Treatment of Constipation in Pediatric Patients
First-Line Treatment Approach
Polyethylene glycol (PEG) 3350 is the laxative of first choice for children 6 months and older at 0.8-1 g/kg/day, with the goal of producing 2-3 soft, painless stools daily. 1
Initial Assessment and Disimpaction
Before starting maintenance therapy, rule out fecal impaction through digital rectal examination. 1
If impaction is present:
- Use glycerin suppositories as first-line suppository therapy 1
- Manual disimpaction may be performed if needed 1
- Avoid suppositories/enemas in children with neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis 1
Maintenance Pharmacological Therapy
Primary options (in order of preference):
- Polyethylene glycol (PEG) 3350: First-line for ages 6 months and older 1
- Lactulose or sorbitol-containing juices (prune, pear, apple): Alternative first-line options, particularly useful in infants 1
- Bisacodyl or glycerin suppositories: Reserved for more severe cases, with goal of one non-forced bowel movement every 1-2 days 1
Critical pitfall to avoid: Do not use stimulant laxatives as first-line therapy instead of osmotic agents. 1 Bisacodyl specifically lacks safety and efficacy data in infants under 6 months. 1
Non-Pharmacological Management
Dietary modifications:
- Increase fluid intake to maintain proper hydration 1
- Increase dietary fiber through age-appropriate foods: fruits, vegetables, whole grains, legumes 1
- For infants: Continue breast-feeding on demand or full-strength formula 1
- For older children: Emphasize high-fiber foods including starches, cereals, yogurt, fruits, and vegetables 1
- Fruit juices containing sorbitol (prune, pear, apple) increase stool frequency and water content in infants 1
Behavioral interventions:
- Implement regular toileting schedule: morning, twice during school, after school, at dinner, and before bed 1
- Ensure correct toilet posture with secure seating, buttock support, foot support, and comfortable hip abduction 1
- Increase regular physical activity appropriate to the child's age 1
Special Considerations for Infants
For breastfed infants with GERD-like symptoms that may include constipation, consider a 2-4 week trial of maternal exclusion diet restricting milk and eggs. 2 For formula-fed infants, consider extensively hydrolyzed protein or amino acid-based formula. 2
Treatment Duration and Weaning
Critical pitfall: Premature discontinuation of treatment leads to 40-50% relapse rates within 5 years. 1 The maintenance phase may need to continue for many months before the child regains normal bowel motility and rectal perception. 1 Gradually taper medications only as bowel habits normalize. 1
Clinical Impact
Aggressive constipation management decreases urinary tract infections and reduces the need for intervention in patients with vesicoureteral reflux. 1