What is the recommended management for fecal withholding in a 3-year-old child with constipation?

From the Guidelines

For constipation with stool withholding in a 3-year-old, I recommend a two-phase approach: first disimpaction followed by maintenance therapy, starting with oral polyethylene glycol (PEG 3350, Miralax) at a higher dose of 1-1.5 g/kg/day for 3-6 days to clear impacted stool, as suggested by the most recent and highest quality study available 1.

Key Considerations

• The goal of treatment is to keep stools soft and painless while establishing positive toileting routines.
• Behavioral interventions, including scheduled toilet sitting for 5-10 minutes after meals, positive reinforcement for sitting attempts, and a diet rich in fiber and fluids, are crucial in addressing stool withholding.
• Avoid punishing the child for accidents or withholding, as this can worsen the fear cycle.
• Stool withholding typically develops when children experience painful bowel movements and subsequently try to avoid defecation, creating a vicious cycle where stool becomes harder and more painful to pass.

Treatment Approach

• Begin with oral polyethylene glycol (PEG 3350, Miralax) at a higher dose of 1-1.5 g/kg/day for 3-6 days to clear impacted stool.
• Once disimpaction is achieved, continue with a maintenance dose of PEG 3350 at 0.4-0.8 g/kg/day for at least 2-3 months to establish regular bowel habits.
• Pair this with behavioral interventions and a diet rich in fiber and fluids.

Monitoring and Follow-Up

• Improvement may take weeks to months, so consistency and patience are essential.
• If there's no improvement after 4-6 weeks of consistent therapy, consult a pediatric specialist for further evaluation, as suggested by 1 and 1.

Additional Considerations

• The use of other laxatives, such as bisacodyl or glycerin suppositories, may be considered if symptoms do not respond to polyethylene glycol, as mentioned in 1 and 1.
• A diet rich in fiber and fluids, as well as regular physical activity, can help prevent constipation and promote overall health, as recommended by 1.

From the FDA Drug Label

Pediatric: Very little information on the use of lactulose in young children and adolescents has been recorded. As with adults, the subjective goal in proper treatment is to produce 2 or 3 soft stools daily. On the basis of information available, the recommended initial daily oral dose in infants is 2. 5 mL to 10 mL in divided doses. For older children and adolescents the total daily dose is 40 mL to 90 mL. If the initial dose causes diarrhea, the dose should be reduced immediately. If diarrhea persists, lactulose should be discontinued The recommended management for constipation in a 3-year-old who is withholding poop is not directly addressed in the provided drug label. However, for a child of this age, the dose would likely fall under the "older children and adolescents" category.

• The recommended initial daily oral dose for older children and adolescents is 40 mL to 90 mL.
• The goal of treatment is to produce 2 or 3 soft stools daily.
• It is essential to monitor for diarrhea and adjust the dose accordingly, as the label advises reducing the dose if diarrhea occurs and discontinuing lactulose if it persists 2.

From the Research

Management of Constipation in a 3-Year-Old

Recommended Treatment

• For a 3-year-old who is withholding poop, the recommended management for constipation includes the use of osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, as the most effective and safe therapy for both long and short term treatment of pediatric functional constipation 3.
• Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability 4.
• Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation, as it is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products 5.

Additional Considerations

• Stimulant laxatives, like Senna and Bisacodyl, probiotics, fiber preparations, enemas, and suppositories make excellent choices for adjunct therapies in specific clinical scenarios 3.
• Non-pharmacological approaches to the management of constipation should be addressed before considering laxative use 6.
• The choice of laxative should be informed by the assessment of the patient, and PEG is more effective in many instances and should be the laxative of choice unless there are contraindications 6.