Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

no impaction: <1 year of age

1st line – dietary modification

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ACUTE
|
no impaction: <1 year of age
1st line – 

dietary modification

Dietary changes remain a common initial recommendation as low fluid and fiber intake often contribute to the development of constipation.[13] Fluid and fiber intake should not be increased above daily recommendations as there is no evidence to suggest that this improves constipation.[13]​​[43]​​​​

Prune or pear juice may be given to infants to increase stool water content and frequency. For infants younger than 6 months, 1-3 mL of juice per kg diluted with 30-60 mL of water may be an appropriate dose.[13]

Plus – osmotic laxative

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ACUTE
|
no impaction: <1 year of age
Plus – 

osmotic laxative

Treatment recommended for ALL patients in selected patient group

Softening the stool with osmotic agents is often needed.

Response to lactulose may take 24 to 48 hours.

Following resolution of acute constipation, children should maintain dietary improvements and osmotic laxatives (e.g., lactulose) to establish normal bowel habits. Generally, osmotic laxative maintenance therapy is recommended for at least 1 month after a good response to treatment.[13]

Primary options

lactulose: 1 mL/kg orally once or twice daily

More

no impaction: ≥1 year of age

1st line – dietary and behavior modification

Back
ACUTE
|
no impaction: ≥1 year of age
1st line – 

dietary and behavior modification

Dietary changes remain a common initial recommendation as low fluid and fiber intake often contribute to the development of constipation.[13] Recommended daily fluid intake is around 4 cups per day for 1 to 3 year olds, 5 cups for 4 to 8 year olds, and 7 to 8 cups for older children.[13] Adding 5 g to the child's age in years can be used to calculate recommended daily fiber intake.​​[13] ​Fluid and fiber intake should not be increased above daily recommendations as there is no evidence to suggest that this improves constipation.[13][43]​​​​

Regular toilet habits and behavior modification (unhurried time on the toilet after meals, relaxation techniques, a reward system linked with successful toilet usage, and a diary of stool frequency) are recommended.[13]

The anxiety of both parent and child should be addressed. The child may be fearful of painful defecation, and parents need to understand that forcing toilet training in this situation will be ineffective. In older children, fecal incontinence and its social consequences need a nonaccusatory, sympathetic management approach. It may be necessary to repeat the education several times during treatment.

Encouraging more exercise and physical activity may be appropriate in older children, as well as pelvic physical therapy and biofeedback, which has been long used and proven in adults.[51]

Plus – osmotic laxative or fecal softener

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ACUTE
|
no impaction: ≥1 year of age
Plus – 

osmotic laxative or fecal softener

Treatment recommended for ALL patients in selected patient group

Softening the stool with osmotic agents is often needed. Response to lactulose may take 24 to 48 hours, while response to polyethylene glycol (PEG) usually takes 1 to 2 hours.

There is evidence that PEG is more effective than lactulose in the treatment of chronic constipation in terms of stool frequency per week, form of stool, and relief of abdominal pain.[44][45][46][47] PEG has also been shown to be superior to other osmotic agents with regard to taste and patient acceptance.[48]

Following resolution of acute constipation, children should maintain dietary improvements, behavioral modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency), and osmotic laxatives (e.g., lactulose, PEG 3350 electrolyte solutions) or stool softeners (e.g., docusate sodium or mineral oil [suitable for children ≥5 years old]) to establish normal bowel habits. Generally, osmotic laxative maintenance therapy is recommended for at least 1 month after a good response to treatment.[13]​ PEG appears to be a safe medication; however, there have been no long-term studies completed in children.[48]

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

OR

lactulose: 1 mL/kg orally once or twice daily

More

OR

docusate sodium: children <3 years of age: 10-40 mg/day orally given in 1-4 divided doses; children 3-6 years of age: 20-60 mg/day orally given in 1-4 divided doses; children >6 years of age: 40-150 mg/day orally given in 1-4 divided doses

OR

mineral oil: children 5-11 years of age: 5-15 mL orally once daily when required; children >12 years of age: 15-45 mL orally once daily when required

Consider – stimulant laxative

Back
ACUTE
|
no impaction: ≥1 year of age
Consider – 

stimulant laxative

Treatment recommended for SOME patients in selected patient group

Some children may require the short-term addition of a stimulant laxative (e.g., senna) to achieve regular bowel movements.

Primary options

sennosides: children 2-6 years of age: 0.5 to 1 tablet orally once daily when required; children 6-12 years of age: 1-2 tablets orally once daily when required

Plus – fecal softener or stimulant laxative

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ACUTE
|
no impaction: ≥1 year of age
|
withholding behavior
Plus – 

fecal softener or stimulant laxative

Treatment recommended for ALL patients in selected patient group

Withholding behavior is an active behavior resulting from a contraction of pelvic floor muscles that reduces the likelihood of defecation. Usually affects children between 1 and 5 years old.

These children may require the addition of a stool softener (e.g., polyethylene glycol) or short-term stimulant laxative (e.g., senna) to achieve regular bowel movements.

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

OR

sennosides: children 2-6 years of age: 0.5 to 1 tablet orally once daily when required

with impaction: <1 year of age

1st line – osmotic laxative

Back
ACUTE
|
with impaction: <1 year of age
1st line – 

osmotic laxative

Fecal impaction is the retention of feces, usually palpable per abdomen, to a degree where spontaneous evacuation is unlikely.[42]

These children may require an osmotic laxative (e.g., lactulose) to achieve regular bowel movements.

Response to lactulose may take 24 to 48 hours.

Primary options

lactulose: 1 mL/kg orally once or twice daily

More

Plus – dietary modification

Back
ACUTE
|
with impaction: <1 year of age
Plus – 

dietary modification

Treatment recommended for ALL patients in selected patient group

Dietary changes remain a common initial recommendation as low fluid and fiber intake often contribute to the development of constipation.[13] Fluid and fiber intake should not be increased above daily recommendations as there is no evidence to suggest that this improves constipation.[13][43]​​​​​

Following resolution of acute constipation, children should maintain dietary improvements and osmotic laxatives (e.g., lactulose) to establish normal bowel habits. Generally, it is necessary to maintain medication until the child has achieved regular bowel movements without difficulty.

with impaction: 1-3 years of age

1st line – osmotic laxative

Back
ACUTE
|
with impaction: 1-3 years of age
1st line – 

osmotic laxative

Fecal impaction is the retention of feces, usually palpable per abdomen, to a degree where spontaneous evacuation is unlikely.[42]

These children may require an osmotic laxative to achieve regular bowel movements.

Osmotic laxatives, such as polyethylene glycol (PEG) 3350 electrolyte solutions, have been shown to be effective.[50]

Other oral medications for initial disimpaction include lactulose and glycerin. PEG appears to be a safe medication; however, there have been no long-term studies completed in children. There is consistent evidence that PEG is superior to lactulose with regard to rates of clinical remission, improvement in symptoms, and patient tolerance.[45][46][47][48]

All treatments are likely to increase the degree of fecal incontinence at first as the stools are loosened.

Softer stools are more difficult for children to withhold, and so their behavior may deteriorate during the period of disimpaction if they are actively withholding.

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

OR

lactulose: 1 mL/kg orally once or twice daily

More

OR

glycerin rectal: 1 infant suppository inserted into rectum once or twice daily when required

Plus – dietary and behavior modification

Back
ACUTE
|
with impaction: 1-3 years of age
Plus – 

dietary and behavior modification

Treatment recommended for ALL patients in selected patient group

Dietary changes remain a common initial recommendation as low fluid and fiber intake often contribute to the development of constipation.[13] Recommended daily fluid intake is around 4 cups per day for 1 to 3 year olds.​[13] Adding 5 g to the child's age in years can be used to calculate recommended daily fiber intake.[13] Fluid and fiber intake should not be increased above daily recommendations as there is no evidence to suggest that this improves constipation.[13][43]​​​​​ Regular toilet habits and behavior modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency) are recommended.[13]​ 

The anxiety of both parent and child should be addressed. The child may be fearful of painful defecation, and parents need to understand that forcing toilet training in this situation will be ineffective.

Consider – fecal softener

Back
ACUTE
|
with impaction: 1-3 years of age
Consider – 

fecal softener

Treatment recommended for SOME patients in selected patient group

In addition to maintaining dietary improvements, behavioral modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency), and osmotic laxatives (e.g., lactulose, polyethylene glycol 3350 electrolyte solutions) following resolution of acute impaction, these children may require the addition of a fecal softener (e.g., docusate sodium) to establish normal bowel habits. Generally, it is necessary to maintain medication until the child has achieved regular bowel movements without difficulty.

Primary options

docusate sodium: children <3 years of age: 10-40 mg/day orally given in 1-4 divided doses; children 3-6 years of age: 20-60 mg/day orally given in 1-4 divided doses

with impaction: ≥4 years of age

1st line – osmotic laxative

Back
ACUTE
|
with impaction: ≥4 years of age
1st line – 

osmotic laxative

Fecal impaction is the retention of feces, usually palpable per abdomen, to a degree where spontaneous evacuation is unlikely.[42]

These children may require an osmotic laxative to achieve regular bowel movements.

Osmotic laxatives, such as polyethylene glycol (PEG) 3350 electrolyte solutions, have been shown to be effective.[50]

Other oral medications for initial disimpaction include lactulose, glycerin, and magnesium salts such as magnesium citrate. PEG appears to be a safe medication; however, there have been no long-term studies completed in children. There is consistent evidence that PEG is superior to lactulose with regard to rates of clinical remission, improvement in symptoms, and patient tolerance.[45][46][47][48]

All treatments are likely to increase the degree of fecal incontinence at first as the stools are loosened.

Softer stools are more difficult for children to withhold, and so their behavior may deteriorate during the period of disimpaction if they are actively withholding.

Primary options

polyethylene glycol/electrolytes: consult product literature for guidance on dose

OR

lactulose: 1 mL/kg orally once or twice daily

More

OR

glycerin rectal: 1 infant suppository inserted into rectum once or twice daily when required

OR

magnesium citrate: children 4-5 years of age: 60-120 mL orally as a single dose (or in divided doses); children 6-12 years of age: 100-150 mL orally as a single dose (or in divided doses); children ≥12 years of age: 150-300 mL orally as a single dose (or in divided doses)

Plus – dietary and behavior modification

Back
ACUTE
|
with impaction: ≥4 years of age
Plus – 

dietary and behavior modification

Treatment recommended for ALL patients in selected patient group

Dietary changes remain a common initial recommendation as low fluid and fiber intake often contribute to the development of constipation.[13] Recommended daily fluid intake is around 5 cups for 4 to 8 year olds and 7 to 8 cups for older children.​[13] Adding 5 g to the child's age in years can be used to calculate recommended daily fiber intake.[13] Fluid and fiber intake should not be increased above daily recommendations as there is no evidence to suggest that this improves constipation.[13]​​​[43]​​​​

Regular toilet habits and behavior modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency) are recommended.[13]

The anxiety of both parent and child should be addressed. The child may be fearful of painful defecation, and parents need to understand that forcing toilet training in this situation will be ineffective. In older children, fecal incontinence and its social consequences need a nonaccusatory, sympathetic management approach. It may be necessary to repeat the education several times during treatment.

Encouraging more exercise and physical activity may be appropriate in older children, as well as pelvic physical therapy and biofeedback, which has been long used and proven in adults.[51]

Consider – stimulant laxative

Back
ACUTE
|
with impaction: ≥4 years of age
Consider – 

stimulant laxative

Treatment recommended for SOME patients in selected patient group

These children may require the short-term addition of a stimulant laxative (e.g., senna, particularly for children ≤12 years of age, or bisacodyl for children >12 years of age) to achieve regular bowel movements.

Primary options

sennosides: children 2-6 years of age: 0.5 to 1 tablet orally once daily when required; children 6-12 years of age: 1-2 tablets orally once daily when required; children >12 years of age: 1-2 tablets orally twice daily

OR

bisacodyl: children >12 years of age: 10-15 mg orally once daily at night

OR

bisacodyl rectal: children >12 years of age: 10-15 mg once daily at night

Consider – phosphate enema

Back
ACUTE
|
with impaction: ≥4 years of age
Consider – 

phosphate enema

Treatment recommended for SOME patients in selected patient group

Older children may require a phosphate enema to clear the impacted rectum. This should be used only as a rescue measure.

The invasiveness and trauma of enemas may exacerbate the child's fear and intensify the psychological disturbance.

The US Food and Drug Administration warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over 55 years of age, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children ages 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.[54]

Primary options

sodium phosphate: consult product literature for guidance on dose

Consider – fecal softener

Back
ACUTE
|
with impaction: ≥4 years of age
Consider – 

fecal softener

Treatment recommended for SOME patients in selected patient group

In addition to maintaining dietary improvements, behavioral modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency), and osmotic laxatives (e.g., lactulose, polyethylene glycol 3350 electrolyte solutions) following resolution of acute impaction, these children may require the addition of a fecal softener (e.g., docusate sodium or mineral oil [also known as liquid paraffin, and suitable for children ≥5 years old]) to establish normal bowel habits. Generally, it is necessary to maintain medication until the child has achieved regular bowel movements without difficulty.

Primary options

docusate sodium: children 3-6 years of age: 20-60 mg/day orally given in 1-4 divided doses; children >6 years of age: 40-150 mg/day orally given in 1-4 divided doses

OR

mineral oil: children 5-11 years of age: 5-15 mL orally once daily when required; children >12 years of age: 15-45 mL orally once daily when required

2nd line – procedural intervention

Back
ACUTE
|
with impaction: ≥4 years of age
2nd line – 

procedural intervention

Children with longstanding constipation unresponsive to maximal medical management may be considered for procedural intervention. Procedural options include surgery via the Malone appendicostomy; or surgical, endoscopic, or radiologic placement of a cecostomy tube. These procedures allow the administration of antegrade cleansing solutions directly to the colon promoting regular evacuation of stool.[33] The use of antegrade continence enemas can be effective in improving incontinence. Evidence also supports an improvement in quality of life after such interventions.[52] Large-volume rectal irrigations using the Peristeen® device (which involves a balloon inflated in the rectum to generate pressure and hold the enema in the colon) have shown similar results to those achieved using anterograde enemas.​[53]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer