Management of Intermittent Constipation in a 10-Year-Old
Start with polyethylene glycol (PEG) as first-line pharmacological therapy after implementing dietary and lifestyle modifications. 1, 2, 3
Initial Assessment Priorities
Before initiating treatment, confirm this is functional constipation by ensuring absence of red flags:
- No rectal bleeding, unintentional weight loss, fever, vomiting, or severe abdominal distension 4, 3
- No delayed passage of meconium (suggesting Hirschsprung disease), neurological abnormalities, or abnormal thyroid function 3, 5
- Physical exam should specifically assess for abdominal masses, anal fissures, perianal abnormalities, and lumbosacral spine abnormalities 4, 3
Since red flags are absent, this is functional constipation (accounting for 90-95% of pediatric cases), and no laboratory investigations or imaging are needed 3, 5.
First-Line Management: Lifestyle and Dietary Modifications
Begin with non-pharmacological interventions before escalating to medications:
- Increase fluid intake and dietary fiber (age + 5 grams daily for children) 2, 3
- Encourage regular physical exercise and establish a consistent toileting routine, particularly after meals to utilize the gastrocolic reflex 4, 3
- Educate the family that constipation is common, treatable, and not dangerous—demystification reduces anxiety and improves compliance 5
Pharmacological Management When Lifestyle Changes Are Insufficient
Polyethylene glycol (PEG) 3350 is the evidence-based first-line laxative for pediatric functional constipation:
- PEG is an osmotic laxative that improves stool consistency and frequency without causing dependency 1, 2, 3
- Dosing: Start with 0.5-1 g/kg/day (maximum 17 g daily for maintenance), adjusting based on response 2, 5
- PEG is superior to lactulose because it does not cause fermentation-related bloating and gas 6, 2
If PEG alone is insufficient after 2-4 weeks, add a stimulant laxative:
- Senna or bisacodyl can be added for refractory cases, but avoid chronic use as monotherapy due to risk of dependency 7, 6, 5
- Goal is achieving 1 non-forced bowel movement every 1-2 days 7
Treatment Duration and Follow-Up
Continue laxative therapy for at least 3-6 months after symptom resolution to prevent relapse:
- 40-50% of children experience at least one relapse within 5 years, so prolonged maintenance is critical 3
- Reassess efficacy after 3 months and adjust dosing or add additional agents if inadequate response 8, 5
- Gradually taper laxatives only after sustained improvement, not abruptly 5
When to Refer for Specialist Evaluation
Refer to pediatric gastroenterology if:
- Treatment failure after 3-6 months of appropriate laxative therapy 3, 5
- Development of red flag symptoms during treatment 3, 5
- Suspicion of underlying organic disease or functional defecation disorder requiring specialized testing (anorectal manometry, colonic transit studies) 9, 5
Critical Pitfalls to Avoid
- Do not use abdominal x-rays routinely—they do not differentiate functional from organic causes and add no diagnostic value 3
- Do not rely on dietary fiber alone without adequate fluid intake, as this can paradoxically worsen constipation 6, 2
- Do not use stimulant laxatives as first-line monotherapy due to dependency risk 6, 5
- Do not discontinue treatment prematurely—most relapses occur when therapy is stopped too early 3, 5