What is the recommended treatment approach for constipation in pediatric patients?

Pediatric Constipation Treatment

For infants under 6 months, start with fruit juices containing sorbitol (prune, pear, or apple juice at 10 mL/kg body weight), followed by lactulose if needed; for children 6 months and older, polyethylene glycol (PEG) 3350 at 0.8-1 g/kg/day is the first-line pharmacological treatment, with a goal of producing 2-3 soft, painless stools daily. 1, 2

Age-Specific Treatment Approach

Infants Under 6 Months

• First-line: Fruit juices containing sorbitol (prune, pear, apple) at 10 mL/kg body weight to increase stool water content through osmotic load 1, 3
• Second-line: Lactulose 2.5-10 mL daily in divided doses if dietary modifications fail 3
• Evaluate feeding history—type of feeding (breast vs. formula) and recent changes can significantly impact bowel patterns 1, 3
• Consider 2-4 week maternal exclusion diet (restricting milk and egg) if milk protein allergy suspected in breastfed infants 1
• Switch to extensively hydrolyzed or amino acid-based formula if milk protein allergy suspected in formula-fed infants 1
• Avoid excessive juice as it causes diarrhea, flatulence, abdominal pain, and poor weight gain 1, 3

Infants 6 Months to 1 Year

• First-line: Continue sorbitol-containing fruit juices 1
• Second-line: Lactulose if juices insufficient 1
• Introduce age-appropriate solid foods when developmentally ready 1
• Continue breastfeeding on demand or full-strength formula 1, 3

Children Over 6 Months (Primary Pharmacological Treatment)

• First-line laxative: Polyethylene glycol (PEG) 3350 at 0.8-1 g/kg/day, targeting 2-3 soft, painless stools daily 2
• PEG is safe, effective, and well-tolerated for long-term use 4, 5
• Note: FDA labeling for over-the-counter PEG products states "children 16 years of age or under: ask a doctor" 6, but guideline societies specifically recommend it for children 6 months and older 2

Treatment Algorithm

Step 1: Assess for Fecal Impaction

• Perform digital rectal examination to identify if rectum is full or impacted 2
• Rule out red flags: bilious vomiting, failure to pass meconium within 48 hours, ribbon stools, blood in stool, severe abdominal distension, perianal fistulas, abnormal neurological exam 1, 5

Step 2: Disimpaction (If Present)

• For infants/young children: Glycerin suppositories are the preferred first-line suppository option 2
• For older children: High-dose PEG for first few days OR repeated phosphate enemas 7
• Manual disimpaction may be necessary in severe cases 2
• Contraindications to suppositories/enemas: neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, severe colitis 2

Step 3: Maintenance Therapy

• Continue PEG 3350 at maintenance dose (0.8-1 g/kg/day) for children ≥6 months 2
• Lactulose or sorbitol-containing juices for infants <6 months 1
• Duration: Maintenance may need to continue for many months before normal bowel motility and rectal perception return 2
• Adjust dosing based on response—goal is soft, painless stools 2, 4

Step 4: Adjunctive Measures

• Dietary modifications: Increase fiber through age-appropriate fruits, vegetables, whole grains, legumes 2
• Ensure adequate fluid intake 2, 3
• Regular physical activity appropriate to child's age 2
• Toilet training: Implement regular toileting schedule (morning, twice during school, after school, dinner, before bed) 2
• Ensure correct toilet posture with buttock support, foot support, and comfortable hip abduction 2, 3
• Take advantage of gastrocolic reflex by scheduling toilet time after meals 3

Step 5: Escalation for Refractory Cases

• Add stimulant laxatives (bisacodyl, senna) if no improvement with osmotic laxatives alone 2, 8
• Bisacodyl suppositories: Children 6-12 years use ½ suppository once daily; ≥12 years use 1 suppository once daily 9
• Do not use bisacodyl in infants under 6 months—no safety or efficacy data exists for this age group 2
• Refer to pediatric gastroenterology if treatment-resistant or organic pathology suspected 4, 5

Critical Pitfalls to Avoid

• Premature discontinuation: Parents often stop treatment too soon before bowel motility and rectal perception normalize—this leads to 40-50% relapse rates within 5 years 2, 8
• Inadequate dosing: Use sufficient doses for adequate duration 7
• Using stimulant laxatives first-line: Always start with osmotic agents (PEG, lactulose, sorbitol juices) 2
• Treating without addressing impaction: Relying solely on dietary changes when impaction is present worsens constipation 2
• Excessive juice consumption: Limit to recommended amounts to avoid diarrhea and poor weight gain 1, 3
• Using suppositories without maintenance: This approach alone leads to high relapse rates 2

Parent Education Points

• Normal bowel patterns vary by age—newborns may stool after every feeding, while older infants may go several days between stools 1
• Treatment requires patience and consistency over months, not weeks 2, 7
• Aggressive constipation management decreases urinary tract infections and reduces need for intervention in children with vesicoureteral reflux 2