eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology
Constipation: Treatment & Medication
Updated: Oct 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Although constipation is an extremely common problem among children, few studies have systematically evaluated different management strategies. Childhood constipation is treated in many ways, and virtually any therapeutic regime is likely to be effective as long as it is sufficiently aggressive and persistent.12 Because of the medical profession's understanding of the pathophysiology of the problem, the basic tenets of therapy include evacuation of the colon, elimination of pain with defecation, and establishing regular bowel habits.
- Evacuate the colon.
- With evidence of a fecal impaction, aim initial therapy at complete evacuation of the colon. Palpating a hard mass of stool upon physical examination, finding a large amount of stool in a dilated rectum during rectal examination, or finding excessive stool in the colon using abdominal radiography can identify a fecal impaction.
- A series of enemas or the aggressive use of oral cathartics such as polyethylene glycol, sodium phosphate, magnesium citrate, or a balanced electrolyte solution with polyethylene glycol can accomplish disimpaction.13 In uncontrolled trials, disimpaction by the oral route, the rectal route, or a combination of both have proven effective.
- Convincing young children to ingest sufficient amounts of oral cathartics to evacuate their colons is difficult; therefore, enemas or suppositories may be necessary.
- Eliminate any pain associated with defecation.
- Once the colon has been evacuated, chronic laxative therapy is generally required. Virtually any laxative can be used as long as it is used in sufficient quantity to produce 1-2 soft stools daily. In young children, eliminating any pain associated with the passage of bowel movements is extremely important. Using very large doses of laxatives to produce very soft stools may be necessary.
- Continuing laxative therapy for a number of months is often necessary. As a result, reassuring caregivers of the safety of long-term laxative usage is very important. Address specific concerns regarding laxative dependency and the risk of colon cancer due to chronic laxative usage. Many popular misconceptions about laxative use and abuse exist.
- If the child has anal fissures, using Xylocaine ointment or hydrocortisone suppositories for a short period of time to provide symptomatic relief may be appropriate.
- Establish regular bowel habits.
- In many cases, long-term success depends on the child establishing regular and routine toilet times. Encouraging the child to attend the toilet once or twice daily for 5-10 minutes, preferably after breakfast and supper to take advantage of the gastrocolic reflex, is generally recommended. Not expecting the child to attend the toilet while at school is also preferable.
- When the affected child has passed bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, attempting to discontinue laxative therapy is reasonable. Inform the family that relapses are common, particularly with changes in the child's daily routine (eg, vacations) and during times of stress. Also inform the family that requiring intermittent therapy with laxatives into adulthood is not unusual.
Consultations
- Consultation with a pediatric gastroenterologist or pediatric surgeon is appropriate if the history or examination findings suggests an underlying organic cause (eg, Hirschsprung disease). Seek consultation when the child fails routine therapy or when management is otherwise complex.
Diet
- Dietary changes, such as increasing the child's intake of fluids and carbohydrates, are commonly recommended as part of the treatment.14 Complex carbohydrates and unabsorbable sugars (eg, sorbitol) are found in many fruit juices (eg, prune, pear, apple). These carbohydrates increase stool frequency as a result of increased fecal water content. Although randomized controlled trials have not been conducted to examine the effects of increased fluids, nonabsorbable carbohydrates, or dietary fiber on childhood constipation, recommending a balanced diet that includes whole grains, fruits, vegetables, and lots of fluid seems appropriate. Because data are limited, forceful implementation of a particular diet does not seem warranted.
- In infants and young children, considering the removal of cow's milk protein from the diet for a period of time is appropriate because chronic constipation may be precipitated by ingestion of cow's milk proteins. Iacono and colleagues found that among 27 Italian children aged 5-36 months who had chronic constipation, the constipation resolved in 78% of the children when soy milk was substituted for cow's milk; in most cases, the constipation recurred when cow's milk was reintroduced.15
- Switching the patient to a low-iron formula is not necessary. Several studies have shown that ingestion of iron-supplemented formulas is not associated with an increased incidence of constipation.16
- Although some evidence suggests that GI flora is important in gut motility, no evidence suggests that gut flora is different in children suffering from constipation than gut flora in healthy controls. Both Lactobacillus and Bifidobacterium have been shown to increase stool frequency and decrease stool consistency in healthy adults; little evidence suggests that probiotics are effective in treating constipation in either adults or children.17
Medication
In several randomized trials, laxatives have been shown to be beneficial in the treatment of chronic childhood constipation.18,19 Studies have shown that polyethylene glycol,20 mineral oil, magnesium hydroxide, and lactulose are effective and can be used for prolonged periods of time without risk. The key to therapy is to use a sufficient amount of laxative to produce the desired effect. The use of stimulant laxatives may be necessary intermittently in some children; however, routine usage of these agents in young children is not generally recommended. Continuous laxative therapy may be required for several months until the child extinguishes the association between pain and the passage of bowel movements.
Osmotic laxatives
These agents produce osmotic effect in colon that results in distention and promotes peristalsis.
Polyethylene glycol (MiraLax, GlycoLax)
Polyethylene glycol (PEG) is a long chain of ethylene glycol molecules. The resulting molecule is extremely large, is very poorly absorbed, and functions as an osmotic laxative. These powders are tasteless and odorless and dissolve completely in nearly all liquids including water. These agents often can also be used as purgatives in preparation for colonoscopy. At very large dosages, PEG is occasionally difficult to take and its usage may be associated with nausea, bloating, abdominal cramps, and vomiting.
Adult
Occasional constipation: 17 g mixed in 180 - 240 mL of fluid PO qd prn
Pediatric
Mix 1 packet (17 g) in 240 mL to yield approximately 1 g per 14 mL; may store refrigerated for 48 h
Disimpaction: 1-3 g (14-42 mL)/kg/d PO divided 2-4 doses
Maintenance therapy in children 6 months to 15 years: ~0.5 g (7 mL)/kg/d PO qd or divided bid
Do not administer PO medications within 1 h of initiation of therapy due to potential risk of reduced absorption
Documented hypersensitivity; colitis, ileus, megacolon, bowel perforation, gastric retention, GI obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Mixing the product in juice or other flavored fluids may make it more palatable; chilled product is more palatable; caution in ulcerative colitis and hot loop polypectomy
Magnesium hydroxide (Philips' Milk of Magnesia, Haley's MO)
Magnesium is a divalent cation maximally absorbed in the distal small intestine. At low concentrations, magnesium appears to absorb by a saturable carrier-mediated process influenced by vitamin D. At higher concentrations, magnesium absorption appears to occur largely by diffusion and is quite inefficient. Increased serum magnesium levels may release cholecystokinin, which stimulates GI motility and secretion; this may explain why some children experience abdominal cramping. Mostly flavorless but has a thick, chalky texture. More palatable when mixed with a fluid (eg, milk, chocolate milk).
Adult
30-60 mL/d (as 400 mg/5 mL PO susp) PO qd or divided bid
Pediatric
1-3 mL/kg/d (as 400 mg/5 mL susp) PO qd or divided bid
Decreases absorption of tetracyclines, digoxin, indomethacin, and iron salts
Documented hypersensitivity; colostomy, ileostomy, fecal impaction, intestinal obstruction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Infants may be more susceptible to magnesium poisoning than older children and adults; overdosage can lead to hypermagnesemia, hypophosphatemia, and secondary hypocalcemia; administer magnesium-containing laxatives cautiously among patients with renal insufficiency because most of a magnesium load is excreted in the urine
Lactulose (Chronulac, Duphalac, Kristalose)
Synthetic, nonabsorbable disaccharide available as a 70% solution. Generally very well tolerated and tastes sweet. Contains 10 g lactulose/15 mL of PO solution.
Adult
10-30 mL PO qd
Pediatric
1-3 mL/kg/d PO qd or divided bid
Neomycin may eliminate certain colonic bacteria and interfere with the desired degradation of lactulose, thus preventing colonic content acidification
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Exercise caution in patients with diabetes mellitus; at commonly used doses, often produces flatulence and occasional abdominal cramping
Sorbitol
This alcohol of glucose is largely nonabsorbable. Available as a 70% solution. As with lactulose, generally well tolerated and tastes quite sweet.
Adult
30-150 mL PO qd prn
Pediatric
1-3 mL/kg/d PO qd or divided bid
None reported
Documented hypersensitivity; anuria
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
At commonly used doses, often produces flatulence and occasional abdominal cramping
Magnesium citrate
Magnesium is a divalent cation maximally absorbed in the distal small intestine. At low concentrations, magnesium appears to absorb by a saturable carrier-mediated process influenced by vitamin D. At higher concentrations, magnesium absorption appears to occur largely by diffusion and is quite inefficient. Increased serum magnesium levels may release cholecystokinin, which stimulates GI motility and secretion; this may explain why some children experience abdominal cramping.
Adult
150-300 mL/d PO qd
Pediatric
<6 years: 1-3 mL/kg/d PO qd
6-12 years: 100-150 mL/d PO qd
>12 years: Administer as in adults
Decreases absorption and effects of tetracyclines, digoxin, indomethacin, and iron salts
Documented hypersensitivity; colostomy, ileostomy, fecal impaction, intestinal obstruction, diabetes mellitus, renal failure
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Infants may be more susceptible to magnesium poisoning than older children and adults; overdosage can lead to hypermagnesemia, hypophosphatemia, and secondary hypocalcemia; administer magnesium-containing laxatives cautiously among patients with renal insufficiency, as most of a magnesium load is excreted in the urine; exercise caution in patients who are taking digoxin and lithium; product may be chilled to improve palatability
Sodium phosphate oral solution (Fleet Phospho-Soda)
Phosphate is a divalent anion largely absorbed in the proximal small intestine. When administered as an enema, only small amounts are absorbed so the phosphate functions as an osmotic agent. Each 15 mL contains 7.2 g monobasic sodium phosphate monohydrate and 2.7 g dibasic sodium phosphate heptahydrate.
Adult
1 tablespoonful mixed with 8 oz water PO qd prn; may increase dose not to exceed 3 tablespoonfuls per day; drink at least 8 oz of extra fluid with each dose
Pediatric
<5 years: Not recommended
5-9 years: Up to 1/2 tablespoon PO qd taken with eight ounces of fluid
10-11 years: Up to 1 tablespoon PO qd taken with eight ounces of fluid
>12 years: Administer as in adults
Sucralfate or antacids that contain aluminum, calcium, or magnesium may bind phosphate in gut and decrease absorption (separate administration by at least 1 h); phosphate may also bind magnesium and reduce its absorption (separate administration by at least 1 h); anion exchange resins (eg, colestipol) may alter phosphate absorption; caution with other drugs that may lower seizure threshold (eg, antipsychotics); caution when coadministered with other drugs that prolong QT interval (eg, antipsychotics, macrolide antibiotics, class IA or class III antiarrhythmic agents); risk of acute phosphate nephropathy may increase with drugs that alter renal perfusion (eg, diuretics, ACE inhibitors, angiotensin II antagonists, NSAIDs)
Do not administer sodium phosphate to patients with renal insufficiency because severe and lethal episodes of hyperphosphatemia may develop with resultant hypocalcemia and tetany; fecal impaction
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in congestive heart failure, and cirrhosis; electrolyte disturbances (eg, hypernatremia, hypokalemia, hyperphosphatemia, hypocalcemia) dehydration, metabolic acidosis, renal failure, tetany, and death have been attributed to prescribing >45 mL as bowel preparation for colonoscopy, surgery, or barium enema and/or prescribing it for people at medical risk
Lubricants
These agents soften stools and decrease water absorption from the GI tract. They may also promote salt and water secretion by the colon.
Mineral oil
Nonabsorbable fat that softens stool and decreases water absorption, partly by its metabolism in the colon to hydroxy fatty acids. Largely tasteless. Has an oily consistency. More palatable if cold or mixed into a fluid (eg, orange juice). When taken in high doses, many children experience seepage of orange oil into their underwear, which can produce perianal pruritus.
Adult
15-45 mL PO qd prn
Pediatric
<1 year: Not recommended
>1 year: 1-3 mL/kg/d PO qd or divided bid
Theoretically, mineral oil may interfere with absorption of fat-soluble vitamins; however, several long-term studies have not demonstrated any deleterious effects on vitamin levels; decreases effect of docusate sodium and may decrease absorption of warfarin, or PO contraceptives
Documented hypersensitivity; do not administer to people with increased aspiration risk because aspiration of mineral oil can result in lipoid pneumonia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not administer with food or meals since may cause aspiration leading to lipid pneumonitis
Stimulant laxatives
These agents increase peristaltic activity in the GI tract. Most of these agents also stimulate salt and water secretion in the colon.
Senna (Ex-Lax, Senokot, Fletcher's Castoria, Aloe Vera)
Sennosides are plant alkaloids that stimulate colonic salt and water secretion and promote colonic motility. At higher doses, these agents often produce abdominal cramping. Long-term use in animals has not been associated with any evidence of cathartic colon, tachyphylaxis, or secondary hyperaldosteronism.
Adult
10-15 mL PO qhs prn
Pediatric
<2 years: Not recommended
2-5 years: 2.5-5 mL/dose (8.8 mg of sennosides/5 mL) PO qd/bid
>5 years: 5-10 mL/dose (8.8 mg of sennosides/5 mL) PO qd/bid
Decreases effects of anticoagulants
Documented hypersensitivity; bowel obstruction, fecal impaction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Chronic use of sennosides can be associated with melanosis coli (brown pigment accumulation in the colonic mucosa); this finding does not appear to have any pathological significance and resolves within several months of discontinuing the laxative
Bisacodyl (Dulcolax)
Colorless and odorless compound that is very poorly absorbed. Can be administered PO or rectally. Bisacodyl increases colonic peristalsis and stimulates salt and water secretion.
Adult
5-15 mg PO as single dose
10 mg PR as single dose
Pediatric
<2 years: Not recommended
>2 years: 0.5-1 of a 10-mg suppository/dose PR or one third of the 5-mg tab/dose PO
Decreases effects of warfarin and antacids
Documented hypersensitivity; intestinal obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
At higher doses, these agents often produce abdominal cramping
Stool softeners
These agents allow incorporation of water and fat into stool, causing stool to soften.
Docusate sodium (Colace, DC 240 Softgels, Diocto, Surfak)
Used to avoid straining during defecation. Allows incorporation of water and fat into stool causing stool to soften.
Adult
50-400 mg/d PO qd or divided qid
Pediatric
3-6 years: 20-60 mg/d PO qd or divided qid
6-12 years: 40-150 mg/d PO qd or divided qid
>12 years: Administer as in adults
Decreases effects of warfarin and increases effects of phenolphthalein
Documented hypersensitivity; nausea, vomiting, acute abdominal pain
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use of medication may result in electrolyte imbalance
Stool softeners in combination with stimulants
Emollient stool softeners cause stool to soften. Most of these agents also promote salt and water secretion by the colon. Stimulants increase peristaltic activity in the GI tract. Most of these agents also promote salt and water secretion by the colon.
Docusate sodium and casanthranol combination (Peri-Colace, Diocto C, Silace-C)
Docusate sodium allows incorporation of water and fat into stool causing stool to soften. Casanthranol is an anthraquinone stimulant hydrolyzed by colonic bacteria into active compound. Usually produce action 8-12 h after administration.
Adult
1-4 cap or tab PO hs
Alternatively, 5-60 mL PO hs if syrup or emulsion administered
Pediatric
<6 years: Not recommended
>6 years: 1-2 cap or tab PO hs; alternatively, 5-15 mL PO hs if syrup or emulsion administered
Decreases effects of warfarin and increases effects of phenolphthalein
Documented hypersensitivity; nausea, vomiting, GI bleeding, appendicitis, GI bleeding, congestive heart failure, fecal impaction, appendicitis, nausea, vomiting, acute abdominal pain
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Excessive use may lead to electrolyte imbalance, osteomalacia, steatorrhea, cathartic colon
Osmotic enemas
These agents produce osmotic effect in colon that results in distention and promotes peristalsis.
Sodium phosphate enema (Fleet enema)
Phosphate is a divalent anion largely absorbed in the proximal small intestine. When administered as an enema, only small amounts are absorbed so the phosphate functions as an osmotic agent drawing water into intestinal lumen increasing intraluminal and hydrostatic pressure. May also decrease water and electrolyte absorption.
Adult
1 adult enema (4.5 fl oz) PR prn
Pediatric
<2 years: Do not use
2-5 years: 1 pediatric enema (2.25 fl.oz) PR once or twice daily prn
>5 years: 1 adult enema (4.5 fl. oz) PR once or twice daily prn
Do not administer aluminum, magnesium antacids, or sucralfate
Documented hypersensitivity; hypernatremia, hyperphosphatemia, renal failure, hypocalcemia, and fecal impaction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, and cirrhosis; electrolyte disturbances (eg, hypernatremia, hypokalemia, hyperphosphatemia, hypocalcemia) dehydration, metabolic acidosis, renal failure, tetany, and death have been attributed to prescribing >45 mL as bowel preparation for colonoscopy, surgery, or barium enema and/or prescribing it for people at medical risk
More on Constipation |
| Overview: Constipation |
| Differential Diagnoses & Workup: Constipation |
 Treatment & Medication: Constipation |
| Follow-up: Constipation |
| Multimedia: Constipation |
| References |
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References
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Further Reading
Keywords
constipation, acquired megacolon, functional constipation, functional megacolon, megacolon, stool hoarding, stool retention, stool withholding, Hirschsprung disease, defecation, fecal incontinence, abdominal mass, rectal fecal mass, treatment, diagnosis
