What is the prescription for constipation in a 4-year-old female?

From the Guidelines

For constipation in a 4-year-old female, I recommend starting with polyethylene glycol 3350 (MiraLAX) at a dose of 0.5-1.5 g/kg/day mixed in 4-8 ounces of liquid, as it has been shown to be efficacious in increasing bowel movements with a similar or greater efficacy compared to other medications 1.

Non-Pharmacological Approaches

Before initiating medication, non-pharmacological approaches can be considered, including:

• Increased fluid intake
• Dietary fiber (20-25g daily)
• Regular physical activity However, given the efficacy and safety profile of polyethylene glycol 3350, it is reasonable to use it earlier in the algorithm for the management of constipation, either after a trial of fiber supplementation or in combination with fiber supplementation 1.

Pharmacological Treatment

If polyethylene glycol 3350 is not effective, other options can be considered, such as:

• Glycerin suppository or bisacodyl suppository (5 mg) for acute relief
• Mineral oil (1-3 ml/kg/day) with caution due to aspiration risk
• Lactulose (1-3 ml/kg/day divided twice daily) or sorbitol

Treatment Duration and Monitoring

Treatment should continue for at least 2-3 months after regular bowel movements are established to prevent relapse. Constipation in children often results from withholding behavior due to painful bowel movements, creating a cycle that needs to be broken with consistent treatment. If there's no improvement after appropriate treatment, or if there are red flags like failure to thrive, vomiting, or blood in stool, further evaluation is warranted.

Side Effects and Safety

Polyethylene glycol 3350 has been shown to have a similar side effect profile to placebo, with mild or moderate effects such as bloating, flatulence, and diarrhea 1. However, it is widely available without the need for a prescription and is relatively inexpensive, making it a reasonable first-line option.

From the FDA Drug Label

Pediatric: Very little information on the use of lactulose in young children and adolescents has been recorded. As with adults, the subjective goal in proper treatment is to produce 2 or 3 soft stools daily. On the basis of information available, the recommended initial daily oral dose in infants is 2. 5 mL to 10 mL in divided doses. For older children and adolescents the total daily dose is 40 mL to 90 mL.

The dose of lactulose for this purpose is the same as the recommended daily dose For a 4-year-old female, the recommended dose is not explicitly stated, but based on the information provided for older children and adolescents, the total daily dose is 40 mL to 90 mL.

• The initial dose for this age group is not specified, so it should be started at the lower end of the range (40 mL) and adjusted as needed to produce 2 or 3 soft stools daily.
• It is also important to monitor for diarrhea and reduce the dose immediately if it occurs. 2

From the Research

Treatment Options for Constipation in a 4-year-old Female

• Osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, are considered the most effective and safe therapy for both long and short term treatment of pediatric functional constipation 3
• Stimulant laxatives, like Senna and Bisacodyl, can be used as adjunct therapies in specific clinical scenarios 3
• The effectiveness of Senna versus polyethylene glycol for the treatment of constipation in children with anorectal malformation has been studied, with Senna showing a clear benefit 4
• A diagnosis of functional constipation can be made in the absence of "red flag" symptoms and a normal physical assessment, and treatment includes dietary changes, medication use, and behavioral modification 5
• Osmotic laxatives are used as first-line treatment, and stimulant laxatives can be added if there is no improvement with osmotic laxatives 5

Considerations for Pediatric Constipation

• Constipation is a common problem in pediatrics, accounting for 3-5% of all pediatric office visits and 10-25% of all pediatric gastroenterology referrals 5
• Functional constipation accounts for about 95% of constipation cases, but "red flag" symptoms that suggest organic causes need to be considered 5
• Laboratory tests and imaging may be helpful in determining most organic concerns, and in the absence of an organic process, functional constipation can be treated with dietary fiber and fluid intake, use of stool softeners, laxatives, and behavioral modifications 6

Pathophysiology and Therapeutic Approaches

• Chronic constipation is a common, persistent condition affecting many patients worldwide, presenting significant economic burden and resulting in substantial healthcare utilization 7
• The definition of constipation includes excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, use of digital manoeuvres for evacuation of stool, abdominal bloating, and hard consistency of stools 7
• Initial therapeutic approach to primary constipation consists of diet and lifestyle changes, and laxatives are the mainstay of pharmacologic treatment for potential long-term therapy in patients who do not respond to lifestyle or dietary modification 7