Treatment of Constipation in a 6-Year-Old Child
Start with polyethylene glycol (PEG/MiraLAX) as the most effective pharmacological treatment, combined with education, lifestyle modifications, and establishing a regular toileting routine. 1, 2
Initial Non-Pharmacological Interventions
Begin with comprehensive education and lifestyle changes as the foundation of treatment:
Explain constipation pathophysiology to parents and establish realistic treatment expectations, emphasizing that management is typically long-term and may continue for months 1
Establish a regular toileting routine with timed voiding after meals (typically 5-10 minutes after breakfast and dinner) to take advantage of the gastrocolic reflex, using a reward system to encourage compliance 1
Ensure proper toilet posture with buttock support, foot support (use a stool if feet don't reach the floor), and comfortable hip abduction to facilitate easier defecation 1
Increase dietary fiber through whole fruits rather than juices, but only if the child has adequate fluid intake 1
Offer specific juices containing sorbitol (prune, pear, and apple juices) which can help increase stool frequency and water content 1
Ensure adequate hydration with increased fluid intake, though this alone is insufficient to treat established constipation and should be considered adjunctive therapy 1, 2
Encourage age-appropriate physical activity as a supportive measure, though it has limited evidence as primary therapy 1, 2
Pharmacological Treatment: First-Line Therapy
Polyethylene glycol (PEG) is the most effective treatment and should be added when lifestyle modifications alone are insufficient:
PEG has demonstrated superior efficacy compared to other laxatives including stool softeners like docusate 2
For children over 6 months of age, PEG is authorized and effective 3
The FDA-approved over-the-counter formulation (17g packets) is labeled for children 17 years and older, but a physician should be consulted for dosing in children 16 years and under 4
PEG generally produces a bowel movement in 1-3 days 4
The key principle is using a sufficient dose for a long duration rather than short-term treatment 3
Treatment Goals and Monitoring
The primary objective is achieving one non-forced bowel movement every 1-2 days 1:
Acceptable outcomes include adequate symptom management, reduction of family distress, and improved quality of life 1
Regular follow-up is essential to monitor progress and adjust treatment as needed 1
If initial treatment fails, reassess for underlying causes and severity 1
Special Considerations for Fecal Impaction
If fecal impaction is present (with or without fecal incontinence):
First stage is fecal disimpaction using high-dose PEG for the first few days, or repeated phosphate enemas 3
Only after disimpaction should maintenance therapy begin 3
What NOT to Do: Common Pitfalls
Avoid relying solely on stool softeners like docusate, as they are less effective than osmotic laxatives like PEG 2
Don't use excessive fruit juices as they lack fiber and contribute to excessive calorie intake 1
Avoid foods high in simple sugars (soft drinks, undiluted apple juice) as they can worsen symptoms through osmotic effects 1
Don't expect quick results - treatment duration is typically months, not weeks 1
Don't forget to address behavioral issues around toileting, including fear of painful defecation, which must be managed concurrently 1, 2