What is the best approach to manage constipation in a 10-year-old child?

Management of Constipation in a 10-Year-Old Child

Start with polyethylene glycol (PEG) 17 grams once daily as first-line treatment after ruling out fecal impaction, and if impaction is present, perform disimpaction with enemas before initiating maintenance therapy. 1

Initial Assessment

Rule Out Fecal Impaction First

• Perform a rectal examination to assess for fecal impaction 2
• If impaction is present, disimpaction must occur before starting maintenance therapy 2, 1
• Use 1-2 phosphate enemas for disimpaction 2

Identify Red Flags for Organic Causes

While functional constipation is most common, organic causes (Hirschsprung disease, cystic fibrosis, spinal cord abnormalities) present with specific warning signs that require different management 1

Treatment Algorithm

Step 1: Disimpaction (If Needed)

• Administer phosphate enemas if rectal impaction is confirmed on examination 2
• Do not proceed to maintenance therapy until disimpaction is complete 2

Step 2: First-Line Maintenance Therapy

Polyethylene glycol (PEG) is the first-line pharmacologic treatment 1

• Dosing for 10-year-old: 17 grams dissolved in 4-8 ounces of any beverage (cold, hot, or room temperature) once daily 3
• Ensure powder is fully dissolved before drinking 3
• Maximum duration without physician consultation: 7 days for over-the-counter use, but chronic constipation typically requires longer physician-supervised treatment 3

Step 3: Second-Line Options (If PEG Inadequate)

• Lactulose 1
• Enemas 1
• Bisacodyl 10-15 mg daily with goal of one non-forced bowel movement every 1-2 days 4

Dietary Modifications

Fiber Supplementation

Add fiber supplementation even if the child is already on laxatives—this provides additional benefit 2

• Fiber (glucomannan) at 100 mg/kg body weight daily (maximum 5 g/day) with 50 mL fluid per 500 mg significantly improves constipation 2
• 45% of children were successfully treated with fiber versus only 13% with placebo 2
• Psyllium dosing for ages 6-11 years: 1/2 packet in 8 oz liquid, up to 3 times daily 5

Important caveat: Most families fail to achieve adequate fiber intake despite being instructed to "eat a high-fiber diet"—constipated children consume less than one-fourth of recommended fiber intake without intensive dietary counseling 6. Simply advising families to increase fiber is insufficient; specific guidance and ongoing support are essential 6.

Fluid Intake

• Increase water intake 4
• Note: Increasing fluids above usual daily recommendations provides no additional benefit beyond normal hydration 1

Fruit Juices (Limited Role)

• Prune, pear, and apple juices contain sorbitol and other carbohydrates that increase stool frequency and water content 4
• This is primarily recommended for infants, not school-age children 4
• Whole fruit is preferred over juice for nutritional reasons 4

Behavioral Interventions

• Have the child sit on the toilet 4 times daily after meals 2
• This capitalizes on the gastrocolic reflex and establishes routine 2

Follow-Up Strategy

Frequent follow-up is critical—treatment failure rates are high due to inadequate monitoring 7

• Schedule regular follow-up visits to assess response 7, 1
• Consider referral to a psychologist to assist with treatment goals 1
• Educate caregivers that functional constipation is chronic with frequent relapses requiring prolonged therapy 1
• Acknowledge the negative effects on the child's quality of life and specific challenges families face 1

When to Refer

Refer to pediatric gastroenterology when:

• Concern exists for organic causes 1
• Constipation persists despite adequate therapy with PEG and fiber 1
• Complications develop (rectal prolapse, hemorrhoids, intestinal perforation) 4

Common Pitfalls to Avoid

• Do not skip disimpaction: Starting maintenance laxatives without first clearing impaction leads to treatment failure 2
• Do not rely on dietary advice alone: Families cannot achieve adequate fiber intake without intensive, ongoing dietary counseling 6
• Do not use probiotics: These provide no additional benefit for treating constipation 1
• Do not assume increasing fluids beyond normal helps: Excessive fluid recommendations are not evidence-based 1
• Do not underestimate chronicity: This condition requires months of treatment, not days or weeks 2, 1