What is the recommended treatment for constipation in pediatric patients?

Treatment of Pediatric Constipation

Polyethylene glycol (PEG) is the first-line pharmacological treatment for constipation in children over 6 months of age, while lactulose is preferred for infants under 6 months. 1, 2

Initial Assessment

Before starting treatment, rule out fecal impaction through digital rectal examination, as impaction requires disimpaction before maintenance therapy 1. Also exclude organic causes including obstruction, hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 1.

Treatment Algorithm

Step 1: Non-Pharmacological Management (All Ages)

• Increase fluid intake to maintain proper hydration 1
• Increase dietary fiber through age-appropriate foods including fruits, vegetables, whole grains, and legumes 1
• Encourage regular physical activity appropriate to the child's age 1
• Establish proper toilet posture with secure seating, buttock support, foot support, and comfortable hip abduction 1, 2
• Implement regular toileting schedule: void in morning, twice during school, after school, at dinner, and before bed 3
• Avoid foods high in simple sugars and fats that worsen constipation 1, 2

Step 2: Disimpaction (If Impaction Present)

• Glycerin suppositories are the preferred first-line suppository option, acting as a rectal stimulant through mild irritant action 1
• Manual disimpaction may be performed if necessary 1
• Contraindications to suppositories/enemas: neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis 1

Step 3: Pharmacological Maintenance Therapy

For infants under 6 months:

• Lactulose is the preferred agent 2
• Dosing: 2.5-10 mL daily in divided doses 4
• Fruit juices containing sorbitol (prune, pear, apple) can increase stool frequency and water content 1

For children 6 months and older:

• Polyethylene glycol (PEG) 3350 is the laxative of first choice 1, 2, 5, 6
• Initial dosing: 0.8-1 g/kg/day (mean effective dose 0.78-0.84 g/kg/day) 7, 8, 9
• Goal: Produce 2-3 soft, painless stools daily 2, 8
• Dose adjustment: Adjust every 2-3 days based on response 2, 8
• Efficacy: PEG provides 56% success rate compared to 29% with lactulose, with fewer side effects 6

For older children and adolescents:

• Lactulose alternative dosing: 40-90 mL total daily dose if PEG unavailable 4

For severe cases:

• Bisacodyl or glycerin suppositories can be used, but stimulant laxatives should not be first-line therapy 1

Step 4: Maintenance Phase

• Continue dietary modifications and adjusted laxative dosing 1
• Duration: Maintenance therapy may need to continue for many months before the child regains normal bowel motility and rectal perception 1
• Gradual tapering: Slowly reduce medications as bowel habits normalize 1
• Monitor response: Adjust dosing as needed and be prepared to restart medication promptly if symptoms recur 2

Critical Pitfalls to Avoid

• Premature discontinuation of treatment is the most common pitfall—parents often stop treatment too soon before bowel motility and rectal perception normalize, leading to 40-50% relapse rates within 5 years 1, 2
• Relying solely on dietary changes without addressing impaction can worsen constipation 1
• Using stimulant laxatives as first-line therapy instead of osmotic agents is not recommended 1
• Using suppositories alone without follow-up maintenance therapy leads to high relapse rates 1

Safety Considerations

• PEG safety profile: Highly effective with good safety profile and well tolerated; only minor adverse events (transient diarrhea, increased gas) reported 7, 5, 9
• Electrolyte monitoring: In patients predisposed to water and electrolyte imbalances, consider monitoring serum electrolytes 5
• Lactulose side effects: More abdominal pain, straining, and pain at defecation compared to PEG 6

Special Considerations

• Aggressive treatment is essential to prevent complications including rectal prolapse, hemorrhoids, and intestinal perforation 2
• Constipation management impacts other conditions: Aggressive treatment decreases urinary tract infections and reduces need for intervention in patients with vesicoureteral reflux 1
• Education is critical: Teach families about normal bowel function and the importance of long-term treatment adherence 2