What is the recommended treatment for constipation in a 2‑year‑old child?

Treatment of Constipation in a 2-Year-Old Child

Polyethylene glycol (PEG) 3350 is the first-line pharmacological treatment for constipation in a 2-year-old, dosed at 0.8-1 g/kg/day, with the goal of producing 2-3 soft, painless stools daily. 1

Initial Assessment

Before starting treatment, perform a digital rectal examination to identify fecal impaction—if the rectum is full or impacted, disimpaction must be completed before maintenance therapy begins. 1 Rule out organic causes including hypothyroidism, hypercalcemia, hypokalemia, and diabetes mellitus, though 95% of childhood constipation is functional without an identifiable organic cause. 1, 2

Critical red flag: If the child had delayed passage of first stool beyond 48 hours after birth, suspect Hirschsprung disease, which requires surgical correction. 1

Treatment Algorithm

Step 1: Disimpaction (If Impaction Present)

• Glycerin suppositories are the preferred first-line option for rectal disimpaction in a 2-year-old, as they act as a mild rectal stimulant and are safe for this age group. 1
• Alternatively, use high-dose PEG 3350 for the first few days to achieve disimpaction. 3
• Manual disimpaction may be performed if suppositories are ineffective. 1

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

Step 2: Maintenance Therapy

Pharmacological management:

• PEG 3350 at 0.8-1 g/kg/day is the laxative of first choice for children 6 months and older, adjusted to produce 2-3 soft, painless stools daily. 1, 4, 5
• Lactulose or lactitol are effective alternatives, particularly for infants under 6 months. 3
• Avoid stool softeners alone (like docusate)—they are ineffective and not recommended. 1
• Do not use bisacodyl or other stimulant laxatives as first-line therapy; osmotic agents are preferred. 1

Non-pharmacological adjuncts:

• Increase dietary fiber through age-appropriate foods: fruits, vegetables, whole grains, and legumes. 1
• Fruit juices containing sorbitol (prune, pear, apple) can help increase stool frequency and water content. 1
• Maintain adequate hydration, though increasing water intake beyond normal has not been proven effective. 6, 7
• Encourage regular physical activity appropriate for age. 1
• Establish a regular toileting schedule (e.g., after meals when gastrocolic reflex is strongest). 1

Common dietary pitfall: The "BRAT" diet (bananas, rice, applesauce, toast) can worsen constipation—instead emphasize high-fiber foods and avoid foods high in simple sugars and fats. 1

Step 3: Monitoring and Adjustment

Evaluate treatment efficacy by:

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

Critical warning signs requiring immediate evaluation:

• Rectal bleeding 1
• Nausea, bloating, cramping, or abdominal pain 1
• Diarrhea (may indicate excessive dosing) 1

Step 4: Long-Term Maintenance and Weaning

Maintenance therapy must continue for many months before the child regains normal bowel motility and rectal perception—premature discontinuation is a common pitfall leading to relapse. 1 Studies show 40-50% of children experience relapse within 5 years if maintenance therapy is stopped too early. 1

Gradually taper laxative dosing as bowel habits normalize, but only after sustained improvement over several months. 1

Special Considerations for This Age Group

At 2 years old, ensure proper toilet posture: the child needs secure seating with buttock support, foot support (use a stool if needed), and comfortable hip abduction to enable relaxed defecation. 1

Behavioral therapy alone (without laxatives) is not effective—behavioral interventions combined with laxatives are no more effective than laxatives alone. 6, 7

What NOT to Do

• Do not rely solely on dietary changes if impaction is present—this will worsen the problem. 1
• Do not use increased water intake as primary therapy—evidence shows no benefit over normal fluid intake. 6, 7
• Do not use probiotics or prebiotics—current evidence does not support their use for functional constipation. 6, 7
• Do not stop treatment prematurely when symptoms improve—this is the most common cause of relapse. 1