FUNCTIONAL CONSTIPATION
Loutit and McKenzie, November 2017
WHAT IS NORMAL STOOLING?
Stool should be soft, normal caliber and easy to pass. (Bristol 3-4)
Typical frequency varies with age:
Infant 3-5 stools/per day – 1 stool/per week
Starting at 2-4 weeks, breastfed babies may have stools only once every 10-14
days. This is normal if the stool is soft.
1-4 years 2-3/day (90% have a bowel movement at least every other day)
4+ years 3x/day – 3x/week
Normal stooling behavior in Infants under 6 months may include straining, turning red, crying as
a result of uncoordinated defecation (infant dyschezia). This is normal as long as the stool is
soft.
WHAT IS FUNCTIONAL CONSTIPATION?
Delay or difficulty in defecation that is present for 2 weeks or more and sufficient to cause
excessive straining and/or pain
Rome III criteria: Red Flags:
• No organic pathology/red flags
• 2 or more of the following lasting for 1 month (<4 years of • No stool in the first 48 hrs of life
age) or 2 months (>4 years of age) • Signs of constipation in < 1 month
olds
- 2 or fewer defecations per week
• Narrow diameter stool (ribbon or
- One episode of incontinence per week toothpaste) suggestive of anal
- History of excessive stool retention atresia
- Painful or hard bowel movements • Anatomic abnormality
- Large fecal mass in rectum (back/coccyx; position of the anus)
- Large diameter stools that may obstruct the toilet • New-onset weakness in legs,
locomotor delay
• Abdominal distension with bilious
COMMON TIMES FOR KIDS TO DEVELOP CONSTIPATION vomiting
• Faltering growth and/or other signs
• Transition from breastmilk to formula suggestive of congenital
• Starting solids hypothyroidism
• Potty training
• Starting school (reluctant to use unfamiliar bathroom)
EVALUATION
• History and exam to rule out organic pathology
• Rectal exams should be reserved for concerns of dilated rectum/other pathology
• X-rays are generally not recommended
BASIC MANAGEMENT
• Medical management should be first line in children over 6 months.
• Avoid using dietary interventions alone.
• Enemas should be used only when oral treatment fails
• Refer to GI if no response to treatment after 3 months
MEDICATION
• Polyethylene glycol (Miralax) is recommended as first line therapy
• Goal of treatment is 1-2 soft/mushy stools (Bristol 4-6) per day depending on symptoms
• See Adjunct Treatment Options (below) for more information
>1 month - 6 months 6-12 months 1 year and older
Prune juice 1-2 oz/day Miralax 0.4-1 g/kg/daily for 2 Maintenance:
months. Miralax 0.4-1 g/kg/day
Miralax 0.4-1 g/kg/daily for 2 Prune juice 2-6 oz/day Impacted:
months. Miralax: 1-1.5mg/kg/day
divided TID 3-6 days, then
switch to maintenance dose
DIETARY AND LIFESTYLE RECOMMENDATIONS
• Develop daily habit of sitting on the toilet for 5-10 minutes 20-30 minutes after a meal
• Use positive reinforcement for good habits
• Increase water
• Increase fiber with goal of 5gm + years in age (use this until child reaches 20-25 grams)
• Increase fresh fruits and vegetables
• Limit milk to 16-24 oz per day in child > 1 year (any additional dairy restriction should be
done under a specialist’s advice and care.)
FOLLOW UP
• 1 week by phone or in person after impaction therapy
• 6 weeks after initiation of maintenance medication
ADJUNCT TREATMENT OPTIONS
OSMOTICS
Lactulose
• Age: 1 month and up
• Dosing:
- 0.7 to 2gm/kg/day (1-3ml/kg/day) given once daily or in divided doses
- Max dose 40 gm or 60 mL
• Use instead of or in addition to Miralax
• Contraindicated in patients with galactosemia
• May cause gassiness
Senna
• Age: 1 month and up
• Formulation: Liquid Senna (8.8mg/5 mL), tablet (8.6 mg/tablet) or chewable chocolate
square (15 mg)
• Dosing:
- 1 mo. – 2 years: 2.2 -4.4 mg at bedtime (max 8.8 mg/day)
- 2-6 years: 4.4 – 6.6 mg at bedtime (max 6.6 mg BID as syrup, or 8.6 BID in tablet form)
- 6-12 years: 8.6 mg tablet at bedtime (no more than 17.2 mg daily)
- 12 years and older = 17 mg tablet at bedtime (no more than 17 mg BID).
• Use in addition to Miralax if impacted
• Expect stool 8-12 hours after dose
Bisacodyl (Dulcolax)
• Age: 1 and up
• Dose:
- 5-15 mg (1 to 3 tablets) daily
• Use in addition to Miralax if impacted
• Expect stool 6-12 hours after dose
References and Resources
Video on impaction: The Poo in You
https://www.youtube.com/watch?v=SgBj7Mc_4schttps://www.gikids.org/
Parent Handout - Using Miralax for your child’s constipation
http://www.plateaupediatrics.com/pages/2014/9/16/using-miralax-for-your-childs-
constipation
General information
http://www.ohsu.edu/xd/health/services/doernbecher/programs-services/upload/ohsu-
constipation-guide.pdf
http://www.eastlouisvillepediatrics.com/client_files/file/Constipation.pdf
http://www.ped.med.utah.edu/pedsintranet/clinical/references/docs/giHandout.pdf
2014 Practice Guideline:
ESPGHAN (European Society for Paediatric Gastroenterology Hepatology and Nutrition) and
NASPGHAN (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition)
Evaluation and Treatment of Functional Constipation in
Infants and Children: Evidence-Based Recommendations
