Functional constipation is a common pediatric condition characterized by infrequent, painful, or difficult defecation without an underlying organic cause. Management involves a combination of behavioral, dietary, and pharmacologic interventions.
1. Initial Assessment and Diagnosis
Before initiating treatment, rule out red flags that suggest organic causes (e.g., Hirschsprung disease, celiac disease, spinal dysraphism). Diagnosis is clinical, based on Rome IV criteria for functional constipation.
Red Flags Indicating Organic Causes:
- Delayed meconium passage (>48 hours)
- Failure to thrive
- Severe abdominal distension
- Bloody stools (without anal fissures)
- Neurological abnormalities
2. General Management Principles
The treatment approach consists of three key phases:
- Disimpaction (if stool retention is present)
- Maintenance Therapy (to prevent recurrence)
- Behavioral and Dietary Modifications (for long-term success)
3. Stepwise Management Approach
A. Disimpaction (If Fecal Impaction Is Present)
- Required in cases with palpable abdominal mass, rectal stool retention, or significant symptoms.
- Oral Therapy (Preferred in cooperative children):
- Polyethylene glycol (PEG) 1-1.5 g/kg/day for 3–6 days
- Lactulose (alternative) 1-3 mL/kg/day
- Rectal Therapy (If oral methods fail or rapid relief is needed):
- Glycerin suppository (infants)
- Bisacodyl suppository or phosphate enema (older children)
B. Maintenance Therapy (To Prevent Recurrence)
Laxatives (First-line treatment):
- Polyethylene glycol (PEG): 0.4-0.8 g/kg/day (adjust based on response)
- Lactulose: 1-2 mL/kg/day
- Milk of magnesia, Senna, or mineral oil (alternative options)
Duration: Minimum of 2 months; continue for at least 1 month after symptom resolution.
C. Behavioral and Dietary Modifications
✅ Toilet Training & Behavioral Therapy
- Encourage a toilet schedule (sit for 5-10 minutes after meals, twice daily).
- Use positive reinforcement (sticker charts, praise).
- Avoid punishment or pressure.
✅ Dietary Changes
- Fiber: Encourage intake of age + 5g/day (e.g., fruits, vegetables, whole grains).
- Fluids: Increase water intake (at least 1L/day for older children).
- Avoid excessive dairy (limit cow’s milk if excessive intake >500 mL/day).
✅ Physical Activity
- Encourage daily outdoor play and exercise to stimulate bowel motility.
4. Follow-Up & When to Refer
- Monitor for relapse (reduced stool frequency, pain, withholding behaviors).
- Gradually taper laxatives only after consistent normal stooling for 1–2 months.
- Refer to a pediatric gastroenterologist if:
- No response to standard therapy for 3-6 months.
- Suspicion of an underlying organic disorder.
- Severe fecal impaction requiring manual disimpaction.
Key Takeaways
🔹 Polyethylene glycol (PEG) is the first-line laxative.
🔹 Behavioral and dietary modifications are essential for long-term success.
🔹 Continue treatment for at least 2 months and taper slowly.
🔹 Early intervention prevents chronic constipation and complications.
