What is the best approach for treating constipation in pediatric patients?

Constipation Treatment in Children

Start with polyethylene glycol (PEG) 3350 as first-line pharmacological therapy for children 6 months and older with constipation, at a dose of 0.8-1 g/kg/day, aiming for 2-3 soft, painless stools daily. 1

Initial Assessment

Before initiating treatment, rule out organic causes that require different management:

• Check for fecal impaction through digital rectal examination—if the rectum is full or impacted, disimpaction must occur before maintenance therapy 1
• Screen for red flag conditions: Hirschsprung's disease, hypothyroidism, hypercalcemia, hypokalemia, diabetes mellitus, and spinal cord abnormalities 1, 2
• Evaluate feeding history in infants, including type of feeding and recent changes that may impact bowel patterns 3

Treatment Algorithm

Step 1: Disimpaction (If Impaction Present)

• Glycerin suppositories are the preferred first-line option for rectal stimulation through mild irritant action 1
• Manual disimpaction is an alternative if suppositories are insufficient 1
• Contraindications to suppositories/enemas: neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis 1

Step 2: Maintenance Pharmacological Therapy

Primary option:

• Polyethylene glycol (PEG) 3350: 0.8-1 g/kg/day for children ≥6 months, dissolved in 4-8 ounces of any beverage 1, 4
• Goal: 2-3 soft, painless stools daily 1
• Generally produces bowel movement in 1-3 days 4

Alternative osmotic agents:

• Lactulose: 2.5-10 mL daily in divided doses for infants 3, 1
• Magnesium hydroxide (milk of magnesia) 2, 5
• Sorbitol-containing fruit juices (prune, pear, apple): 10 mL/kg body weight for infants 3, 1

What NOT to use:

• Avoid docusate (stool softeners alone): ineffective and not recommended 1
• Avoid bisacodyl in infants <6 months: no safety or efficacy data exists for this age group 1
• Avoid stimulant laxatives as first-line: osmotic agents are preferred 1

Step 3: Non-Pharmacological Interventions (Concurrent with Medication)

Dietary modifications:

• Increase fiber intake through age-appropriate fruits, vegetables, whole grains, and legumes 1
• Maintain adequate fluid intake to ensure proper stool consistency 3, 1
• Continue breastfeeding on demand for breastfed infants 3, 1
• Use full-strength formula (lactose-free or lactose-reduced preferred) for bottle-fed infants 6
• Consider trial of withholding cow's milk if milk protein sensitivity suspected 2

Behavioral modifications:

• Establish regular toileting schedule: after meals to utilize gastrocolic reflex, with dedicated time for bowel movements 3, 1
• Ensure proper toilet posture: secure seating with buttock support, foot support, and comfortable hip abduction 3, 1
• Implement scheduled voiding: morning, twice during school, after school, at dinner, and before bed 1

Step 4: Monitoring and Adjustment

Evaluate treatment efficacy by:

• Stool frequency and consistency 1
• Absence of pain with defecation 1
• Weight gain and growth parameters 1

Warning signs requiring immediate evaluation:

• Rectal bleeding 4
• Worsening nausea, bloating, cramping, or abdominal pain 4
• Diarrhea 4

Step 5: Long-Term Maintenance

• Continue maintenance therapy for months to years—premature discontinuation is a common pitfall as children need time to regain normal bowel motility and rectal perception 1
• Gradually taper medications only after bowel habits normalize 1
• Expect 40-50% relapse rate within 5 years if maintenance therapy is discontinued too early 1
• Only 50-70% demonstrate long-term improvement despite treatment 2

Critical Pitfalls to Avoid

• Do not rely solely on dietary changes if impaction is present—this worsens constipation 1
• Do not use stimulant laxatives as first-line instead of osmotic agents 1
• Do not stop treatment prematurely—maintenance may need to continue for many months before normal bowel function returns 1
• Do not exceed 7 days of PEG use without medical supervision in over-the-counter settings 4
• Avoid excessive juice consumption as it may cause diarrhea, flatulence, abdominal pain, and poor weight gain 3

Special Considerations

• Aggressive constipation management in children with vesicoureteral reflux decreases urinary tract infections and reduces need for intervention 1
• PEG 3350 is effective and well-tolerated with the best evidence supporting its use among osmotic laxatives 7, 8, 2, 5
• Behavioral education improves treatment response, though biofeedback training does not 2