Pediatric constipation

Pediatric constipation is a condition in which a child has infrequent bowel movement, fewer than three in a week or bowel movements that are difficult or painful to pass. Constipation is a common concern among parents of small children. In fact, almost 5 percent of pediatrician visits are related to constipation and at least 25 percent of visits to pediatric gastroenterology specialists are due to problems with constipation.

Constipation may cause painful or incomplete bowel movements. If bowel movements are painful, a child may try to “hold” his or her stools. This makes constipation worse. In children who have constipation, formed, soft, or liquid stools can leak from the anus. This is the opening to the rectum. This is caused by a mass of stool stuck in the lower bowel. This happens because the amount of stool can become so large that it leaks out of the anus, causing soiling. These stools have a very bad smell.

Constipation may occur if your child is not eating enough high-fiber foods, drinking enough water, or getting enough exercise. In many children, a cause for constipation cannot be found. Painful bowel movements may cause a child to begin resisting the urge to have a bowel movement. Not having a bowel movement when the urge occurs can lead to constipation. Your child could be scared of being alone in the bathroom or scared of the toilet. Some children just don’t want to stop playing to go to the bathroom.

An illness that leads to poor food intake, physical inactivity, or fever can also result in constipation and stool soiling. This problem can remain even after the illness goes away.

Constipation symptoms include:

• Extreme straining during a bowel movement.
• Abdominal pain and bloating.
• Crankiness.
• Tiredness.
• Loss of appetite between bowel movements.
• Wetting during the day or night.
• Extreme reluctance to use the toilet.

If your child doesn’t have a bowel movement for 3 or 4 days in a row, see your child’s doctor. He or she will want to remove the stool that has collected in the lower bowel. Your doctor can do this in the office by giving your child an enema or a suppository. This is medicine that is inserted into the anus. Your doctor may have you give your child high doses of laxatives to remove the stool.

After the stool has been removed, it is important to be sure that your child can have bowel movements easily. Easy bowel movements will help prevent another large collection of stool. Treatment may include changing your child’s diet to include more fluids and fiber-rich foods, having your child sit on the toilet several times a day, and giving your child laxatives every day to help soften the stools.

Pediatric constipation that is prolonged and does not resolve with the usual therapeutic measures is called “intractable constipation.” It’s usually been present for many years and requires more comprehensive testing and therapy.

Figure 1. Constipation in infants younger than six months evaluation and management algorithm

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Figure 2. Constipation in children six months and older evaluation and management algorithm

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Pediatric constipation causes

In general, there is no specific abnormality associated with pediatric constipation. It can be triggered by changes occurring in your child’s life and may not be related to an underlying medical condition. There are probably some genetic factors since this problem often seems to run in families. Contributing causes may include:

• Unhealthy diet, full of high-fat, low-fiber foods and/or not enough liquids. Constipation can be due to a diet that doesn’t include enough water and fiber, both of which help the bowels move as they should. Children who eat lots of processed foods, cheeses, white bread and bagels, and meats may find they’re constipated often. A healthier diet that includes high-fiber foods (like fruits, vegetables, and whole grains) can keep the stool from getting hard and dry. Eating high-fiber foods, like fruits, vegetables, and whole-grain bread, can help prevent constipation. Fiber can’t be digested, so it helps clean out the intestines by moving the bowels along. A diet full of fatty, sugary, or starchy foods can slow the bowels down. To get more fiber in your diet, try fresh fruits like pears, apples (with the skin), oranges, and ripe bananas, or dried fruits like prunes. Other high-fiber foods include beans, oatmeal, whole-grain breads, and popcorn.
• Changes in diet, such as a switch from breast milk to formula or beginning to eat solid foods
• Lack of exercise or not enough exercise. Moving around helps food move through the digestive system. So not getting enough physical activity can contribute to constipation.
• Emotional issues related to using public bathrooms, toilet training or stress. Children can get constipated when they’re anxious about something, like a life change or a problem at home. Stress can affect how the digestive system works and can cause constipation, as well as other conditions, like diarrhea.
• Changes in bowel routines.
• Avoidance or ignoring the natural urge. Avoiding going to the bathroom, even when your child really have the urge to go, can cause constipation. When your child ignore the urge to go, it can be harder to go later on. Hard, dry stools can be painful to push out, and the child might avoid using the bathroom to avoid the discomfort. Eventually, the intestine will not be able to sense the presence of stool.

Medical conditions and problems that can cause constipation in children include the following:

• Hirschsprung’s disease (A condition that occurs when some of your baby’s intestinal nerve cells don’t develop properly, causing them to interfere with the movement of food and stools in the intestines.)
• Congenital abnormalities of the intestinal tract, rectum or anus, like imperforate anus
• Problems of the nervous system, such as cerebral palsy
• Endocrine problems, such as hypothyroidism
• Certain medications, such as iron preparations used to treat iron deficiencies, some antidepressants, ADHD medications and narcotics
• Underlying problems with the way the colon moves
• Neurologic problems associated with low muscle tone, or spinal cord injury or defect.

See your child’s doctor if your child continues to have problems or if the constipation lasts for 2 to 3 weeks.

Pediatric constipation prevention

Talk to your doctor or nurse to help you decide what would work best for your child. A good program for preventing constipation may require trying several approaches, time, and patience to find what works for your child. Keep in mind that each child’s bowel program is different. Try different methods until the successful one is found for your child.

• Get into the habit of going. If your child is toilet-trained, have him or her sit on the toilet for 5 to 10 minutes after breakfast and dinner. Eating stimulates the bowel to empty. But ignoring the body’s signals that it’s time to go can make it harder to go later on.
• If the child’s feet do not touch the floor when sitting on the toilet, put a box or stepstool under the feet so the knees are just a bit higher than the hips. This squat position helps in passing the stool. It also helps your child feel well supported so he or she can relax and not tighten muscles while balancing on the toilet.
• Praise your child for sitting the decided amount of time, even if he or she does not have a bowel movement. You may want to use a reward system, such as stickers.
• Clean the skin well after each bowel movement or accident. This prevents skin irritation. When the skin hurts, children may try to hold back the stool, making matters worse.
• Encourage active play and exercise; lack of activity tends to slow bowel function. Physical activity helps move food through the digestive system and nudges the bowels into action, so make sure your child get plenty of exercise. It can be as simple as playing catch, cycling, or shooting a few hoops.
• Set a regular meal schedule. Eating is a natural stimulant for the bowels, so regular meals may help you develop routine bowel habits. You might schedule breakfast a little earlier to give yourself a chance for a relaxed visit to the bathroom before school.

Toilet training

It’s possible that your child is going through “a phase.” Your child may not have the skills yet to use the toilet. Teach your child to know when it’s time to go to the toilet. Teach your child to tell you and not wait for you to ask. Young children should tell a parent before they use the bathroom, in case they need help.

If your child keeps soiling after about 3 months of being able to use the toilet to urinate, it’s time for him or her to learn to work on bowel movements. Here are some tips to toilet train your child for bowel movements:

1. Keep a toilet diary. This shows when, where and what kind of bowel movements your child has. It helps you and your doctor see patterns in your child’s bathroom habits. Try to keep a toilet diary for at least 1 week before going on to step 2. If your child is in day care, ask the teacher to help you track patterns in your child’s toileting. Below is a sample toilet diary you can print out and use at home or daycare.
2. Teach your child to sit on the toilet. Play in the bathroom with your child to teach him or her that the bathroom is not a bad place. Allow your child to sit on the toilet with pants on at first. It may be helpful to have a foot stool so your child can rest his or her feet. Allow your child to have his or her favorite books, dolls, or small toys in the bathroom. Read to, play with, and talk to your child when you’re in the bathroom together. Don’t expect or ask your child to have a bowel movement at first. Remember, he or she is still getting used to the idea of sitting on a toilet. Start with a very short amount of time (30 seconds). Slowly work up to 5 minutes. A kitchen timer can be the signal for the end of “bathroom fun.” Move to step 3 once your child is sitting on the toilet 3 to 5 times a day, for 5 minutes each time.
3. Make sure your child’s bowel movements are soft and well-formed. It helps if you give your child fewer dairy foods and more high-fiber foods. If your doctor approves, you may be able to give your child fiber supplements for a short time. Ask your family doctor about diet changes. At first, your child may have more soiling accidents. Have your child help clean the messes. Don’t yell or punish your child for soiling. Being angry with your child when he or she soils only makes toilet training harder. Stay calm when your child soils, so he or she won’t feel bad.
4. Have set times for sitting on the toilet. Once your child has healthy bowel movements and sits on the toilet, have him or her sit on the toilet at regular times during the day. Time them to start about 10 to 20 minutes after each meal and during times when your child usually has a bowel movement. You’ll be able to tell these times from the toileting diary. Your child should sit on the toilet at least 3 to 5 times per day, for about 5 minutes each time.
5. Reward bowel movements in the toilet. The first time your child has a bowel movement in the toilet, give him or her a reward. Good rewards include stars on a chart or fun activities. Give a reward after every bowel movement in the toilet. Later, give the reward after every few bowel movements. Pretty soon your child will be trained. Then you can stop giving rewards.

What your child should eat to prevent constipation

Encourage drinking lots of fluids (water and fruit juices, especially apple, pear, cherry, grape, or prune). Make sure your child is eating fruits, vegetables, and whole grain products each day, which help soften stools and make them easier to pass.

Add bran (wheat or corn) to the daily diet. It may be mixed in cereal, pancakes, hamburger, casseroles, or other foods, or be taken alone.

• Children younger than 6 years: 2 heaping teaspoons of bran each day
• Children 6 years or older: 3 heaping teaspoons of bran each day

Limit binding foods such as apples, bananas, rice, cooked carrots, cheese, and gelatin such as fruit snacks and Jell-O. Limit milk and dairy products (substitute with non-dairy and soy products) until constipation is gone. The lactose in milk products is binding to some children.

Pediatric constipation symptoms

While children may experience symptoms differently, constipation symptoms may include:

• not having a bowel movement for several days (only one in 3 to 7 days) or passing hard, dry stools
• abdominal bloating, cramps or pain
• decreased appetite
• clenching teeth, crossing legs, squeezing buttocks together or turning red in the face as your child tries to hold in a bowel movement to avoid discomfort
• pain when passing stools
• fecal incontinence, including small liquid or soft stool smears that soil your child’s underwear
• hard, pebbly, rock-like stools

Many children who have wetting problems also have constipation. Constipation can make the wetting problem worse because the bladder and the bowel are next to each other in the abdomen. When a child is constipated, the rectum may be quite full of hard stool. This can affect the bladder so it does not hold as much urine as it should. The pressure of the stool may cause pressure on the bladder making it feel like it should empty quickly. A bowel program needs to be used, along with a bladder retraining program to get successful bladder control.

Pediatric constipation diagnosis

A history and physical examination are usually sufficient to distinguish functional constipation from constipation caused by an organic condition ². A medical history should include the family’s definition of constipation and a careful review of the frequency, consistency, and size of stools; age at onset of symptoms; timing of meconium passage after birth; recent stressors; previous and active therapies; presence of withholding behaviors, pain, or bleeding with bowel movements; abdominal pain; fecal incontinence; and systemic symptoms (Table 1). The presence of withholding behaviors supports the diagnosis of functional constipation. Further evaluation may be warranted in children with red flags that might suggest an organic etiology (Table 2).

Table 1. Components of a medical history in the evaluation of childhood constipation

Components	Clinical significance
Frequency, consistency, and size of stools	Larger, hard stools may be a sign of withholding; normal bowel movement frequency associated with symptoms may indicate irritable bowel syndrome
Age of onset	Infants younger than one month with constipation have a relatively greater likelihood of an organic etiology
Pain or bleeding with passing stools	May suggest stools that are hard enough to produce fissures or that are associated with an allergy
Abdominal pain	It is important to see if pain is relieved or affected by defecation (may suggest irritable bowel syndrome); rule out other causes because abdominal pain is often misdiagnosed as being related to constipation
Timing of first bowel movement after birth	Lack of a bowel movement in first 48 hours suggests Hirschsprung disease
Fecal incontinence	Suggests fecal impaction
Withholding behaviors	Important contributor to constipation in younger children; behavior interventions may be beneficial
Systemic symptoms (e.g., fever, vomiting, weight loss, decreased appetite)	May indicate an organic etiology, such as Hirschsprung disease
Social history, including toilet training, stressors	May be associated with the onset of constipation
Review of current and previous therapies including diet, behavior, medications	It is important to ascertain how the patient has been treated previously and if medication dosages were appropriate
Assess adherence and effectiveness of previous and current treatments	It is important to understand factors that may influence the treatment outcome

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Table 2. Red Flags suggesting an organic cause of constipation in children

Red flags	Suggested diagnoses
Onset before one month of age	Congenital malformation of anorectum or spine, Hirschsprung disease, allergy, metabolic/endocrine condition
Delayed passage of meconium (more than 48 hours after birth)	Hirschsprung disease, cystic fibrosis, congenital malformation of anorectum or spine
Failure to thrive	Hirschsprung disease, malabsorption, cystic fibrosis, metabolic condition
Abdominal distension	Hirschsprung disease, impaction, neurenteric problem (e.g., pseudo-obstruction)
Intermittent diarrhea and explosive stools	Hirschsprung disease
Empty rectum	Hirschsprung disease
Tight anal sphincter	Hirschsprung disease, anorectal malformations
Pilonidal dimple covered by tuft of hair	Spinal cord abnormality
Midline pigmentary abnormalities of lower spine	Spinal cord abnormality
Abnormal neurologic examination (absent anal wink, absent cremasteric reflex, decreased lower extremity reflexes and/or tone)	Spinal cord abnormality
Occult blood in stool	Hirschsprung disease, allergy
Extraintestinal symptoms (vomiting, fever, ill-appearance)	Hirschsprung disease, neurenteric problem
Gushing of stool with rectal examination	Hirschsprung disease
No history of withholding or soiling	Hirschsprung disease, neurenteric problem, spinal cord abnormality
No response to conventional treatment	Hirschsprung disease, neurenteric problem, spinal cord abnormality

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Physical examination should include a review of growth parameters, an abdominal examination, an external examination of the perineum and perianal area, an evaluation of the thyroid and spine, and a neurologic evaluation for appropriate reflexes (cremasteric, anal wink, patellar). A digital examination of the anorectum is recommended to assess for perianal sensation, anal tone, rectum size, anal wink, and amount and consistency of stool in the rectum. However, in children with normal neonatal courses or clear withholding behaviors, or in whom trauma is suspected, the rectal examination may be deferred. A test for occult blood in the stool should be performed in all infants with constipation and in any child with constipation who has pain, failure to thrive, diarrhea, or a family history of colon cancer or polyps. The presence of a hard mass in the lower abdomen combined with a dilated rectum filled with hard stool indicates fecal impaction.

Most children with constipation do not need any specific testing. However, for children with constipation that does not resolve with dietary or therapeutic measures, more tests may be necessary to understand exactly how your child’s entire gastrointestinal system is working. These tests may include:

• Anorectal manometry: A test that measures rectal nerve reflexes.
• Colonic manometry: An advanced test that shows how the whole colon is moving.
• Colorectal transit study: This procedure uses X-rays to monitor the movement of markers through the intestine and colon.
• Barium enema: A procedure to examine the large intestine for abnormalities. A fluid called barium is instilled into the rectum as an enema. Barium is a chalky liquid that coats the inside of the organs so they show up clearly on an x-ray.
• Biopsy of the rectum or large intestine: Your child’s gastroenterologist take a sample of the tissues in your child’s rectum or large intestine for examination under the microscope.
• Colonoscopy: Your child’s gastroenterologist gently insert a long, flexible, lighted tube through the rectum and up into the colon to view the entire colon.
• MRI of the spine: A specialized scan to look at the nerves of the spine.

Pediatric constipation treatment

Once your clinician is able to determine the cause of your child’s constipation, treatment may include:

• changes in diet, habits or exercise
• specific medications, laxatives and stool softeners
• behavioral therapy
• surgical treatments (rarely needed)

Pediatric constipation remedies

You can usually treat pediatric constipation at home with high-fiber foods and lots of fluids. Do not use any suppositories, laxatives or enemas without first consulting your child’s doctor or nurse practitioner.

You’ll also need to base your treatment on your child’s age.

Babies under two months old generally do not have constipation. Talk to your child’s doctor before you make any changes to your baby’s milk or formula or give any medicine to treat constipation.

If your child is younger than 4 months old, try:

• 1 ounce (30 mL) of apple, pear or prune juice in 1 ounce (30 mL) of water, one or two times a day

If your child is 4 months to 1 year, try:

• High-fiber baby foods, such as cereals, fruits (especially prunes), vegetables, spinach and peas
• Prune juice

If your child is 1 year or older, try:

• Feeding him raw, unpeeled vegetables and fruits (peaches, apples and pears) at least three times a day. Some good examples are apples, apricots, beans, blueberries, brocolli, cabbage, cauliflower, dates, figs, lettuce, peas, pears, prunes and raisins. Avoid any foods that could cause choking in younger children.
• Increasing the bran in her diet by offering her graham crackers, bran cereal, oatmeal and whole-wheat bread. If your child is older than four years of age, popcorn is another great fiber source.
• Decreasing the amount of dairy products you give him
• Give your child plenty of fluids, especially water.
• Some foods are known to cause constipation. You may wish to limit them in your child’s diet. Examples include low-fibre foods such as white rice or bread, and junk food such as chips and pop. Filling up on too much dairy may also contribute to constipation.
• Having your child sit on the toilet for 10 minutes after meals, especially after breakfast, to encourage a regular bowel pattern. Even if there is no bowel movement, you are helping to set a pattern. You might find it helpful to use a calendar to reinforce the schedule. Younger children may like stickers they can put on a chart for sitting on the toilet after a meal. Your child should be comfortable, with the knees up. A foot rest can prevent your child’s legs from hanging down. It will also keep the knees bent, which helps bowel movements pass more easily. If you are having problems with toilet training and your child is holding back stool, you may need to delay toilet training until the constipation is successfully treated.
• Regular physical activity. Exercise or physical activity can help keep the bowels moving. Children ages one to four need 180 minutes (3 hours) regular physical activity each day. Children ages five or older need 60 minutes (1 hour) of physical activity.

Most of the time, home treatment will help. Diet changes are most successful when the entire family follows these healthy choices. If not, contact your pediatrician to develop a plan for your child.

See your child’s doctor immediately if your child is in severe pain or has blood in his stool. You should also talk to your child’s doctor if:

• Your child doesn’t have a bowel movement after five days.
• He develops any tears in the rectal area that don’t heal.
• She is soiling herself despite being toilet trained.

Pediatric constipation medication

Some children with constipation will not respond to diet and toilet routine changes alone and will need medicine. Talk to your child’s doctor about which of these methods to use and when and how to use them:

• Stool softener: Medicine that prevents hardening of stool. It can be taken on a regular basis. Your doctor can tell you which one and what dose is best for your child.
• Suppository: Medicine inserted into the rectum that stimulates the bowel and causes it to contract and push the stool out.
• Enema: A liquid is inserted into the intestine through the rectum to stimulate the bowel. Do not use enemas until you have talked to the doctor or nurse.

The most effective medicines for constipation are stool softeners. These work by drawing water into the bowel to ‘flush’ out the stool. The most commonly used medicine is polyethylene glycol (PEG 3350 or Miralax). Polyethylene glycol is safe for children and can be used long-term. Many brands are available without a prescription and it is tasteless when fully dissolved in a drink.

For children who are severely constipated, higher doses of medicines are often needed at first to clean out backed-up stool and provide relief from the pain linked to constipation. You can then adjust the dose so your child has at least one soft stool every day.

Avoid using suppositories or enemas when possible. Only use suppositories or enemas if your child’s doctor has suggested them.

Do not be afraid to give your child long-term medicine under your doctor’s supervision to help treat their constipation. The bowels do not become dependent on PEG 3350 and will not become lazy. Routine emptying of the bowel is important for overall bowel health.

Fecal impaction treatment

When fecal impaction is present, disimpaction with oral or rectal medication is required before initiation of maintenance therapy. Oral medications are less invasive but require more patient cooperation and may be slower to relieve symptoms. A number of therapies are available (Table 3) ². The advent of polyethylene glycol–based solutions (PEG 3350 or Miralax) has changed the initial approach to constipation in children because they are effective, easy to administer, noninvasive, and well tolerated ³. Rectal therapies and polyethylene glycol are similarly effective in the treatment of fecal impaction in children ⁴. Although some evidence supports polyethylene glycol as first-line treatment, the overall data do not clearly demonstrate superiority of one laxative ⁵.

Table 3. Therapies for fecal impaction in children

Therapy		Dosage
Oral
Osmotics
	Polyethylene glycol 3350 (Miralax)*	1.5 g per kg per day
	Polyethylene glycol solution (Golytely)*	25 mL per kg per hour via nasogastric lavage
	Magnesium citrate	< 6 years: 2 to 4 mL per kg per day
		6 to 12 years of age: 100 to 150 mL per day
		> 12 years: 150 to 300 mL per day
Stimulants
	Senna (Senokot)	2 to 6 years of age: 2.5 to 7.5 mL (8.8 mg per 5 mL); ½ to 1 ½ tablets (8.6 mg per tablet) per day
		6 to 12 years of age: 5 to 15 mL; 1 to 2 tablets per day
	Bisacodyl (Dulcolax)	≥ 2 years: 5 to 15 mg (1 to 3 tablets) per day in a single dose
Lubricants
	Mineral oil	15 to 30 mL per year of age per day
Rectal agents
Enemas (one per day)
	Saline	5 to 10 mL per kg
	Mineral oil	15 to 30 mL per year of age up to 240 mL
	Phosphate soda	2 to 12 years of age: 66-mL enema (should not to be used in children < 2 years because of the risk of electrolyte abnormality)
		> 12 years: 133 mL
Suppository (one per day)
	Bisacodyl	≥ 2 years: 5 to 10 mg (½ to 1 suppository)
	Glycerin*	½ to 1 infant suppository; adult suppository for those older than 6 years
Other
Manual (used rarely; general anesthesia needed)		—

Footnote: * May be used in infants < 1 year.

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Maintenance therapy

The goal of maintenance therapy is to avoid reaccumulation of stool by maintaining soft bowel movements, preferably occurring once a day. Given a robust placebo response, there is insufficient evidence to support the effectiveness of laxative therapies over placebo in the treatment of childhood constipation ⁶. However, most studies show that the addition of laxatives is usually necessary and more effective than behavior modification alone ⁷. Although the use of enemas has been advocated in the past, recent studies have shown that the addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation ⁸.

Table 4 summarizes maintenance therapies. Overall, polyethylene glycol achieves equal or better treatment success than other laxatives, such as lactulose or milk of magnesia ⁹, although it may be associated with more episodes of fecal incontinence ³. The dose of polyethylene glycol can be adjusted according to treatment response. Maintenance doses of medications need to be continued for several weeks to months after a regular bowel habit is established. Children who are toilet training should remain on laxatives until toilet training is well established.

Stimulant laxatives (e.g., bisacodyl [Dulcolax], sennosides) may be required in some children, although data on their use in children are limited. The lack of liquid formulations limits the practical use of stimulant laxatives in younger children. In the primary care setting, stimulant laxatives should be reserved for rescue therapy when an osmotic laxative is ineffective. Patients requiring constant administration of stimulant laxatives should be evaluated further.

Table 4. Maintenance therapies for children with constipation

Therapy	Dosage	Adverse effects
Osmotics
Polyethylene glycol 3350 (Miralax)*†	0.5 to 0.8 g per kg up to 17 g per day	Anaphylaxis, flatulence
Lactulose†	1 mL per kg per day once or twice per day, single dose or in two divided doses	Abdominal cramps, flatulence
Magnesium hydroxide	< 2 years: 0.5 mL per kg per day	Infants are susceptible to magnesium overdose (hypermagnesemia, hyperphosphatemia, hypocalcemia)
	2 to 5 years of age: 5 to 15 mL per day
	6 to 11 years of age: 15 to 30 mL per day
	≥ 12 years: 30 to 60 mL per day
	Medication may be given at bedtime or in divided doses
Sorbitol (e.g., prune juice)†	1 to 3 mL per kg once or twice per day in infants	Similar to lactulose
Stimulants
Senna (Senokot)†	1 month to 2 years of age: 1.25 to 2.5 mL (2.2 to 4.4 mg) at bedtime (< 5 mL per day); 8.8 mg per day	Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy
	2 to 6 years of age: 2.5 to 3.75 mL (4.4 to 6.6 mg) or ½ tablet (4.3 mg) at bedtime (< 7.5 mL or 1 tablet per day)
	6 to 12 years of age: 5 to 7.5 mL (8.8 to 13.2 mg) or 1 tablet (8.6 mg) at bedtime (< 15 mL or 2 tablets per day)
	> 12 years: 10 to 15 mL (26.4 mg) or 2 tablets (17.2 mg) at bedtime (< 30 mL or 4 tablets per day)
Bisacodyl (Dulcolax)	> 2 years: 5 to 15 mg (1 to 3 tablets) once per day	Abdominal cramps, diarrhea, hypokalemia, abnormal rectal mucosa, proctitis (rare), urolithiasis (case reports)
Lubricants
Mineral oil	Children: 5 to 15 mL per day	Lipoid pneumonia if aspirated, theoretical interference with absorption of fat-soluble substances, foreign body reaction in intestine
	Adolescents: 15 to 45 mL per day

Footnote:
* First-line therapy.
† May be used in infants < 1 year.

[Source ¹ ]

Pediatric constipation prognosis

Most children with functional constipation require prolonged treatment and have frequent relapses ¹⁰. Studies have shown that only 60% of children with constipation achieve treatment success after one year of therapy. Children with fecal incontinence or who are younger than four years at onset of constipation are particularly at risk of poor long-term outcomes ¹¹.

Referral to a pediatric gastroenterologist may be needed when a child with constipation has red flags for organic disease or the constipation is unresponsive to adequate therapy. Subspecialists may pursue newer medical therapies, such as lubiprostone (Amitiza), which acts on chloride channels in the intestine ¹² or onabotulinumtoxinA (Botox) injected into a nonrelaxing sphincter ¹³. Surgical therapies, such as antegrade colonic enemas, have also been shown to improve continence in children with intractable constipation ¹⁴. Motility testing often helps guide management in children with intractable constipation ¹⁵. Although most children have functional constipation, it is important to reevaluate those who do not follow the expected course.

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