What are the treatment options for a child experiencing constipation?

Parent Information for Childhood Constipation

Immediate First-Line Treatment Based on Age

For infants under 1 year, start with fruit juices containing sorbitol (prune, pear, or apple juice) at 10 mL/kg body weight daily, and if this fails, use lactulose as the next step. 1

For children over 1 year, the same juice approach applies, though whole fruit is nutritionally superior to juice when the child can consume it. 2

Age-Specific Management Strategies

For Infants Under 6 Months:

• Continue breastfeeding on demand if nursing, as this remains the optimal nutrition source 1
• Maintain full-strength formula for bottle-fed infants—never dilute formula as this compromises nutrition without helping constipation 1
• Evaluate for milk protein allergy if symptoms persist, which can mimic constipation 1
  • Consider a 2-4 week trial of maternal diet excluding milk and eggs if breastfeeding 1
  • Switch to extensively hydrolyzed or amino acid-based formula if formula-feeding 1
• Watch for red flags: bilious vomiting, poor weight gain, or failure to thrive warrant immediate medical evaluation 1

For Infants 6-12 Months:

• Start with sorbitol-containing juices (prune, pear, apple) at 10 mL/kg body weight daily 1
• The sorbitol and carbohydrate ratios create an osmotic load that increases stool water content 1
• Avoid excessive juice as this causes diarrhea, flatulence, abdominal pain, and poor weight gain 1
• Introduce age-appropriate solid foods when developmentally ready 1

For Children Over 1 Year:

• Increase dietary fiber intake to age + 5 grams per day (e.g., 7 grams daily for a 2-year-old) 3
• Prioritize whole fruits over juice for better nutrition 2
• Increase water intake 2
• Include starches, cereals, yogurt, fruits, and vegetables 4
• Avoid foods high in simple sugars and fats 4

Medication Options When Dietary Measures Fail

First-Line Pharmacologic Treatment:

• Lactulose is the recommended first medication after juice fails in infants 1
  • Infant dosing: 2.5-10 mL daily in divided doses 5
  • Older children/adolescents: 40-90 mL total daily dose 5
  • Reduce dose immediately if diarrhea occurs; discontinue if diarrhea persists 5

Alternative Options for Older Children:

• Polyethylene glycol (PEG): 17 grams dissolved in 4-8 ounces of beverage once daily for children 17+ years 6
  • For children 16 and under, consult a physician for dosing 6
  • Do not use longer than 7 days without medical supervision 6
• Bisacodyl 10-15 mg daily as second-line option 2
• Other maintenance options include mineral oil, milk of magnesia, and sorbitol 7

Critical Dietary Counseling Points

Parents consistently fail to achieve adequate fiber intake without intensive, ongoing dietary counseling—even health-conscious families only succeed 50% of the time, and constipated children typically consume less than one-fourth of recommended fiber intake despite being told to "eat high-fiber." 3

Practical Fiber Implementation:

• Glucomannan supplementation (100 mg/kg daily, maximum 5 grams) with 50 mL fluid per 500 mg is effective even when added to existing laxative therapy 8
• 45% of children improve with fiber supplementation versus only 13% with placebo 8
• Children with constipation alone respond better (69% success) than those with encopresis (28% success) 8

Important Warnings and Red Flags

When to Seek Immediate Medical Evaluation:

• Bilious vomiting 1
• Decreased urine output 4
• Irritability or lethargy 4
• Poor weight gain or growth concerns 1
• Persistent symptoms despite treatment 4

Common Pitfalls to Avoid:

• Never dilute infant formula—this worsens nutrition without helping constipation 1
• Do not rely on stool pH or reducing substances alone; clinical symptoms matter more 1
• Avoid cow's milk in some children as it may promote constipation 7
• Do not combine PEG with starch-based thickeners 6
• Ensure powder medications are fully dissolved before drinking 6

Physical Examination Considerations

Visual inspection of the perianal area for fissures, skin tags, or redness is essential 1. Digital rectal examination is typically unnecessary for functional constipation and should be reserved for cases with red flags 1.

Long-Term Expectations

Only 50-70% of children demonstrate long-term improvement despite treatment, and maintenance therapy may be required for months to years due to high relapse rates. 7 Constipation symptoms are likely to persist into adulthood if not properly managed. 9

Monitoring Instructions:

• Have child sit on toilet 4 times daily after meals 8
• Keep a stool diary 8
• Goal: 3+ bowel movements per week with minimal soiling and no abdominal pain 8
• Contact physician if symptoms worsen or new concerning signs develop 4