Treatment of Constipation in Pediatric Patients
Polyethylene glycol (PEG) 3350 at 0.8-1 g/kg/day is the first-line laxative for children 6 months and older, with the goal of producing 2-3 soft, painless stools daily. 1
Initial Assessment and Disimpaction
Before starting any maintenance therapy, perform a digital rectal examination to identify fecal impaction. 1 If impaction is present:
- Use glycerin suppositories as first-line suppository therapy 1
- Manual disimpaction may be performed as an alternative 2
- Avoid suppositories or enemas in children with neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis 2
First-Line Pharmacological Treatment
PEG 3350 is the laxative of first choice for children 6 months and older, dosed at 0.8-1 g/kg/day (maximum 17g per dose). 1 The FDA label indicates that for over-the-counter use, children 16 years and under should ask a doctor, and the product should not be used for more than 7 days without medical supervision. 3
Critical Warning Signs Requiring Immediate Evaluation:
These symptoms may indicate a serious condition and require cessation of PEG treatment. 2
Alternative Pharmacological Options
If PEG is not available or tolerated:
- Lactulose or sorbitol-containing juices (prune, pear, apple) 1, 2
- Bisacodyl or glycerin suppositories for more severe cases 2
Important caveat: Stool softeners alone (like docusate) are ineffective and not recommended. 2 Stimulant laxatives should not be used as first-line therapy. 2
Non-Pharmacological Management
Dietary Modifications
- Increase fluid intake to maintain proper hydration 2
- Increase dietary fiber through age-appropriate foods: fruits, vegetables, whole grains, and legumes 1, 2
- For infants: fruit juices containing sorbitol (prune, pear, apple) can increase stool frequency 2
- Continue breastfeeding on demand or full-strength formula for infants 2
Critical pitfall: While fiber supplementation can be beneficial 4, families struggle to achieve adequate fiber intake without intensive ongoing dietary counseling. 5, 6 Even with dietary advice alone, children consume less than one-fourth of recommended fiber intake. 6 Therefore, do not rely solely on dietary changes—pharmacological therapy is essential. 2
Behavioral Interventions
- Establish a regular toileting schedule: morning, twice during school, after school, at dinner, and before bed 2
- Ensure correct toilet posture: secure seating with buttock support, foot support, and comfortable hip abduction 2
- Increase physical activity appropriate to the child's age 2
Treatment Duration and Maintenance
The maintenance phase may need to continue for many months before the child regains normal bowel motility and rectal perception. 1, 2 The goal is one non-forced bowel movement every 1-2 days. 1
Critical Warning About Premature Discontinuation:
Premature discontinuation leads to 40-50% relapse rates within 5 years. 1, 2 Parents often cease treatment too soon, which is a major pitfall to avoid. 2
Monitoring Treatment Efficacy
Evaluate success based on:
- Stool frequency and consistency 2
- Absence of pain with defecation 2
- Weight gain and growth parameters 2
Clinical Impact Beyond Constipation
Aggressive constipation management decreases urinary tract infections and reduces the need for intervention in patients with vesicoureteral reflux. 1 This underscores the importance of thorough treatment rather than minimal intervention.
Treatment Algorithm Summary
- Rule out impaction via digital rectal exam 1
- If impaction present: glycerin suppositories or manual disimpaction 1, 2
- Start PEG 3350 at 0.8-1 g/kg/day 1
- Add dietary modifications (fiber, fluids) and behavioral interventions (toileting schedule, posture) 1, 2
- Continue maintenance for months, not weeks 1, 2
- Monitor for warning signs (bleeding, worsening pain, diarrhea) 2, 3
- Gradually wean only after sustained improvement 2