INTRODUCTION — Constipation is common among children, affecting up to 30 percent of children [1-3], and the vast majority of chronic constipation is functional [4]. The approach to treatment of functional constipation depends on the child's age, presence of underlying behavioral or dietary triggers, and chronicity of the symptoms.
The treatment of chronic functional constipation and fecal incontinence in infants and children will be discussed here. Related material is presented in the following topic reviews:
●(See "Constipation in infants and children: Evaluation".)
●(See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".)
●(See "Recent-onset constipation in infants and children".)
DEFINITIONS
●Functional constipation – Functional constipation is defined by criteria that include infrequent, hard, and/or large stools; fecal incontinence; painful defecation; or volitional stool retention, if these symptoms are not explained by another medical condition, as outlined by the Rome IV consensus (table 1) [5,6]. Although abdominal pain is often associated with functional constipation, it is not among the diagnostic criteria. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".)
●Functional fecal incontinence – Functional fecal incontinence is the repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically after four years of age), in the absence of overt neuromuscular anorectal dysfunction. This term is preferred rather than encopresis or soiling. It is classified as "retentive" if it is associated with functional constipation and "nonretentive" if it occurs in the absence of symptoms and signs of functional constipation [6]. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation".)
●Fecal impaction – This term is used to describe markedly increased amounts of stool in the rectum and colon. It is a subjective judgement based on clinical findings, such as a large stool mass noted on physical examination and/or radiograph (if performed), especially in association with a history of passing infrequent and large-caliber stools. (See 'Disimpaction (for select children)' below.)
TREATMENT OF CONSTIPATION IN INFANTS — Constipation is evaluated and treated somewhat differently in infants than in children. When constipation presents early in life, organic disease (eg, cystic fibrosis, Hirschsprung disease), an anorectal malformation, and, especially, anal stenosis must be considered [7]. The organic causes of constipation in infants are discussed in a separate topic review. (See "Constipation in infants and children: Evaluation" and "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Differential diagnosis'.)
Initial measures (nonpharmacologic) — Infants with functional constipation frequently respond to treatment with nondigestible osmotically active carbohydrates, such as sorbitol-containing juices (eg, apple, prune, or pear). Although dark corn syrup was previously used, we no longer suggest it, because not all preparations contain osmotically active carbohydrates.
Pharmacotherapy — If these measures are unsuccessful, addition of osmotic laxatives and/or occasional disimpaction with glycerin suppositories can be useful. Appropriate choices for infants include the following (all are off-label uses for this age group):
●Lactulose or sorbitol – These are frequently used and are usually effective in infants. A typical dose for either lactulose or sorbitol is 1 mL/kg, once or twice daily (table 2).
●Polyethylene glycol 3350 – Experience with polyethylene glycol 3350 (or Miralax) is increasing in infants, although the safety is less well established than with older age groups. The use of this laxative for infants and toddlers <24 months of age was reported in several case series [8-10]. In addition, a randomized trial that compared polyethylene glycol with and without electrolytes in children included a few subjects between 6 and 24 months of age [11]. The treatment was generally effective, and no adverse effects were noted in these studies. The mean effective maintenance dose was approximately 0.8 g/kg body weight per day.
●Glycerin suppositories – Occasional disimpaction with glycerin suppositories can be useful. However, these should be used with caution because they can cause rectal and anal irritation and may lead to chronic symptoms. (See 'Details on medications' below and "Recent-onset constipation in infants and children", section on 'Infants'.)
For infants who do not respond to osmotic laxatives, senna may be tried short-term (eg, by giving 1 to 2.5 mL daily of syrup with 8.8 mg sennosides per 5 mL for up to three months) [12]. However, this has not been well studied in this age group and is an off-label use. Senna may cause perianal skin breakdown and blistering if the stool is left in contact with the skin for a prolonged time and/or if high doses are given.
The following drugs are not recommended for infants:
●Mineral oil – Oral administration of mineral oil is not recommended for infants, because of potential risks of pneumonitis if aspirated.
●Enemas – Potential complications in this age group, such as hyperphosphatemia (which could be life-threatening), hypocalcemia, or perforation. Occasionally, pure saline enemas (with no phosphate) may be used for infants but only when necessary and under close medical supervision.
●Bisacodyl – Bisacodyl tablets are enteric coated and are therefore ineffective when crushed, so there is no preparation appropriate for infants.
TREATMENT OF CONSTIPATION IN CHILDREN
General approach and goals — Treatment of chronic functional constipation and fecal incontinence is based on the concept that chronic constipation causes the colon to be unresponsive to stool burden due to distension and that effective treatment requires consistent and complete emptying of the colon, so that it becomes conditioned to work on its own. This concept is known as "bowel retraining" [7,13-18]. There are four general steps in bowel retraining:
●Disimpaction (for children with a large rectal stool mass or fecal incontinence)
●Prolonged laxative treatment and behavioral therapy to achieve regular evacuation and avoid recurrent constipation
●Dietary changes (primarily increasing fiber and fluid content) to maintain soft stools
●Gradual tapering and withdrawal of laxatives as tolerated
This multimodal therapy is particularly helpful for children who have gone several days between bowel movements, have an anal fissure with pain or bleeding, or have very large-diameter stools with marked straining. The type and intensity of the intervention should be tailored to the severity of constipation and the child's developmental stage, and close follow-up is often necessary.
The goal of therapy is the passage of soft stools, ideally once per day and no less than every other day. This goal of frequent defecation is important to overcome constipation, although less frequent defecation patterns are common and acceptable in children without a history of constipation. Weeks to months and sometimes years of laxative and behavioral therapy may be necessary before this goal is achieved. The child's parents or caregivers must be effectively educated about bowel retraining and behavior modification, so that they can carry out the sustained treatment at home. Ultimately, the symptoms improve in most patients. (See 'Prognosis' below.)
The combined laxative and behavioral approach is supported by a systematic review of randomized and quasi-randomized trials that concluded that combination therapy was more effective than laxative therapy alone [18]. It is also supported by observational studies and clinical experience [19-26]. Analysis of intervention trials is complicated by the varied methods used for laxative and behavioral treatments. Consequently, conclusions also vary but generally support the use of combination therapy that incorporates both of these modalities.
The following tables summarize a typical treatment plan for children with chronic constipation (details are provided in the remainder of this topic review):
●For children with chronic constipation and fecal incontinence (table 3)
●For children with chronic constipation but without overflow fecal incontinence (table 4)
Parental education — Effective education of the parents/caregivers and the child with regard to constipation is crucial in changing chronic behavior patterns [7,27]. Regular follow-up and ongoing support and encouragement during periodic office visits or phone conversations are essential.
Key messages for education are:
●Remove negative attributions – The parent or caregiver must understand that fecal incontinence due to overflow does not constitute willful and defiant behavior by the child but actually represents physiologic loss of continence. The child should therefore not be scolded or otherwise punished for episodes of incontinence [28,29]. In toddlers with constipation, toilet training should be postponed since it will prove unsuccessful until rectal awareness is restored and defecation is pain-free [14]. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
●Understand the cyclic nature of constipation and how to reverse this – The clinician should explain the behavioral and physiologic contributors to constipation in easy-to-understand lay language, with descriptions of how and why the constipation became chronic, how constipation can cause fecal incontinence, and the concept of bowel retraining. A diagram to support this explanation, with key points in lay language, is shown in the figure, which can be printed and given to the family to support the verbal explanations (figure 1). Other education for children and their families is provided in this video [30].
●Both behavioral interventions and laxatives are important parts of treatment – Education should emphasize the role of behavioral contributors to functional constipation, especially the vicious cycle of pain/fear and stool withholding, and that behavioral interventions are geared toward reversing this cycle. This is particularly important for younger children who develop constipation around the time of toilet training. In addition, it is important to explain the need for laxatives and the safety of the type of laxative that will be prescribed to allay any concerns about the safety of long-term laxative use. (See 'Stepwise approach to bowel retraining' below.)
●Recovery will be gradual – Parents or caregivers should be advised that the process of bowel retraining, with readjustment of the nerves and muscles in the rectum, can take as long as six months to several years. Most children experience improvement with appropriate treatment, but relapses or chronic symptoms are common. (See 'Prognosis' below.)
In severe cases, the parents and/or clinician may need to enlist the help of the school and teacher. Some children may benefit from access to a private bathroom. The teacher should be sensitive to the child's problem, permitting use of the bathroom whenever requested (perhaps using a prearranged, unobtrusive signal to avoid drawing attention). In addition, it may be helpful to have a change of clothing available in case an episode of fecal incontinence occurs.
Stepwise approach to bowel retraining
Disimpaction (for select children) — "Fecal impaction" is a term used to describe markedly increased amounts of stool in the rectum and colon, which is a subjective judgement based on clinical findings.
●Indications – The majority of children who come to medical attention because of chronic constipation have fecal impaction and will benefit from a regimen to disimpact the rectum before beginning maintenance therapy [7,27,31]. This step is sometimes described as a "clean out" in discussions with patients and their families. We suggest a disimpaction step for children with any of the following characteristics:
•Constipation-associated fecal incontinence
•Significant stool mass palpable on abdominal or digital rectal examination or on abdominal radiograph (if performed)
•History of incomplete or infrequent evacuation
●Choice of regimen – Disimpaction and catharsis can be effectively accomplished with oral or nasogastric medications, rectal medications, or a combination. The parents/caregivers and child should be involved in the decision regarding the appropriate route [32]. Considerations are:
•For most children, we suggest an oral regimen for disimpaction because this method is noninvasive and may help the child feel in control [7]. Oral medications also are particularly valuable for children with a history of painful defecation, perineal trauma, or difficulty tolerating enemas [13,32]. However, adherence with the necessary volume may be difficult and two to three days (up to a maximum of six days, sometimes split between two weekends) of treatment are often needed to achieve complete disimpaction [33]. In a randomized trial, an oral laxative (polyethylene glycol 3350) was found to be as effective as enemas in treating impaction, but children treated with the polyethylene glycol had more fecal incontinence [34].
•For patients with severe impaction, rectal medications may be needed and are typically used in combination with oral medications. Rectal medications are more rapidly effective than oral medications for disimpaction and may be a powerful motivator for toilet sitting [7,20]. However, we avoid their use except in patients with severe impaction because enemas are invasive and may be difficult to administer to an uncooperative or fearful child [32].
●Care setting – Disimpaction can usually be performed in the outpatient setting using oral medications, occasionally in combination with rectal medications (table 3) [27]. It is important to assess the response to the regimen as soon as possible after it is completed. Successful disimpaction is usually indicated by abundant bowel movements with solid stool content and decreased episodes of fecal incontinence [27].
If one or more attempts at outpatient disimpaction have failed to yield abundant stool, hospitalization may be necessary. In this case, consultation with a pediatric gastroenterologist is also indicated [7]. Inpatient regimens may include nasogastric administration of a balanced electrolyte solution (eg, GoLYTELY) to flush out the colon, sometimes in combination with rectal medication and/or manual disimpaction [27].
●Disimpaction regimens
•Oral medications – For most children, we suggest an oral regimen for disimpaction, especially if the impaction is not severe. Polyethylene glycol with or without electrolytes is generally the first-line choice for this purpose due to established efficacy, safety, and tolerability. (See 'Polyethylene glycol' below.)
-Outpatients – For outpatient disimpaction, polyethylene glycol 3350 (polyethylene glycol without electrolytes; Miralax and others) is generally the most palatable oral laxative and is reasonably well accepted by children [7]. The dose for disimpaction is 1 to 1.5 g/kg/day by mouth for up to six days. The medication is dissolved in approximately 10 mL/kg body weight of water or flavored beverage (some clinicians suggest an electrolyte-containing "sports" beverage for this purpose). In a randomized study, these doses successfully disimpacted 95 percent of children with chronic constipation [35]. An example of this protocol is outlined in the table (table 3).
Patients with inadequate disimpaction using six days of polyethylene glycol-based treatment at home may require escalation of therapy (eg, adding rectal medications or performing polyethylene glycol-electrolyte cleanout in the hospital), as described below.
Other oral agents that have been used successfully for disimpaction include mineral oil [36], magnesium hydroxide [37], magnesium citrate [38], lactulose [39], sorbitol, senna, and bisacodyl [37]. We do not generally use these agents for disimpaction, because they are typically less well tolerated than polyethylene glycol 3350 and are probably less effective, based on limited evidence from clinical trials [40]. Furthermore, mineral oil has a risk of lipoid pneumonia if aspirated. (See 'Other laxatives' below.)
-Inpatients – For inpatient treatment, polyethylene glycol-electrolyte solution (eg, GoLYTELY) may be given by nasogastric tube at 25 mL/kg/hour up to a maximum of 400 mL/hour until the stool becomes thin, brown liquid [41]. We generally use nasogastric administration because most children are unable to take sufficient quantities of this solution by mouth. The rate of the infusion should be slowed if the child develops vomiting or abdominal distension. Bowel perforation has been reported in children undergoing bowel disimpaction with nasogastric polyethylene glycol-electrolyte solutions, especially in patients with previous bowel surgeries, who may have unrecognized subacute bowel obstruction due to a stricture or an adhesion.
If there is a large impaction by examination or radiograph, it is prudent to first remove some stool distally by digital disimpaction, rectal softening (mineral oil retention enema), stimulant rectal suppositories, and/or enemas, before beginning nasogastric solutions, to avoid vomiting.
Pulsed irrigation enhanced-evacuation systems [42] and enemas with Gastrografin have been successfully used for disimpaction when the standard oral and rectal disimpaction regimens described above have been unsuccessful [43-45]. Gastrografin enemas can be administered in or out of the hospital.
•Rectal medications – For patients with severe impaction, rectal medications may be needed for effective disimpaction [7,14]. Rectal medications are more rapidly effective than oral medications. For patients with severe impactions, they may help reduce the risk for vomiting.
The main options for either outpatient or inpatient treatment are:
-Sodium phosphate enema – For children ≥12 years old, use a 4.5-ounce (133 mL) enema (this bottle delivers 118 mL). For children 5 to <12 years old, use a 2.25-ounce (66 mL) enema (this bottle delivers 59 mL). For children 2 to <5 years, use one-half of the 2.25-ounce enema (this delivers approximately 29 mL).
These enemas should not be used in children younger than two years of age. This dose may be repeated once within 12 to 24 hours, if necessary. Because these are small-volume enemas, the caregiver should be instructed to point the tip of the enema device toward the child's back after it is inserted to direct the contents toward the bowel wall, where it will be effective, rather than into the fecal mass.
More frequent dosing should be avoided because there are several case reports of life-threatening hyperphosphatemia and hypocalcemic tetany, particularly in young children, those with colonic dysmotility, and/or those with repeated administration of enemas [46-49]. Phosphate-based enemas should be avoided in children with renal insufficiency.
-Saline enema – This can be administered using a dose of 10 to 15 mL per kg. When possible, we typically use a prepared saline solution (eg, an isotonic [9%] saline solution intended for intravenous administration), to ensure the appropriate electrolyte concentration.
-Mineral oil enema – For children ≥12 years old, use a 4.5-ounce (133 mL) enema (this bottle delivers 118 mL). For children 2 to <12 years, use one-half of the 4.5-ounce bottle (this delivers approximately 59 mL).
Bisacodyl suppositories may be used for older children, and glycerin suppositories may be used for infants [7,50]. These approaches are generally not as effective as enemas but are well tolerated. (See 'Treatment of constipation in infants' above and 'Considerations for adolescents' below.)
We do not recommend the use of enemas made of soapsuds [51,52], tap water [53,54], milk and molasses [55], magnesium (ie, Epsom salt) [56-58], or herbal formulations [14], because of potential complications, which include colitis, water intoxication, bowel perforation, and bowel necrosis [7,14,51,52,59].
•Oral and rectal medications – Combination treatment with oral and rectal medications is often the most effective approach for moderate or severe fecal impaction. An example of an outpatient protocol that combines polyethylene glycol 3350 (without electrolytes) and sodium phosphate enemas is outlined in the table (table 3). In this case, the initial treatment is with oral medication to soften the stool and rectal medication is added on day 2 to help evacuate the impacted stool. An alternative combination approach consists of three to four consecutive three-day cycles, in which a phosphate sodium enema is administered on day 1, a bisacodyl suppository on day 2, and bisacodyl tablet (10 mg) on day 3 [13,27].
After disimpaction, patients should be treated with a maintenance regimen of oral laxatives to "retrain" the bowel and avoid reimpaction. It is important to start this maintenance regimen of laxatives immediately after disimpaction to avoid reaccumulation of stools.
Maintenance laxative therapy — For children with no fecal impaction or for those who have successfully completed a disimpaction regimen, the next step in management is a regimen of laxatives, which are given regularly and adjusted to achieve soft daily stools. For most children, the maintenance regimen consists of daily doses of an osmotic laxative, supplemented by intermittent or daily use of stimulant laxatives when needed [6]. An example of a typical maintenance regimen is outlined in the table (table 4). Expert opinion and guidelines encourage aggressive treatment; early intervention appears to lead to more rapid recovery [7,31].
The practice of prolonged treatment with osmotic laxatives is supported by extensive clinical experience and a few randomized trials. The laxatives that are considered safe and are used most often for children include polyethylene glycol 3350 (without electrolytes), magnesium hydroxide (milk of magnesia) and lactulose. Polyethylene glycol is the best-studied medication and appears to be efficacious and safe, although this is based on low-quality evidence [40]. The type of laxative is not as important as using an adequate dose and ensuring compliance; the choice should be individualized according to circumstances, familiarity, and the child's acceptance [20,31]. The dose should be based upon age, body weight, and severity of constipation (table 2). There is no evidence that tolerance develops to osmotic or lubricant laxatives [60].
For patients who do not respond sufficiently or do not tolerate osmotic laxatives, stimulant laxatives (eg, bisacodyl or senna) are useful as alternative or adjunctive therapy. Case series and considerable clinical experience suggest that these stimulant laxatives can be used for chronic therapy (eg, one year), tolerance does not develop, and these medications can be eventually weaned off [60,61]. Senna may be helpful in children who have difficulty passing even soft stool because of withholding behavior. However, in the author's personal experience, children treated with senna seem to have more difficulty weaning off of medication as compared with those treated with bisacodyl or other medications. This may be due to the severe clinical phenotype requiring multiple laxatives rather than developing dependence on a stimulant laxative like senna.
The parents or caregivers should be advised to adjust the laxative dose according to the response and to increase the dose every two days until the child has one or two soft stools each day or to decrease it if the patient develops diarrhea. They should be warned that the child may continue to have fecal incontinence initially, especially if the child fears or continues to resist having a bowel movement.
Behavior modification — After starting the laxative treatment, the behavioral modification plan should be added. Behavior modification consists of a regular toileting regimen with behavioral reinforcement to encourage cooperation. In children who are not fully toilet trained, we delay this toileting plan until the child has had at least two to four weeks of effective laxative treatment to make sure that the child is not experiencing any pain or hard stools when using the toilet. Because the child's family or caregivers must implement the behavioral protocol, it is important that they be educated about the pathogenesis of constipation, including the cycle of pain, stool withholding, and fecal incontinence, as discussed above (figure 1). Some institutions offer group educational programs to teach this behavioral modification and report improvement in medication adherence, stool pattern, and fecal incontinence [62]. (See 'Parental education' above.)
The typical behavior modification program includes [7]:
●Toilet sitting – For a child who is toilet trained, the parents or caregivers should implement and supervise a program of regular toilet sitting:
•The child should sit on the toilet shortly after a meal for 5 to 10 minutes, two to three times per day [63].
•Toilet sitting episodes should occur at the same time each day and be timed with a timer or stopwatch [64].
•The routine should be followed every day, particularly during times of transition (eg, holidays, vacations, or weekends) [13].
•The child's adherence to the program should be encouraged with positive reinforcers, as described below, rather than negative reinforcers (criticism or punishment).
•For children whose feet do not touch the floor sitting on a regular toilet seat, it is helpful to use a stool for foot support (figure 2). A foot support that raises the knees above the level of the hips can help relax the pelvic floor and is particularly helpful for a child who tends to withhold stool. (See "Recent-onset constipation in infants and children", section on 'Toilet training'.)
●Reward system – The parents or caregivers should implement a reward system that is tailored to the child [13,65] and in which the reward is provided for effort (ie, toilet sitting) rather than success (ie, evacuation in the toilet) [21,66,67]. Rewards for preschoolers may include stickers or small sweets, reading books or singing songs while sitting, or special toys that are only used during toilet sitting [13]. Rewards for school-aged children may include reading books together, activity books, or handheld computer games that are only used during sitting time or coins that can be redeemed for small drug store items [13].
Management of relapses — Relapses are common and may be managed in several ways, depending on the severity and history of fecal impaction. One of these steps should be taken if the child has not had a bowel movement for several days:
●If polyethylene glycol 3350 has been prescribed, ensure that the parents are mixing it as advised in the correct type and amount of fluid (water, juice, or soda; milk is acceptable if it is not being used for a colonoscopy preparation) and that the child drinks this within 30 minutes and does not sip it throughout the day or bring it to school.
●Briefly increase the dose of oral laxative (eg, double the dose for one to three days, until the child is having large soft stools).
●Give one or two doses of a stimulant laxative, such as senna and bisacodyl. (See 'Other laxatives' below.)
●Use an enema to empty the rectum.
If this intervention is successful, treatment is continued with the maintenance osmotic laxative but at a higher dose. If fecal incontinence recurs, a full disimpaction regimen, as described above, may be necessary [68]. (See 'Disimpaction (for select children)' above.)
This approach is sometimes known as "rescue" therapy and is supported by extensive clinical experience and expert guidelines [7]. The development of such a plan empowers the child and family to anticipate, tolerate, and treat recurrences [13].
Monitoring and follow-up — The parents or caregivers should use a diary or log to record bowel movements; use of medications; and episodes of fecal incontinence, abdominal pain, and wetting. A sample of such a diary and a blank one that can be printed out for use by the child's caregivers are shown in the following figures (figure 3A-B).
The management of chronic constipation requires monitoring by the clinician or clinician's staff to prevent recurrences. Planned follow-up is particularly important during the first few days of treatment, especially if disimpaction was warranted. The initial discussion can occur by telephone, but the children who continue to pass hard stools may need to return to the office for a more detailed evaluation including a physical examination to evaluate for fecal impaction. Patients who required initial disimpaction also should have an office visit soon after completing the disimpaction protocol to review the progress and transition to maintenance therapy.
After entering the maintenance phase, the child should have regular follow-up visits, initially on a monthly basis and then less frequently (eg, every three to four months). The clinician should review the child's stool records (figure 3A-B) and repeat the abdominal and, if needed, rectal examinations [20,69]. The follow-up visits provide opportunities to evaluate progress, adjust medication regimens, anticipate challenges, and celebrate successes [13].
Tapering laxative therapy — Once the child has achieved regular bowel habits (and independently uses the toilet), the frequency of mandatory toilet sitting and the use of laxatives can be reduced [20]. The laxative dose is gradually decreased to a dose that will prevent fecal incontinence and maintain one to two bowel movements per day [20].
We typically wait until optimal bowel habits are achieved and stable for at least six months before laxative use is further decreased or discontinued. In many cases, laxatives need to be taken for months and sometimes years to maintain daily soft stools [15,70]. The parents or caregivers must be warned not to stop the laxative without consulting the child's clinician. Stopping laxatives too soon will likely lead to a prompt recurrence and disrupt the treatment program [69].
As laxative therapy is discontinued, it is particularly important to reemphasize compliance with the behavioral and dietary regimens because this may help avoid relapses. In addition, the parents and child should have a "rescue" plan if the child goes more than three days without a stool or has other indications of recurrence (ie, hard stools, abdominal pain, smears in the underwear) [13]. The rescue plan may involve the use of an enema or suppository, followed by an increase in the laxative dose. The development of such a plan empowers the child and family to anticipate, tolerate, and treat recurrences [13]. (See 'Management of relapses' above.)
Dietary changes — During the treatment of chronic constipation and/or fecal incontinence, it is important to ingest a diet that is conducive to fecal regularity [7,27]. Increased intake of fruit and raw vegetables, bran, and whole-grain breads and cereals is commonly recommended, as is adequate intake of fluids other than milk. However, the evidence supporting these interventions is weak, especially in moderate to severe constipation.
●Fiber – We suggest a balanced diet that includes whole grains, fruits, and vegetables as a component of the treatment of constipation in children (table 5A-B). Dietary changes should not be forced, nor should they replace the other interventions described above. It is also reasonable to avoid dietary changes in the initial management to allow the family to focus their efforts on medications and toileting behaviors. For children with acute or mild chronic constipation, a reasonable target for dietary fiber can be calculated as the child's age plus 5 to 10 g/day (ie, 11 to 16 g/day for a six-year-old child). Giving more than this fiber goal has no proven benefit for management of constipation in children [7]. For children with a history of fecal impaction, extra fiber intake should be encouraged only after colorectal function has been restored, eg, after several months of successful treatment with laxatives [14].
Adequate intake of fiber may be more important during the time that laxative therapy is discontinued, when the increased stool bulk may raise the child's awareness of the need to evacuate [14]. Supplementation with glucomannan was a useful adjunct to disimpaction and behavioral interventions in a small randomized trial [71]. If necessary, a variety of fiber products are available over the counter (psyllium, wheat dextrin, or methylcellulose). Preparations include powdered fiber (which can be mixed into juice or frozen into popsicles), wafers, or tablets [14].
Although increasing the intake of fiber is often recommended for acute and chronic constipation, the evidence base for this practice is weak and somewhat conflicting [7,71-76]. This may be because dietary fiber can have either beneficial or adverse effects in children with constipation, especially in the setting of chronic constipation and recurrent impactions. On the one hand, fiber adds bulk and water content to the stool; this can make the stool softer and easier to release. On the other hand, the increased stool bulk also may cause greater distension of the rectum and colon in children with fecal retention and interfere with the child's ability to sense the need to defecate. Moreover, if there is inadequate accompanying fluid intake, impactions can occur.
●Fluid intake – To ensure adequate hydration, children with chronic constipation or fecal incontinence should be encouraged to consume at least 32 to 64 ounces (960 to 1920 mL) of water or other nonmilk liquids per day, particularly if they are using fiber supplements. Contrary to popular belief, there is no evidence that constipation can be successfully treated by increasing fluid intake unless the patient is clinically dehydrated.
Whether increasing fluids beyond the usual intake affects constipation is unclear. In one study, 108 prepubertal children (2 to 12 years of age) with moderate to severe simple constipation were randomly assigned to one of three groups: One was instructed to increase daily water intake by 50 percent, the second to ingest additional hyperosmolar liquids such as juices, and the third to make no changes [77]. There were no changes regarding stool frequency or consistency or ease of defecation with either intervention.
●Cow's milk – In children whose constipation is unresponsive to other noninvasive measures (behavioral and dietary interventions, with or without oral laxatives) and especially in those with atopic symptoms, we suggest a trial for at least two weeks of eliminating all cow's milk protein from the diet [7,19,78]. If the constipation improves substantially, the diet should be continued. A nondairy form of milk (eg, soy) can be used as a substitute.
Eliminating cow's milk from the diet improves constipation in some children. This is particularly true in children with atopic symptoms, probably because of an occult cow's milk intolerance [78,79]. In one double-blind crossover study in 65 constipated children who were refractory to laxative therapy, 68 percent of children improved while receiving soy milk compared with cow's milk [80,81]. Constipation recurred within days of reintroduction of cow's milk. Another study suggested that constipation can be a delayed clinical manifestation of cows' milk protein intolerance, particularly in children with a personal or family history of atopy [82].
Although not clinically proven, it is also possible that excessive consumption of milk may contribute to constipation in some children, even in the absence of cow's milk protein intolerance. The proposed mechanism is that cow's milk slows intestinal motility and satiates the child, thereby diminishing the intake of other fluids and fiber-containing foods. This mechanism may be most relevant for toddlers, who are most likely to have a high intake of milk and low intake of dietary fiber. Therefore, we recommend limiting the intake of cow's milk to 24 fluid ounces (720 mL) per day.
Considerations for adolescents — Compared with younger children, adolescents with chronic constipation are more likely to have longstanding symptoms and are less likely to respond to the combination of behavioral intervention, dietary changes, and osmotic laxatives described above. Adolescents are also more likely to have abnormal colonic motility, such as slow-transit constipation. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Slow-transit constipation' and "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
●If the abdominal pain persists despite successful treatment of constipation with a laxative, constipation-predominant irritable bowel syndrome should be considered. (See "Functional abdominal pain in children and adolescents: Management in primary care" and "Clinical manifestations and diagnosis of irritable bowel syndrome in adults".)
●For adolescents with a short history of chronic constipation or mild symptoms and no evidence of an organic cause (see "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis"), the first step is to treat with osmotic laxatives (table 2) and dietary changes, as outlined above, with disimpaction if needed. (See 'Stepwise approach to bowel retraining' above and 'Disimpaction (for select children)' above.)
●For some adolescents and especially those with a long history of constipation, high doses and prolonged courses of laxatives may be needed, with behavioral support to promote adherence to the regimen.
●For all adolescents, screen for behavioral and psychosocial comorbidities that may promote or exacerbate the constipation, including attention deficit hyperactivity disorder (ADHD) [83], school stressors, and eating disorders, and refer for further evaluation and treatment as indicated.
●If the above strategies are not successful, additional pharmacologic options for adolescents include linaclotide, lubiprostone, or prucalopride, in an off-label use for this age group. (See 'Other laxatives' below.)
●In refractory cases, further evaluation of colonic motility and anorectal function may be useful to define the underlying cause and guide treatment (see "Constipation in infants and children: Evaluation", section on 'Motility testing for patients with functional constipation refractory to treatment'). For those with dyssynergic defecation, biofeedback therapy may be useful. (See 'Treatment failure' below.)
●Fecal incontinence associated with chronic constipation is especially distressing for adolescent patients. In addition to achieving regular, painless bowel movements, treatment goals should also include achieving social continence [84].
TREATMENT FAILURE
Reinforcement and intensification of treatment — Failure of treatment, manifested by recurrent impaction and/or continued fecal incontinence, suggests the need to review education and other treatment components. Most treatment failures are caused by inadequate medication or premature discontinuation [14]. Poor adherence with the treatment program is another important cause of treatment failure. In some children, adherence to the medication or behavioral program may be impaired by behavioral problems (eg, oppositional behavior, poor attention span, high activity level) [20,27,85]. Such patients and their families may benefit from individual or group psychotherapy and a more rigorous behavioral approach [86].
Further evaluation — Repeated failure despite adequate compliance with a maximal laxative regimen (eg, daily use of an osmotic and stimulant laxative) requires reconsideration of the diagnosis and the possibility of further testing [7]. Patients with ongoing chronic constipation despite adherence to an optimal medical and behavioral intervention should be evaluated by anorectal manometry and/or balloon expulsion testing. These tests can also help identify patients with internal anal sphincter (IAS) achalasia or other anatomic causes of constipation, as well as dyssynergic defecation, which is a functional disorder characterized by the incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate (see "Constipation in infants and children: Evaluation", section on 'Motility testing for patients with functional constipation refractory to treatment'). Colon transit studies using Sitz markers or radioisotopes can help evaluate oro-anal transit and colon manometry studies can identify regional or pancolonic dysmotility. Slow transit or regional and pancolonic dysmotility have been associated with chronic refractory symptoms.
Specific interventions for selected patients
●Biofeedback therapy – For the subset of patients with dyssynergic defecation, biofeedback therapy is occasionally added as an adjunct to medical and behavioral therapy. However, it requires a highly motivated patient and its efficacy in the pediatric age group is uncertain. Because biofeedback requires serial learning sessions with an anal probe and exercises, it is only practical for use in highly motivated older children and adolescents. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Dyssynergic defecation'.)
For children with constipation but without dyssynergic defecation, there is no evidence that biofeedback has benefits over laxatives alone [87-89].
●Anal sphincter release – Some children with constipation refractory to medical therapy may respond to an intervention to release the IAS through injection of botulinum toxin or myectomy. The effect of the botulinum toxin treatment is temporary (lasting up to several months). For patients who respond to initial treatments, additional injections may be given every few months, as needed, to maintain efficacy over the long term. Limited information is available to guide selection of patients for surgical approaches [90]. These interventions are effective for patients with IAS achalasia, which is characterized by absence of the rectoanal inhibitory reflex on anorectal manometry (with exclusion of Hirschsprung disease by rectal suction biopsy). Interestingly, these interventions also tend to be effective for patients with refractory idiopathic chronic constipation (ie, with no apparent IAS dysfunction) [91]. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Internal anal sphincter achalasia'.)
●Other surgical interventions – The rare patient with intractable constipation and normal anorectal manometry (or one who fails to respond to botulinum toxin injection) may be considered for sacral nerve stimulation or for other surgical approaches:
•Sacral nerve stimulation appears to be a promising new treatment option for children with chronic constipation, especially those who are unresponsive to intensive medical management [92]. Since it also helps to improve urinary incontinence, this treatment may be especially suited to patients with combined fecal and urinary incontinence. Larger randomized studies with long-term follow-up are required. The experience with sacral nerve stimulation in adults is described separately. (See "Fecal incontinence in adults: Management", section on 'Sacral nerve stimulation'.)
•Other surgical procedures include antegrade continence enema (ACE) [93-98], intestinal diversion (ileostomy or colostomy) [93,99], or colonic resection [93,100,101], as summarized in a systematic review [90]. ACE provides a conduit for daily colonic irrigation and is also used for patients with myelomeningocele and bowel dysfunction. (See "Myelomeningocele (spina bifida): Management and outcome", section on 'Bowel management'.)
A retrospective series of 44 patients reported the following outcomes of surgical interventions [93]:
-ACE was performed in 16 patients and had a satisfactory outcome in 10 (63 percent). These patients generally required ongoing ACE treatment throughout the follow-up period but displayed some improvement in colonic motility after one year of treatment.
-Diversion procedures (with ileostomy or colostomy) were performed in 19 patients and had satisfactory outcomes in 18 (95 percent); intestinal continuity was reestablished in 14 (74 percent) at a mean of 27 months post-diversion. Those with colonic dysmotility as documented by manometry underwent resection of the dysfunctional segment at the time of reanastomosis.
-Colonic resection was performed in nine patients and yielded satisfactory outcome in only two (22 percent), either because of persistent constipation or fecal incontinence. Four of the nine patients (44 percent) required a second surgical procedure. Somewhat better outcomes were reported in a separate systematic review [90].
Based on this and other anecdotal reports, we feel that colonic resection should not be offered as a treatment for refractory constipation. Rarely, ACE procedures and diversion via colostomy or ileostomy with subsequent resection and reanastomosis may be appropriate. A systematic review provides a summary of studies using these techniques, concluding that there is insufficient evidence to support one technique over the others [90].
PROGNOSIS — Improvement can be expected in virtually all patients who adhere to the type of comprehensive approach described above [17,19,64,102,103]. On the other hand, complete recovery (defined as three or more bowel movements weekly with no fecal incontinence while off of laxatives) is seen less often [19,20,22,104]. A systematic review was unable to identify factors that predict which patients would fail to respond to treatment [105].
Recovery rates increase significantly over time: approximately 30 to 50 percent after one year and 48 to 75 percent after five years [19,22,103,106]. Recovery rates are higher in populations in primary care practices, presumably because this population includes children with less severe or refractory constipation as compared with children referred for specialty care [4].
Most children with functional constipation who are adequately treated during childhood will have good clinical outcomes in adulthood. In a study of 401 children treated with a six- to eight-week treatment protocol in the Netherlands and followed for a median of 11 years, 75 percent had no symptoms as adults [107]. Risk factors for lack of long-term recovery included older age at onset, longer delay before referral to a pediatric gastroenterologist, and fewer bowel movements per week at presentation.
DETAILS ON MEDICATIONS
Polyethylene glycol — Polyethylene glycol 3350 (polyethylene glycol without electrolytes, eg, Miralax, Glycolax, or Restoralax) is an osmotic laxative. Because it is more palatable and has fewer adverse effects than other agents, polyethylene glycol 3350 is preferred by most experts for disimpaction and treatment of chronic constipation, although it is not labeled for this use [7]. It is approved for short-term management of constipation in adults and is available without prescription in the United States.
●Dosing – The typical dose of polyethylene glycol 3350 is 0.4 to 0.8 g/kg/day (up to 17 g) (table 2) [108-111]. One capful (17 g) should be mixed with 8 oz of water, juice, or soda (and not milk) and taken within 30 minutes. The osmotic effect is substantially diminished if the dose is spread out over a longer time (eg, taken in sips throughout the day). For optimal adherence, we generally advise the parents or caregiver not to have the child take the dose at school.
In a dose-ranging trial, the dose of 0.4 g/kg/day was most likely to give high success rates (74 percent), while generating fewer complaints of abdominal pain or fecal incontinence than higher doses [112]. The effective dose in an individual patient is not predictable, and many patients require relatively high initial treatment doses with somewhat lower maintenance doses. Therefore, we suggest an empiric approach to dosing. In our practice, we use an initial dose of 4 tsp (17 g = approximately 4.5 tsp) for patients weighing 20 kg or more, increasing or decreasing by 0.5 tsp to 1 tsp every other day until the consistency of the stools is soft to loose. We have rarely had to use more than 6 to 7 tsp per day. For patients weighing less than 20 kg, it is reasonable to use a slightly lower initial dose (0.4 to 0.8 g/kg/day), with dose adjustments up or down to achieve soft stools. Further dose-ranging trials are needed to determine optimal dosing, especially in children requiring long-term polyethylene glycol treatment [40].
●Adverse effects – Adverse effects of polyethylene glycol include diarrhea (10 percent), bloating or flatulence (6 percent), and abdominal pain (2 percent) [110]. These symptoms tend to be mild, transient, and responsive to dose reduction [33]. Short- and long-term studies revealed no significant changes in serum electrolytes or other laboratory tests during treatment with polyethylene glycol [9,113]. Theoretical concerns have been raised as to whether polyethylene glycol might cause neuropsychiatric effects, eg, due to neurotoxic effects of ethylene glycol, a polyethylene glycol metabolite. To investigate this possibility, one study measured serum concentrations of polyethylene glycol metabolites after an oral dose of PEG and found that serum concentrations of ethylene glycol and one other polyethylene glycol metabolite increase transiently, peaking 90 minutes after the dose of polyethylene glycol but remaining well below the threshold for toxicity, then returning to levels that are found in controls [114]. The total dose of ethylene glycol ingested with chronic use of polyethylene glycol is estimated to be less than 1/15th of the amount allowed by the Environmental Protection Agency in drinking water. Thus, neurotoxicity is very unlikely with acute or chronic use of polyethylene glycol. Behavioral symptoms that are occasionally reported in children during polyethylene glycol treatment are more likely related to the known association of constipation with comorbid neuropsychiatric conditions [115]. The North American Society For Pediatric Gastroenterology, Hepatology and Nutrition has published a statement with frequently asked questions about the use of polyethylene glycol in children [116].
●Efficacy – Clinical trials indicate that polyethylene glycol 3350 (without electrolytes) has similar or greater efficacy than that of lactulose and magnesium hydroxide, with fewer adverse effects and greater acceptance [113,117-120]. In particular, a systematic review concluded that polyethylene glycol is superior to either lactulose or milk of magnesia for outcomes of higher frequency of bowel movements and reduced need for additional therapy, although the difference was small and the quality of the evidence was weak [40]. Patients tolerated polyethylene glycol as well or better than the other therapies, suggesting the possibility that polyethylene glycol is associated with improved treatment adherence (eg, 95 versus 65 percent in one study) [118].
●Alternate formulations – Oral preparations of polyethylene glycol with electrolytes (Transipeg, Movicol, Movicolon) are available outside of the United States. The addition of electrolytes offers the theoretical benefit of avoiding electrolyte depletion, but this also alters the taste, which may decrease palatability. One trial from the Netherlands compared the efficacy of polyethylene glycol with electrolytes (Transipeg) to lactulose in 100 children with functional constipation [121]. Compared with the pretreatment period, defecation frequency increased, and episodes of fecal incontinence decreased in both groups after eight weeks of therapy. However, success (defined as ≥3 bowel movements per week and ≤1 episode of fecal incontinence every two weeks) occurred more frequently in the polyethylene glycol group (56 versus 29 percent). Children in the polyethylene glycol group reported less abdominal pain, straining, and pain at defecation but complained of bad taste more often than did those in the lactulose group. Similar results were reported in a smaller study [117].
Other laxatives — Several other types of laxatives may be appropriate and useful:
●Mineral oil – Mineral oil is a lubricant laxative that was often used in the past for chronic constipation and fecal incontinence. It has largely been replaced by osmotic laxatives, which appear safer and at least as effective as mineral oil, as well as more palatable and easier to administer.
•Cautions and adverse effects – Mineral oil can cause a dangerous lipoid pneumonia if aspirated [122,123]. Therefore, it should not be used in patients at risk for aspiration, including infants (<12 months of age), children with neurodevelopmental abnormalities, or those with gastroesophageal reflux. For the same reason, it should not be used if it causes nausea or vomiting, even in otherwise healthy children. There is a theoretic concern that chronic use of mineral oil may interfere with the absorption of fat-soluble vitamins, but any effects are probably clinically insignificant. In addition, this effect can be minimized by administering it in the mid-afternoon and at bedtime and/or by prescribing a daily multivitamin [13,68,124,125].
•Administration – Typical doses of mineral oil are 1 to 2 mL/kg/day, once or in divided doses (maximum 45 mL/day), with dose adjustment to achieve soft stools (table 2). Mineral oil, particularly in large amounts, may not be palatable in children. It may be more palatable if served chilled and mixed in a 1:1 ratio with a fat-containing food that the child likes (eg, pudding, yogurt, chocolate syrup) [13]. Families should be warned about the possibility of anal leakage of mineral oil, which may stain clothing or furniture. If anal leakage of oil occurs, this usually indicates either a need for disimpaction or that the dose of mineral oil is excessive.
•Efficacy – In one randomized trial in 37 children (3 to 13 years old) with chronic functional constipation, mineral oil compared favorably to senna concentrate (a stimulant laxative) in symptom control, frequency of recurrence, and duration of therapy [126].
●Magnesium hydroxide – Magnesium hydroxide (milk of magnesia) is an osmotic laxative that has a long history of success but has been largely replaced by polyethylene glycol 3350 because of palatability and, possibly, lower efficacy [40]. It releases cholecystokinin, which stimulates gastrointestinal motility and secretion. Magnesium hydroxide should be avoided in infants or patients with renal insufficiency since they are susceptible to hypermagnesemia [127-130]. Typical doses are 1 to 2 mL/kg once daily (of 400 mg/5 mL solution) (table 2).
●Lactulose – Lactulose is an osmotic laxative and is usually well tolerated in the long-term [7]. Lactulose is not absorbed by the small intestine. Some patients report loss of effectiveness over time, presumably due to enhanced degradation by the colonic bacteria. Side effects include flatulence and abdominal cramps, which occur when the sugar is metabolized by colonic flora. Typical doses are 1 mL/kg (up to 30 mL) once or twice daily (table 2).
●Stimulant laxatives – Stimulant laxatives, such as senna and bisacodyl, are sometimes used for brief periods to avoid recurrence of impaction ("rescue" therapy), and their use for this purpose is supported by extensive clinical experience and expert guidelines [7], although controlled trials on the use of these agents for constipation in children are lacking [131]. Traditionally, concerns were raised about the possible development of tolerance or physical dependence with chronic use of stimulant laxatives. The issue has not been systematically studied in humans, but it appears that most patients remain responsive to these drugs with chronic use [60]. Nonetheless, most pediatric providers reserve stimulant laxatives for patients with severe constipation who do not respond to osmotic laxatives and dietary changes, preferably under supervision from a pediatric gastroenterologist [132]. These laxatives are often used in conjunction with stool softeners such as docusate (Colace) or in addition to osmotic agents such as polyethylene glycol 3350. Stimulant laxatives also may be helpful for patients with anorectal malformations or other disorders that affect anorectal innervation, which can affect sensory and motor function and predispose to both constipation and fecal incontinence [133].
●Newer pharmacologic agents – Newer drugs that are used for adults with chronic idiopathic constipation include the secretory agents linaclotide (Linzess), a guanylate cyclase receptor agonist, and lubiprostone (Amitiza), a chloride channel activator. In a randomized trial in 606 pediatric patients with chronic functional constipation, lubiprostone was not more effective than placebo, although it was generally well tolerated [134]. These drugs are approved in the United States for chronic constipation in adults but are second-line agents (bulk-forming and osmotic laxatives are preferred). Prucalopride (Motegrity, Resotran, Resolor), a serotonin receptor agonist that enhances bowel motility, is also a second-line agent approved for use in adults. Although clinical trials have suggested that prucalopride is efficacious in adults, a large randomized study in children found no efficacy compared with placebo [135]. These findings do not exclude the possibility that prucalopride may be effective for subsets of children, such as those who are older (≥12 years of age) or perhaps those who have slow-transit constipation [136]. (See "Management of chronic constipation in adults", section on 'Pharmacologic therapy'.)
Probiotics — We do not routinely recommend probiotics for treatment of constipation in children, because the available evidence from controlled trials in children and adults is insufficient to determine efficacy or to identify the most effective strain, dose, or treatment duration [7,137-139]. On the other hand, standard probiotic preparations are probably safe, provided that the child is not immunosuppressed.
The hypothesis that probiotics may have therapeutic potential for the treatment of constipation is supported by data demonstrating differences in the intestinal microbiota between healthy individuals and patients with chronic constipation [140]. Administration of Bifidobacterium or Lactobacillus has also been shown to improve colonic transit times in constipated patients [141,142]. Only a few clinical trials in children have addressed the use of probiotics for constipation, with mixed results [143-146]. The experience with probiotics for constipation in adults is discussed separately. (See "Probiotics for gastrointestinal diseases", section on 'Constipation'.)
INDICATIONS FOR REFERRAL — Consultation with a pediatric gastroenterologist should be considered in children in whom oral or rectal medications are ineffective for disimpaction and in whom dietary changes and laxative therapy are ineffective for maintenance therapy [7]. Additional evaluation before or after consultation should include thyroxine (T4), thyroid-stimulating hormone (TSH), calcium, celiac disease antibodies, and lead. For children with atypical features or constipation that is refractory to optimal medical and behavioral therapy, diagnostic testing may include tests of colonic transit and anorectal and colonic manometry. (See 'Further evaluation' above and "Constipation in infants and children: Evaluation".)
TREATMENT OF NONRETENTIVE FECAL INCONTINENCE — Nonretentive fecal incontinence is the term used to describe fecal incontinence that occurs in the absence of constipation or other organic disease. Children with this disorder usually have full bowel movements in their clothing rather than just minor episodes of fecal incontinence. Treatment typically involves behavior modification and sometimes dietary changes, without laxative therapy [13].
It is important to distinguish this disorder from constipation-associated fecal incontinence, which is far more common (in children with fecal incontinence, 80 percent have associated constipation). Children with fecal incontinence should have a careful evaluation for underlying constipation, including a digital rectal examination and, in some cases, a colonic transit study using radiopaque markers, because constipation is not always recognized by the child or caregiver. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation", section on 'Further evaluation'.)
No widely effective treatments have been established for nonretentive fecal incontinence, but most approaches focus on behavior modification and psychosocial evaluation and support [23]. The behavioral protocol generally includes a highly structured toilet training protocol designed to encourage frequent and sustained efforts at defecation and supported by behavior modification techniques, including a reward system. Laxatives, enemas, and biofeedback are not helpful in these children (provided that occult constipation has been carefully excluded) [89,147,148]. In our practice, we find that many of these children benefit from referral to a therapist for behavioral intervention and support.
Only one study has reported long-term outcomes in patients with nonretentive fecal incontinence, and this suggested very slow resolution of the problem [149]. Among children who had intensive medical and behavioral treatment for two years, only 29 percent had resolved after two years of treatment, 65 percent after five years, and approximately 90 percent after 10 years.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Constipation".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Constipation in children (The Basics)" and "Patient education: Fecal incontinence in children (The Basics)")
●Beyond the Basics topic (see "Patient education: Constipation in infants and children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Infants – Treatment of infants may include osmotically active carbohydrates such as sorbitol-containing juices (eg, apple, prune, or pear), with osmotic laxatives and/or occasional glycerin suppositories, if necessary. Glycerin suppositories should be used with caution because they can cause anal irritation. Mineral oil, enemas, and stimulant laxatives should not be used in infants, due to safety concerns. (See 'Treatment of constipation in infants' above.)
●Functional constipation with or without fecal incontinence
•General strategy – Treatment of constipation in children typically includes four general steps for bowel retraining. It is essential to educate and engage parents or caregivers in each of these steps, including the need for prolonged therapy to "retrain" the bowel (figure 1). Improvement can be expected in the majority of such patients, although it may be gradual (see 'General approach and goals' above and 'Parental education' above):
-Disimpaction (for children with a large stool mass or fecal incontinence)
-Prolonged laxative treatment and behavior therapy to achieve regular evacuation and avoid recurrent constipation
-Dietary changes (primarily increasing fiber content) to maintain soft stools
-Gradual tapering and withdrawal of laxatives as tolerated
•Disimpaction – Disimpaction can be accomplished with oral medications, rectal medications, or a combination (table 3). We suggest using oral rather than rectal medications for most children and particularly in those with a history of painful defecation or perineal trauma (Grade 2C). Enemas or brief hospitalization for disimpaction may be necessary for children with severe constipation or when rapid disimpaction is desired. (See 'Disimpaction (for select children)' above.)
•Bowel retraining – After disimpaction, we suggest treating children with chronic constipation (with or without fecal incontinence) with a combination of daily laxatives and behavior modification, rather than either therapy alone (Grade 2B).
-Laxative therapy – The choice of laxative is less important than using an adequate dose and assuring compliance. The dose should be based upon the child's age, body weight, and severity of constipation (table 2), titrated to achieve approximately one soft, normal-caliber stool daily. An example of a typical maintenance regimen is outlined in the table (table 4). (See 'Maintenance laxative therapy' above.)
We suggest use of polyethylene glycol 3350 as the initial choice for maintenance therapy rather than other laxatives (Grade 2C). This drug is safe, effective, and usually better accepted by children than other laxatives. High doses of polyethylene glycol also may be effective for initial disimpaction of children with mild to moderate constipation. (See 'Polyethylene glycol' above and 'Disimpaction (for select children)' above.)
-Behavior therapy – Include a behavior modification plan to support regular toileting habits and encourage a child's cooperation. Components include toilet sitting after meals under the supervision and encouragement of a caregiver, proper positioning on the toilet (figure 2), a reward system to enhance the child's cooperation, and keeping a record of stooling (figure 3A). (See 'Behavior modification' above.)
-Rescue plan – Arrange a "rescue" plan if the child goes more than three days without passing stool or has other indications of recurrence (ie, hard stools, abdominal pain, smears in the underwear). The rescue plan may involve temporary escalation of the osmotic laxative dose or administration of a stimulant laxative, enema, or suppository. After successful rescue therapy, continue treatment with the maintenance osmotic laxative but at a higher dose. (See 'Management of relapses' above.)
-Follow up – Arrange regular and frequent follow-up to reinforce the need for continuation of laxative therapy, toilet sitting, and dietary changes. Titrate the laxative dose as needed and review the rescue plan. (See 'Monitoring and follow-up' above and 'Management of relapses' above.)
•Tapering laxatives – Once the child has achieved regular bowel habits, reduce the frequency of toilet sitting and laxative use. We typically wait until optimal bowel habits are achieved and stable for at least six months before laxative use is further decreased. Some children require ongoing laxative treatment for one or more years. Maintaining behavioral and dietary interventions is particularly important as laxative therapy is discontinued. (See 'Tapering laxative therapy' above.)
●Nonretentive fecal incontinence – Treatment of children with functional nonretentive fecal incontinence (fecal incontinence without evidence of constipation) includes similar behavioral interventions, without laxatives. This disorder is far less common and must be distinguished from constipation-associated fecal incontinence. Children with fecal incontinence should have a careful evaluation for underlying constipation, including a digital rectal examination, because constipation is not always recognized by the child or caregiver. (See 'Treatment of nonretentive fecal incontinence' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges George Ferry, MD, who contributed to earlier versions of this topic review.
