What laxatives are recommended for a 1‑year‑old child with constipation, hard stools, and vomiting likely related to stool burden?

Laxatives for a 1-Year-Old with Constipation

For a 1-year-old child with constipation, hard stools, and vomiting from stool burden, polyethylene glycol (PEG) is the first-line laxative, starting with disimpaction doses if fecal impaction is present, followed by maintenance therapy. 1

Initial Assessment and Disimpaction

• Check for fecal impaction first through abdominal examination or rectal examination, especially when vomiting accompanies constipation (which may indicate overflow around impaction). 2

• If impaction is present, begin with high-dose PEG for the first few days to achieve disimpaction before starting maintenance therapy. 1

• Manual disimpaction may be necessary in severe cases, preceded by analgesic ± anxiolytic medication. 2

First-Line Laxative Therapy

Polyethylene glycol (PEG) is the recommended laxative for infants over 6 months of age:

• PEG is authorized and effective for children ≥6 months. 1
• Administer 1 capful mixed in 8 oz water twice daily, adjusting dose to achieve soft stools. 2
• The treatment principle is sufficient dose for a long duration—underdosing and premature discontinuation are common pitfalls. 1

Alternative Laxative Options

If PEG is unavailable or not tolerated, consider these alternatives in order of preference:

• Lactulose 30–60 mL twice to four times daily 2
• Sorbitol 30 mL every 2 hours × 3 doses, then as needed 2
• Magnesium hydroxide (milk of magnesia) 30–60 mL daily to twice daily 2, 3
• Mineral oil (less commonly prescribed but effective) 1

Stimulant Laxatives for Maintenance

Once disimpaction is achieved, add a stimulant laxative:

• Bisacodyl 10–15 mg daily to three times daily, with a goal of one non-forced bowel movement every 1–2 days. 2
• Bisacodyl suppositories (one rectally daily to twice daily) can be used if oral route is problematic. 2

Rectal Interventions

For immediate relief or when oral medications fail:

• Glycerin suppository as a gentle first option 2
• Bisacodyl suppository for more robust stimulation 2
• Phosphate enemas for severe impaction (repeated as needed during disimpaction phase) 1
• Tap water enema until clear if other measures fail 2

What NOT to Use

Critical contraindications:

• Antimotility agents (loperamide) are absolutely contraindicated in all children under 18 years—they can cause severe abdominal distension and death. 4
• Hyperosmotic mineral water, dietary changes alone, and endoanal medications are not treatments for established constipation at any age. 1
• Adsorbents (kaolin-pectin) do not reduce symptoms. 4

Dietary Adjuncts (Not Primary Treatment)

While laxatives are essential, support with:

• Increased fluid intake 2
• Age-appropriate foods including fruits, vegetables, and whole grains 2
• Do not rely on dietary fiber alone—it is insufficient for established constipation and requires adequate fluid intake and physical activity to be effective. 2

Treatment Duration and Monitoring

• Continue laxative therapy for months, not weeks—constipation recurs in 94% of children when laxatives are discontinued prematurely. 3
• Children under 2 years have significantly higher recovery rates than older children, but one-third still have persistent symptoms 3–12 years later. 3
• Reassess for impaction or obstruction if symptoms persist despite treatment. 2

Common Pitfalls to Avoid

• Do not stop laxatives too early—the rule is sufficient dose for a long time. 1
• Do not assume dietary changes alone will resolve established constipation—pharmacologic therapy is required. 1
• Do not miss fecal impaction—vomiting with constipation strongly suggests this diagnosis. 2
• Do not use inadequate doses—underdosing is a primary reason for treatment failure. 1