What is the best treatment approach for constipation in a 2-year-old child?

Treatment of Constipation in a 2-Year-Old

For a 2-year-old with constipation, start with polyethylene glycol (PEG) 3350 at 0.8-1 g/kg/day as first-line pharmacological therapy, combined with education, dietary modifications (increased fiber and fluids), and establishment of a regular toileting routine. 1

Initial Assessment

Before starting treatment, perform a digital rectal examination to identify if fecal impaction is present. 1 Rule out organic causes including:

• Hypothyroidism, hypercalcemia, hypokalemia, and diabetes mellitus 1
• Anatomical abnormalities 1

The diagnosis of functional constipation is clinical, based on infrequent defecation, painful or hard bowel movements, and large diameter stools. 1

Treatment Algorithm

Step 1: Disimpaction (If Impaction Present)

If the digital rectal exam reveals fecal impaction, address this first:

• Glycerin suppositories are the preferred first-line suppository option for this age group, acting as a rectal stimulant through mild irritant action 1
• Alternatively, manual disimpaction may be performed 1
• High-dose PEG for the first few days can also achieve disimpaction 2

Critical contraindications: Do not use suppositories or enemas in children with neutropenia, thrombocytopenia, recent colorectal surgery, anal trauma, or severe colitis. 1

Step 2: Maintenance Pharmacological Therapy

Polyethylene glycol (PEG) 3350 is the laxative of first choice for children 6 months and older, recommended by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. 1

• Dosing: 0.8-1 g/kg/day initially 1
• Goal: Produce 2-3 soft, painless stools daily 1
• Duration: Continue for many months before the child regains normal bowel motility and rectal perception 1

Alternative first-line options include:

• Lactulose 1
• Sorbitol-containing juices (prune, pear, apple) 1

What NOT to use:

• Avoid docusate (stool softeners alone) - these are ineffective and not recommended 1
• Avoid bisacodyl - stimulant laxatives should not be used as first-line therapy 1

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

Dietary modifications:

• Increase fluid intake to maintain proper hydration 1, 3
• Increase dietary fiber through age-appropriate foods: fruits, vegetables, whole grains, and legumes 1
• Offer fruit juices containing sorbitol (prune, pear, apple) to increase stool frequency and water content 1, 3
• Avoid foods high in simple sugars and fats that worsen constipation 1

Behavioral interventions:

• Establish a regular toileting schedule, particularly after meals to utilize the gastrocolic reflex 3
• Ensure proper toilet posture: secure seating with buttock support, foot support, and comfortable hip abduction 1, 3
• Implement a reward system for successful toileting 3

Education:

• Explain normal bowel function and the pathogenesis of constipation to the family 1
• Set realistic treatment expectations - this is typically long-term management 3

Monitoring and Follow-Up

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 and potential cessation of PEG:

• Rectal bleeding 1
• Nausea, bloating, cramping, or abdominal pain 1
• Diarrhea 1

Regular follow-up is essential to monitor progress and adjust treatment as needed. 3

Common Pitfalls to Avoid

Do not rely solely on dietary changes without addressing impaction if present - this can worsen constipation. 1 The most common mistake is premature discontinuation of treatment; parents often cease treatment too soon before the child regains bowel motility and rectal perception. 1 Using suppositories alone without follow-up maintenance therapy leads to high relapse rates of 40-50% within 5 years. 1

Treatment must be aggressive and sustained - constipation is often a lifelong problem that can lead to serious complications including rectal prolapse, hemorrhoids, and intestinal perforation if inadequately treated. 1 Maintenance therapy may need to continue for many months, and only 50-70% of children demonstrate long-term improvement despite treatment. 4