Pediatric Constipation Treatment & Management
- Author: Stephen Borowitz, MD; Chief Editor: Carmen Cuffari, MD more...
Approach Considerations
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 regimen 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.
There is a group of patients with has severe constipation that does not respond to conservative medical therapy and requires more aggressive treatments, including surgery. A discussion of these interventions is beyond the scope of this article. See Surgery for Pediatric Constipation and Bowel Management.
Also see Constipation.
Colon Evacuation
When there is evidence of a fecal impaction, initial therapy should be directed to evacuate the colon. A fecal impaction can be identified by palpating a hard mass of stool on physical examination, finding a large amount of stool in a dilated rectum during rectal examination, or finding excessive stool in the colon on an abdominal radiograph.
Aggressive use of oral cathartics such as polyethylene glycol, sodium phosphate, magnesium citrate, or a balanced electrolyte solution with polyethylene glycol or a series of enemas can accomplish disimpaction.[13] In trials, disimpaction by the oral route or the rectal route is reported to be equally effective.[14, 15]
Convincing young children to ingest sufficient amounts of oral cathartics to evacuate their colons may be difficult; therefore, enemas or suppositories may be necessary. See the images below.
Position for enema administration in an infant.
Another position for enema administration.
Administration of an enema.
Incorrect enema administration. The enema is administered against stool impaction and cannot be successful.
Enema administration with a tube.
Enema with inflated Foley balloon catheter.
Administration of an enema against impacted stool.
Administration of an enema against fecal impaction. Removal of Pain-Associated Defecation
Once the colon has been evacuated, chronic laxative therapy is generally required.[16] 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, it is very important to reassure caregivers that long-term laxative usage is safe. Address the common misconceptions regarding laxative dependency, laxative abuse, and the risk of colon cancer due to long-term laxative usage.
If the child has anal fissures, using Xylocaine ointment or hydrocortisone suppositories for a short time period to provide symptomatic relief may be helpful.
Establishing Regular Bowel Habits
In many cases, long-term success in the management of constipation depends on the child establishing regular and routine toilet times. It is generally recommended that the child be encouraged to attend the toilet twice daily for 5-10 minutes, preferably after breakfast and supper to take advantage of the gastrocolic reflex. For school age children, it is preferable not to expect the child to attend the toilet while at school.
When the affected child has passed bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, it is reasonable to attempt to discontinue laxative therapy. 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.
Dietary Modification
Dietary changes, such as increasing the child's intake of fluids and carbohydrates, are commonly recommended as part of the treatment of constipation.[17]
Balanced diet
Complex carbohydrates and unabsorbable sugars (eg, sorbitol) are found in many fruit juices (eg, prune, pear, apple). These carbohydrates increase stool frequency by increasing fecal water content. Although randomized controlled trials have not been conducted to examine the effects of increasing the intake of fluids, nonabsorbable carbohydrates, or fiber on childhood constipation, recommending a balanced diet that includes whole grains, fruits, vegetables, and an abundance of fluids seems appropriate. Because data are limited, forceful implementation of a particular diet does not seem warranted.
Cow milk avoidance
In infants and young children, it is appropriate to consider removing cow-milk protein from the diet for a period is appropriate, because chronic constipation may be precipitated by ingestion of cow-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 milk; in most cases, the constipation recurred when cow milk was reintroduced.[18]
Unnecessary or ineffective dietary changes
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.[19]
Although some evidence suggests that gastrointestinal flora is important in gut motility, no evidence suggests that gut florae are different in children with constipation than gut florae in healthy controls. While both Lactobacillus and Bifidobacterium have been shown to increase stool frequency and decrease stool consistency in healthy adults, there is little evidence that probiotics are effective in treating constipation in either adults or children.[20]
Consultations
Consultation with a pediatric gastroenterologist or pediatric surgeon is appropriate if the child's history or examination findings suggest an underlying organic cause (eg, Hirschsprung disease). Also seek consultation when the child fails routine therapy or when management is otherwise complex.
See Surgery for Pediatric Constipation and Bowel Management.
Long-Term Monitoring
Assessment of constipation after disimpaction assures that the prescribed therapy was effective. At that time, maintenance laxative therapy can be prescribed. When the patient has bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, attempting to discontinue laxative therapy is reasonable.
[Best Evidence] van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. Oct 2006;101(10):2401-9. [Medline].
Borowitz SM, Cox DJ, Kovatchev B, et al. Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome. Pediatrics. Apr 2005;115(4):873-7. [Medline].
[Guideline] North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. Sep 2006;43(3):405-7. [Medline].
Benninga M, Candy DC, Catto-Smith AG, et al. The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. J Pediatr Gastroenterol Nutr. Mar 2005;40(3):273-5. [Medline].
Issenman RM, Hewson S, Pirhonen D, et al. Are chronic digestive complaints the result of abnormal dietary patterns? Diet and digestive complaints in children at 22 and 40 months of age. Am J Dis Child. Jun 1987;141(6):679-82. [Medline].
Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. Jun 2007;92(6):486-9. [Medline].
Saps M, Sztainberg M, Di Lorenzo C. A prospective community-based study of gastroenterological symptoms in school-age children. J Pediatr Gastroenterol Nutr. Oct 2006;43(4):477-82. [Medline].
Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary-school children. In: Ambulatory Child Health. Vol 4. 1998:277-82.
de Araujo Sant Anna AM, Calcado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Pediatr Gastroenterol Nutr. Aug 1999;29(2):190-3. [Medline].
Borowitz SM, Cox DJ, Tam A, et al. Precipitants of constipation during early childhood. J Am Board Fam Pract. May-Jun 2003;16(3):213-8. [Medline].
De Lorijn F, Reitsma JB, Voskuijl WP, et al. Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests. J Pediatr. Jun 2005;146(6):787-92. [Medline].
Abrahamian FP, Lloyd-Still JD. Chronic constipation in childhood: a longitudinal study of 186 patients. J Pediatr Gastroenterol Nutr. Jun 1984;3(3):460-7. [Medline].
Loening-Baucke V. Polyethylene glycol without electrolytes for children with constipation and encopresis. J Pediatr Gastroenterol Nutr. Apr 2002;34(4):372-7. [Medline].
Bekkali NL, van den Berg MM, Dijkgraaf MG, et al. Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG. Pediatrics. Dec 2009;124(6):e1108-15. [Medline].
Miller MK, Dowd MD, Friesen CA, Walsh-Kelly CM. A Randomized Trial of Enema Versus Polyethylene Glycol 3350 for Fecal Disimpaction in Children Presenting to an Emergency Department. Pediatr Emerg Care. Jan 20 2012;[Medline].
Pijpers MA, Tabbers MM, Benninga MA, Berger MY. Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary measures. Arch Dis Child. Feb 2009;94(2):117-31. [Medline].
Corkins MR. Are diet and constipation related in children?. Nutr Clin Pract. Oct 2005;20(5):536-9. [Medline].
Iacono G, Cavataio F, Montalto G, et al. Intolerance of cow's milk and chronic constipation in children. N Engl J Med. Oct 15 1998;339(16):1100-4. [Medline].
Lloyd B, Halter RJ, Kuchan MJ, et al. Formula tolerance in postbreastfed and exclusively formula-fed infants. Pediatrics. Jan 1999;103(1):E7. [Medline].
Vandenplas Y, Benninga M. Probiotics and functional gastrointestinal disorders in children. J Pediatr Gastroenterol Nutr. Apr 2009;48 Suppl 2:S107-9. [Medline].
Muller-Lissner SA. Adverse effects of laxatives: fact and fiction. Pharmacology. Oct 1993;47 Suppl 1:138-45. [Medline].
Schiller LR. Clinical pharmacology and use of laxatives and lavage solutions. J Clin Gastroenterol. Jan 1999;28(1):11-8. [Medline].
Dupont C, Leluyer B, Amar F, et al. A dose determination study of polyethylene glycol 4000 in constipated children: factors influencing the maintenance dose. J Pediatr Gastroenterol Nutr. Feb 2006;42(2):178-85. [Medline].
Khan S, Campo J, Bridge JA, et al. Long-term outcome of functional childhood constipation. Dig Dis Sci. Jan 2007;52(1):64-9. [Medline].

