Treatment of Constipation in Children

Initial Assessment and Treatment

• The National Comprehensive Cancer Network recommends increasing fluid intake, particularly if the child is in the lowest quartile of daily fluid consumption, to help manage constipation 2, 3, 4
• Regular physical activity is encouraged to utilize the gastrocolic reflex and help manage constipation 1, 5

First-Line Maintenance Treatment

• The American Gastroenterological Association recommends polyethylene glycol (PEG) as a first-line treatment for constipation, with a dosing regimen of 17 grams once daily mixed in 4-8 ounces of beverage 2, 3, 4
• Fiber supplementation can be added to the treatment regimen if the child has adequate fluid intake, with a target fiber intake of age + 5 grams per day minimum 2, 3, 4

Treatment Goal

• The goal of treatment is to achieve one non-forced bowel movement every 1-2 days without abdominal pain or straining 1, 5, 6, 7, 8

Second-Line Options

• If constipation persists after 4 weeks of PEG therapy, bisacodyl can be added as a stimulant laxative, with a dosing regimen of 5-10 mg once daily 1, 5, 6, 7
• Alternative osmotic agents such as lactulose, magnesium hydroxide, and sorbitol can also be used as second-line options 1, 5, 6, 7

Management of Persistent Constipation

• The National Comprehensive Cancer Network recommends reassessing for underlying causes of constipation, including medication-induced constipation and metabolic causes 1, 5, 6, 7
• Rescue interventions such as glycerin suppository, bisacodyl suppository, and mineral oil retention enema can be used to manage impaction 1, 5, 6, 7

Important Clinical Considerations

• The recommendation for PEG is based on moderate-quality evidence in adults, with supportive pediatric data showing glucomannan fiber supplementation benefits 2, 3, 4
• Common pitfalls to avoid include using stool softeners alone, adding supplemental fiber without adequate fluid intake, and limiting PEG to 7 days in chronic constipation 2, 3, 4, 10, 6, 7, 8