step 2: Maintenance Therapy

For Infants (<6 months):

• Ensure adequate fluid intake for breastfed infants who should continue nursing on demand 3
• Small amounts of fruit juices containing sorbitol (prune, pear, or apple juice) can help increase stool frequency 3
• Lactulose/lactitol-based medications are authorized and effective for infants under 6 months 4
  • Initial daily oral dose: 2.5 mL to 10 mL in divided doses 6
  • Reduce dose immediately if diarrhea occurs 6

For Infants (>6 months) and Children:

• Polyethylene glycol (PEG) is the first-line treatment for children over 6 months 4, 5
  • For children 16 years and under: dosage should be determined by a doctor 2
  • For older children and adolescents: total daily lactulose dose is 40 mL to 90 mL if PEG is not used 6

Dietary Modifications:

• Increase dietary fiber intake according to the "age + 5" rule for grams of fiber per day 7
  • Most constipated children consume less than one-fourth of recommended fiber intake 7
  • Fiber supplements such as glucomannan (100 mg/kg body weight daily, max 5 g/day) can be beneficial, especially for children with constipation without encopresis 8

Step 3: Behavioral Modifications

• Establish regular toilet sitting schedule, particularly after meals 8
• Education regarding appropriate toilet posture and daily bowel movement routine 4

Duration of Treatment

• Maintenance therapy should continue for months to prevent relapse 5
• High-fiber diet should be maintained lifelong 7
• Regular reassessment of bowel habits is essential to monitor treatment effectiveness 3

Important Considerations

• Treatment is often delayed with psychosocial and digestive consequences, but is well-codified and effective when properly implemented 4
• Chronicity may significantly interfere with the child's emotional growth and development, making proper treatment crucial 9
• Intensive and ongoing dietary counseling is necessary for successful implementation of high-fiber diets 7
• Children with constipation only respond better to fiber treatment (69% success) compared to those with constipation and encopresis (28% success) 8