Pediatric Constipation Primary Care Pathway
4. Management principles
Updated: October 2022
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BackgroundProvider resources
Quick links:
Expanded details
Advice options Patient resources
Pathway primer
• Symptoms and age of onset
• Assess for growth, behaviour and development
• Systemic exam – if unwell, sick, febrile
• Abdominal, perianal +/- rectal exam
• Spine and neurological exam
• Medication review
• Consider bloodwork/other investigations only if indicated by
clinical features or family history
1a. Key history and physical exam
• Family education
• Monitoring, diary of symptoms, and interventions
• Toilet training and behavioural modification (as age appropriate)
• Laxatives (oral route preferred) and fluid intake
• Dietary modifications - not a substitute for laxatives; implement
only after normal stool patterns are re-established
• PEG 3350 orally 1-1.5 g/kg/day x 3-6 days (until passage of clear, watery stools)
• If PEG ineffective, add oral stimulant (e.g. Senna, Bisacodyl) as additional cleanout agent
* Rectal therapies are considered second line
• Dry, hardened stools (Bristol type 1 or 2), which may be painful, of large diameter, and/or associated with straining;
• Stools occurring < 3 times per week, except in breastfed infants; and/or
• Excessive stool retention by history or physical exam +/- retentive posturing and fecal incontinence after the acquisition of toileting skills
Suspect constipation if child presents with:
1b. Alarm features / red flags
Non responsive/relapse
> 6 months of age
• Initial goal is BM Bristol stool 4-5
• Ensure adequate fluid intake
• PEG 3350: 0.5-1 g/kg/day or
• Lactulose: 1-2g/kg/day in 1-2 doses or
• Mineral oil (lubricant laxative) if painful BMs*
* do not use below 1 year of age
8. Laxatives and fluid intake
Response in 2-4 weeks?
9. Maintenance therapy for 6-12 months
• Essential for long term success
• Reinforce family understanding of management concepts and the
need for long-term intervention
• Maintain laxatives, slowly transition to BM Bristol stool 3-4
• Add dietary modifications
Relapse?
10. Wean and observe for 6-12 months
• Decrease laxatives by 25% every 1-2 months
• Reinforce high risk of recurrence and importance of early intervention as needed
• Reassess / re-educate
• Query fecal impaction (if yes, return to #7)
• Ensure adherence
• Change laxatives / optimize dosing
• Query behavioural / mental health factors
11. Optimize management
Assess in 5-7 days if clean out achieved
No
No
Yes
No
Yes
Yes
Yes
No
Non responsive/
need advice
5. Management (< 6 months of age)
7. Bowel cleanout/disimpaction
No
No
2. Normal variations in healthy infants?
• Infrequent BMs in exclusively breastfed infant more than two weeks old
• Infant dyschezia (>10 minutes of straining/crying before passage of soft stools)
Yes
Provide Feedback
• 2 or more symptoms present for > 1 week (treatment can be initiated earlier)
• Assess triggers and risk factors, including nutrition to guide management
< 6 months of age
• URGENT assessment in ED if any of the following:
Unwell, fever > 38°C, bilious vomiting, severe abdominal distention
• Referral to Pediatric Surgery if any of the following:
Ribbon-like stool, abnormal position of the anus, perianal fistula, stenosis
• Referral to Pediatrics if any of the following:
Onset < 1 month of age or passage of meconium > 48 hours
Blood in stool in absence of anal fissures
Malnutrition or hypothyroidism concern
Abnormal spinal or lower extremities neurological exam suggestive of spinal abnormalities
Developmental delay or behavioural or mental health conerns
Anal scars or suspicion of abuse
• Verify diet/formula prepration (modify intake, as needed)
• If no improvement in 2-4 weeks:
First line approach: 100% undiluted prune, pear, or apple
juice (if > 4 months) in addition to normal feeding. Start with
2 tbsp and slowly increase as needed to a max of 8
tbsp/day. Reduce dose to minimum requried to maintain
soft stools.
Second line approach:
Lactulose (g/kg/day) in - doses
Occasional
pediatric glycerine suppository, if needed
• Once normal stool is established, maintain for 1-2 months,
then wean from juice and/or laxatives and observe for 1 month
3. Functional constipation diagnosis (Rome IV criteria, see expanded details)
• Assess functional retention by history (large stools that may plug up the toilet, fecal
incontinence, and/or incomplete/infrequent evacuation)
• Assess for excessive amount of stool in the colon by abdominal exam
6. Is fecal impaction present?
Seek advice
or refer to
Pediatrics
Seek advice
or refer to
Pediatrics
Provide education, reassurance, reassess in 2-4 weeks.
No rectal stimulation or laxatives.
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Provide Feedback ˃
PEDIATRIC CONSTIPATION PATHWAY PRIMER
• Constipation is the subjective complaint of the passage of abnormal stool: dry, hardened feces that may be
accompanied by straining or pain, and/or is less frequent than expected for age.
• Organic causes of constipation are rare in children without any ‘red flags’ or alarm features. Children presenting
w
ith ‘red flags’ require further evaluation to rule out organic disorders (see Appendix A).
• Because most cases of pediatric constipation are non-organic, lab investigations are not needed in the absence
of
red flags.
• Over 95% of childhood constipation is due to disorganized function and interaction of the otherwise normal colon,
rectum, or pelvic floor musculature and is classified as “functional.”
• Functional constipation in children has a complex pathophysiology, as children undergo developmental
changes affecting their responses to internal and external stimuli. As the etiology is unlike the one in adults,
it requires different management
.
• In up to 60% of cases, especially among young children, it is caused by voluntary withholding of feces due to
fear of defecation (in the anticipation of pain or other triggers) or avoidance. Repeated painful bowel movements
establish a pain-retention-pain cycle.
• Some children may not recognize the urge to defecate due to inattention or developmental stage. Chronic rectal
distension in functional constipation may also lessen sensation, preventing recognition of rectal fullness with
a
nor
mal-sized stool.
• Continuing retention can then result in encopresis, due to formed, soft, or liquid stools bypassing the fecal mass
(“sneaky poops”), and/or involuntary external sphincter relaxation.
• Management includes education, cleanout/disimpaction, long-term maintenance therapy with oral laxatives, toilet
training and behaviour modification, nutrition counselling, and close follow up.
1
• M
anagement should start right away to prevent chronic constipation which can lead to fecal incontinence,
abdominal pain, anorexia, and enuresis; these can affect family dynamics, school/social success, and self-
esteem
.
• T
he most frequent reasons for treatment failure include:
o inadequate family education (triggers, behavioral components, and the expected length of treatment),
o ineffective clean out, and
o suboptimal laxative use, including dose and consistent (daily) use for enough time to allow for
behavioral changes to be implemented.
EXPANDED DETAILS
1 a/b. Key history and physical exam is important to exclude alarm features and red flags such as a
life-threatening bowel obstruction, anatomic abnormalities affecting patency of gastrointestinal tract, neuromuscular
disorders that prevent normal gut motility or relaxation of the anal sphincters, or rare disorders of other systems
resulting in constipation.
1
Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam M, Nurko S, et al. Evaluation and treatment of functional constipation
in infants and children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014
Feb;58:258–74.
This primary care pathway was co-developed by primary and specialty care and includes input from multidisciplinary
teams. It is intended to be used in conjunction with specialty advice services, when required, to support care within
the medical home. Wide adoption of primary care pathways can facilitate timely, evidence-based support to
physicians and their teams who care for patients with common low-risk GI conditions and improve appropriate
access to specialty care, when needed. To learn more about primary care pathways, check out this short video.
Last Updated: October 2022 3 of 17 Back to Algorithm
Table 1. Alarm features and red flags requiring referral and further work up
ED
• Unwell, sick child
• Fever > 38°C
• Bilious vomiting
• Severe abdominal distension
Surgery
• Ribbon stools only
• Abnormal position of the anus
• Perianal fistula
• Anal stenosis
Pediatrics
• Onset < 1 month
• Passage of first meconium > 48 hours
• Family history of Hirschsprung disease
• Blood in the stools in the absence of anal
fissures
• Malnutrition, abnormal growth pattern
• Symptoms of systemic disease/ hypothyroid
• Gluteal cleft deviation
• Tuft of hair on spine, sacral dimple
• Decreased lower extremity strength/tone/reflex
• Absent anal or cremasteric reflex
• Developmental delay, behavioral, or mental health
issues
• Suspicion of abuse, anal scars
History
• Bowel obstruction must be ruled out in patients with bilious vomiting, severe abdominal distension, poor
feeding, and lack of stools. These patients are usually unwell and may be febrile. They should be redirected
immediately to ED for further work up and management.
• Onset of constipation within the first month of life has a higher likelihood of being caused by an underlying
disorder or congenital anomaly.
• Passage of first meconium beyond 48 hours after birth and/or family history should raise suspicion of
Hirschsprung disease.
• Malnutrition or abnormal growth pattern (weight loss, poor weight gain, abnormal growth velocity,
unexplained short stature) suggest an underlying organic pathology.
• Other signs and symptoms that raise suspicion for an underlying disorder include: poor appetite, nausea,
and non-bilious vomiting; fever; blood in the stools in the absence of anal fissures; significant abdominal
distension; polyuria; polydipsia; dehydration; pulmonary disease; steatorrhea; and rectal prolapse (see
Appendix A
).
o If suspected, these conditions require workup in the medical home or by a Pediatrician.
• Developmental delay, behavioural challenges or mental health concerns (e.g. Autism Spectrum Disorder,
ADD, ADHD, Oppositional Defiant Disorder) may affect the child’s attention necessary to process defecation
signals, and the ability and willingness to respond to body clues. They contribute significantly to defecation
disorders and require further work up by a Pediatrician.
• Child maltreatment (e.g. physical, sexual, or emotional abuse) must be ruled out. If maltreatment is
suspected, inspect for anal scars. Consult appropriate community resources. The Child Abuse Hotline is
available for reporting concerns 24/7 at 1-800-387-5437.
• Trauma, including exposure to civil unrest or war, may also contribution to constipation and other functional
GI disorders.
• Consider diet history (features of high processed food, low fibre, low fluid). Diet changes to be reviewed and
addressed in the maintenance stage of treatment
.
Physical examination
• Complete a detailed perianal inspection to identify rare anatomic anorectal malformations (see Appendix A
for more information).
o The anal opening should be well-defined, aligned with the ischial tuberosities and in the female
located one-third of the distance between the coccyx and the fourchette. In males, the diagnosis is
made if the distance from the base of the scrotum to the anal aperture is <46% of the total distance
from scrotum to coccyx.
Last Updated: October 2022 4 of 17 Back to Algorithm
o In the absence of an anal opening, a fistula may be formed that opens anywhere from just anterior
to the normal position of the anus to along the median raphe and up to the penile shaft in boys.
With a fistula to the urogenital system, meconium staining may be seen at the urethral opening in
both boys and girls, and vaginal opening in girls. All require further work up by Pediatric Surgery.
• Digital rectal examination is most valuable if there is an anatomic concern and should be done by a
healthcare provider who is comfortable with the assessment and management of anatomical abnormalities
that can lead to constipation.
• Neuromuscular etiologies should be suspected with a history of abnormal gait, delayed walking, or any of
the following findings on physical exam:
o Flat buttocks with poorly discernible buttock groove
o Gluteal cleft that is not straight; deviation may indicate suggest spinal cord anomaly
o Tufts of hair or abnormal skin dimples over the spine; a shallow midline dimple within 2cm of the
anus is normal
• Spinal abnormalities will result in abnormal innervation of lower extremities and perianal area resulting in
decreased tone, strength and abnormal deep tendon reflexes of lower extremities, lack of sensation in the
saddle area and absence of the anal wink and cremasteric reflex (in boys).
Medication review
• Certain medications may cause or contribute to constipation (anti-depressants, chemotherapy, opiates,
anticholinergics, vitamin D intoxication), and should be suspected if onset of constipation coincides with start
of medications. Stop or modify the offending agent if possible then reassess.
Investigations
• Abdominal x-rays lack specificity and should not be routinely used to diagnose or rule out
constipation. Other imaging is rarely necessary, unless recommended by a specialist.
• Routine lab testing is not recommended in the absence of other features of underlying organic disease
during clinical evaluation.
2. Normal variations in healthy infants?
2,3
• Variation in stool frequency is normal and decreases with a child’s age as a result of the colon’s improved
ability to conserve water.
• Greater variation is observed in infants, especially in breastfed infants before solids are introduced. If the
infant is growing normally without evidence of obstruction, diarrhea, or other clinical symptoms there is little
cause for concern.
• From birth to six months of age, normal stools can be runny, pasty, or even liquid on occasion.
• Hard, dry stools in exclusively breastfed infants are extremely rare. Assess hydration.
• Provide education and reassurance on the importance of soft stools and the range of normal stool
frequency (see Appendix B).
Infant dyschezia
• Affects up to 3% of infants up to 9 months of age.
o Infants have straining, crying, and turn red in the face when trying to defecate (for up to 10-20
minutes), followed by the passage of soft stools.
o Represents lack of coordination between increased intra-abdominal pressure and pelvic floor
relaxation. Resolves spontaneously as the infant matures (usually by 9 months).
o Medical intervention is not necessary – provide parental reassurance.
o Avoid rectal stimulation and laxatives for infant dyschezia.
2
Steer CD, Emond, AM Golding, J, Sandhu, B. The variation in stool patterns from 1 to 42 months: a population-based
observational study. Arch Dis Child. 2009;94:231-4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/18676434
3
Dietitians of Canada. Knowledge Pathways: Gastrointestinal System - Pediatric/Paediatric Constipation. In: Practice-based
Evidence in Nutrition [PEN] [Internet]. 2018-04-19 Available from: http://www.pennutrition.com
Last Updated: October 2022 5 of 17 Back to Algorithm
3. Functional constipation diagnosis
• Functional constipation can be diagnosed if the history and physical examination are consistent with Rome
IV criteria, and the symptoms cannot be attributed to another medical condition and are insufficient for
diagnosis of irritable bowel syndrome (see Appendix C
).
Table 2. Rome IV criteria for the diagnosis of pediatric functional constipation
Infants and toddlers up to 4 years of age
(developmental age)
Children above 4 years of age
(developmental age)
Two or more symptoms present for > 1 month
• Two or fewer defecations per week
• History of excessive stool retention
• History of painful or hard bowel movements
• Presence of a large fecal mass in the rectum
Additional criteria that may be used in toilet trained
children:
• At least one episode/week of fecal incontinence
• History of large diameter stools that may obstruct the
toilet
Two or more symptoms present for > 1 month, at least
once/week
• Two or fewer defecations in the toilet per week
• History of retentive posturing or excessive volitional
stool retention
• History of painful or hard bowel movements
• History of large diameter stools which may obstruct
the toilet
• Presence of a large fecal mass in the rectum
• At least one episode/week of fecal incontinence
• Triggers and risk factors:
o Functional constipation most commonly starts at transition times. Identifying the impact of transition
times helps with family education and intervention. Common transition times include:
Diet changes in infancy: Transitions (e.g. breast milk to cow’s milk or liquids to solids) may
alter stool consistency and lead to stool withholding.
Toilet training: If attempted when the child is not physiologically or psychologically ready,
may result in anxiety around toileting, conflict with parents, and emotional trauma. These
factors may lead to the inability to relax the pelvic floor for defecation and subsequent
stool retention.
Start of school: Changes in routines, avoidance of school bathroom, and inability to use
the bathroom when needed, may result in dysfunctional toileting behavior.
o Nutritional concerns (e.g. low fibre diet, consumption of low nutrient dense foods, limited family
meals, irregular meal patterns) and inadequate fluid intake may lead to hard, painful stooling and
initiate a pain-retention-pain cycle.
o Developmental delay, behavioral or mental health problems that may impact child’s maturity or
ability to recognize and respond to normal physiological cues.
o Home and school related psychological stress (e.g. separate parental households, poor parenting
skills, family dysfunction).
o Child maltreatment or trauma (e.g. physical, sexual, or emotional abuse; exposure to civil unrest or
war).
4. Management principles
• The best outcomes occur with effective treatment started within 3 months of symptom onset.
• Five components are required (see details below):
o Family education
o Monitoring and use of a diary of symptoms/interventions (see Patient Resources
for examples)
o Toilet training and behavioral modification (appropriate for age)
o Laxatives (including for cleanout/disimpaction if required)
o Diet modifications (after normal stool patterns have been re-established)
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Family education (see Patient Resources)
• Family education about normal intestinal function and the pathophysiology of functional constipation is
essential to facilitate successful management.
• It is critical to verify the family’s understanding of the concepts.
• Only about 50% of children treated for constipation will recover and be without laxatives after one
year. The remaining patients require long-term treatment (up to 10 years) or may remain symptomatic
despite laxatives.
o Provide anticipatory guidance to families about long-term treatment required for successful
behavioural modification and return of rectal tone/sensation to prevent disappointment, improve
long-term compliance, and prevent early discontinuation of therapy leading to symptom recurrence
and poor outcomes.
Monitoring (diary of symptoms and interventions)
• Encourage families to keep a calendar or diary of symptoms (Bristol stool type and frequency) and
interventions. This can help to monitor progress, provide positive reinforcement, and support the family’s
self-management.
• The diary also helps to facilitate the provider and family’s review/reassessment if interventions do not
achieve the necessary improvement.
Toilet training/behavioural modification (as age appropriate)
• Encourage a positive and supportive parental attitude, to reduce the child’s toileting avoidance and anxiety.
Identify reasons for toilet avoidance. Punishment is unwarranted and counterproductive.
• Educate parents about helping their child to recognize the urge to defecate. Parents need to learn to
recognize that “stool withholding behaviours” signal “the urge to go”. When parents observe these
behaviours, they need to redirect the child to use the bathroom. When the urge to defecate occurs, it must
become a habit for the child to use the toilet.
• Institute a regular toileting schedule. The child should try to defecate for 5 minutes on the toilet within 30
minutes of a meal, to take advantage of the gastrocolic response. This routine allows the gradual re-
establishment of normal bowel habits.
• Ensure proper positioning – the child must feel safe and comfortable on the toilet seat or potty. No dangling
feet! Placing feet on a footrest (or a squatty potty) for support helps to flatten the anorectal angle and
facilitate stool expulsion.
• Children may need to learn the sequence of abdominal wall straining and pelvic floor relaxation required for
normal defecation. Recommend activities that promote relaxation, generate an increase in intra-abdominal
pressure, and show the child how to Valsalva in a coordinated fashion (e.g. have the child gently blow air
using bubble wands, party noise makers, a pin wheel, or play harmonica while seated on the toilet).
• A reward system using stickers or small gifts may be helpful. Positive reinforcements or rewards should be
given for the child sitting on the toilet not just stooling in the toilet. Positive reinforcement increases the
likelihood of a child participating in the sit time. NOTE: Food rewards are not recommended.
Diet modifications (after normal stool patterns have been re-established)
• Low dietary fibre intake may contribute to constipation; however, increased fibre should not be used as the
initial treatment in children. It is not feasible to increase fibre sufficiently to resolve constipation/fecal
impaction in a timely manner, without also causing gas, bloating, and/or other symptoms that may be
uncomfortable for the child.
• Ensure adequate fluid and fibre intake to maintain a healthy bowel routine after constipation is resolved (#9).
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5. Management (< 6 months of age)
• Initial intervention should focus on verifying diet/formula preparation and modifying intake as needed.
o Breast fed infants should feed on demand. Ensure they are well hydrated and gaining weight
appropriately. For babies under 6 months, there is no need to give the baby fluids other than
breastmilk. If there are concerns about lactation or breastfeeding, recommend consultation with a
public health nurse or lactation consultant.
o If the infant is formula fed, ensure the formula is being prepared according to directions. Iron
fortified formula does not cause constipation and is important to prevent iron deficiency anemia.
o Daily fluid intake guidelines for infants under 6 months:
700 ml (24 oz), assumed to be from breastmilk
If drinking formula, range 420-1170 ml (14-39 oz)
o Adequate fluid intake can be determined by assessing intake (e.g., breastmilk and formula) and
comparing to the patient’s output (i.e. wet or dirty diapers).
o Ensure any solid foods are age-appropriate.
For babies 0-4 months, discontinue solid foods.
For babies 4-6 months, discontinue foods that are suggested for infants >6 months.
• If no issues are identified with baby’s diet or modifications are made without improvement after 2-4 weeks,
pursue additional diet modifications and/or laxatives:
o For infants >4 months, provide sorbitol-containing juices (100% undiluted prune, pear, apple)
outside the feedings. Start with two tablespoons between feedings and slowly increase to a
maximum of eight tablespoons/day. If infant has a bowel movement within 24 hours, reduce to
minimum amount required to maintain soft stools. Note – prune juice has a stronger effect than
apple or pear juice, so a smaller amount may be required. Monitor to ensure breastmilk or formula
consumption is not affected.
o Lactulose is safe and effective in infants. It works by drawing water into the intestinal lumen through
an osmotic gradient.
Dose at 1-2g/kg/day (1.5-3ml/kg) in 1-2 doses. Adjust dose according to response.
o Glycerin suppositories can be a useful treatment option in infants, without notable adverse effects.
o PEG 3350 should only be used on the advice of a specialist.
o Stimulant laxatives, phosphate enemas, and mineral oil are not recommended, due to potential
adverse effects in infants.
o Honey should be avoided for infants up to 12 months, due to the risk of Clostridium botulinum
spores and infant botulism.
o If a breastfed baby has no response to laxatives and diet modifications, a two-week trial of cow’s
milk elimination in the mother’s diet may be considered. If effective, consider consulting a
Registered Dietitian to support proper substitutions and/or supplementation to ensure adequacy of
the mother’s diet, due to risk of inadequate calories, protein, calcium, and vitamin D on a cow’s milk
elimination diet.
o For infants on cow’s milk based formula, a 2-3 week trial of hypoallergenic formula is appropriate.
• Once normal stools are established with laxatives and diet adjustments, monitor for 1-2 months. If no
relapse, wean from laxatives and observe for one month.
• If no improvement after 1-2 months, or there is a later relapse, optimize management through
reassessment, adjusted use of laxatives, and ensuring parental adherence to recommendations.
• Referral or advice from a pediatrician may be beneficial.
Management for children < 6 months of age
Last Updated: October 2022 8 of 17 Back to Algorithm
6. Is fecal impaction present?
• Fecal impaction or functional retention may be present when there is one or more of the following:
o Markedly increased amounts of stool in the colon (significant stool mass palpable)
o History of large stools (that may plug up the toilet)
o Fecal incontinence/leakage
o Incomplete evacuation (e.g. small stools, “rabbit poops,” stool looks “broken off”)
o Very infrequent evacuation.
Physical exam
• Assess the size of the fecal mass through percussion and/or by palpating the abdomen on either side of the
rectus muscle.
• Inspect the perineum to determine the presence of anal fissures (frequently explains the presence of small
amounts of blood that may be alarming to caregivers but are strongly suggestive of fecal retention).
• Digital rectal examination is not necessary but if the provider is comfortable performing this examination, it
may be informative to rule out fecal impaction if not obvious by history or abdominal palpation.
Imaging for fecal impaction (if needed)
• Fecal impaction can normally be determined by history and physical exam.
• If unclear after history and physical exam, x-ray could be ordered to assess for excessive stool in the left-
sided colon/rectum (lacks specificity).
7. Bowel cleanout/disimpaction (if required, for children > 6 months of age)
• Osmotic laxative PEG 3350 has superior outcomes as a first-line treatment. Prescribe PEG 3350 orally (1-
1.5 g/kg/day for 3-6 days). See the CHEO handout for dosing information (also found in Patient Resources
).
Advise parents that passage of large volume of watery stools for 2-3 days is likely sufficient. Reassess in 5-7
days to determine if clean-out achieved.
o If clean-out achieved, proceed to #8.
o If clean-out not achieved, consider:
Oral stimulant such as Senna or Bisacodyl (see Table 3 for dosing)
Glycerin suppository (one daily x 3 days)*
Pico-salax (under advice of a specialist)
Sodium phosphate enema (only for children > age 2, see Table 3 for dosing)
*Rectal therapies are considered second line because they are more invasive. They may
compound the problem of uncomfortable defecation that is often at the heart of functional
constipation.
• If clean-out not achieved with addition of secondary treatment, refer to pediatrician or use an advice service.
8. Laxatives and fluid intake
• Once fecal impaction is resolved, re-establish a healthy bowel routine through use of laxatives and adequate
fluid intake.
• The initial goal of laxative use and increased fluids is to achieve stool consistency of Bristol type 4 or 5 (see
Appendix D
). The goal at this stage is to induce very soft stools so that holding is not necessary or easy to
do. This is the first stage of long-term intervention.
• Assess after 2-4 weeks to evaluate the child’s response to treatment.
o If Bristol 4-5 has been achieved, proceed to the maintenance stage (#9).
o If not achieved, optimize management (#11).
Management for children > 6 months of age
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Laxatives
• Laxatives are initiated at this stage with dosage adjusted to induce a daily soft bowel movement (see Table
3 for dosage information). Remind families that laxatives will be utilized for an extended period to allow for
bowel retraining and behaviour modification.
• Lubricant or osmotic laxatives with polyethylene glycol (PEG) are the preferred initial treatment due to ease
of administration, palatability, fewer side effects, and superior outcomes.
• Osmotic laxatives are poorly absorbed substances that draw water into the intestinal lumen through an
osmotic gradient. They include non-toxic organic polymers (PEG), poorly absorbed sugars (lactulose,
sorbitol), and inorganic salts (magnesium compounds).
• Mineral oil (lubricant laxative) is less effective than PEG. It is worth considering if defecation is painful. It is
not recommended for children < 1 year of age or children unable to protect their airways due to the risk of
aspiration.
• If osmotic laxatives are not sufficient to achieve the goal of a daily soft bowel movement, seek specialty
advice as a different approach to bowel retraining may be required.
• Other medications such as lubiprostone, linaclotide, and prucalopride should not be used for initial treatment
in children. Although they are effective in adults, neither lubiprostone nor prucalopride was shown to be
effective in children.
4, 5,6,7,8
Table 3. Laxatives for children > 1 year old
Generic name Trade name
Dosage
*adjust to meet the goal of at least 1 soft stool/day that is easy to pass – Bristol 4/5
Osmotic laxatives – first line
PEG 3350 (preferred) LAX-A-DAY
Restoralax
Relaxa
Cleanout dose: 1-1.5 g/kg/day
Usual dose: 0.5-1.0 g/kg/day
See CHEO handout
for more details
Lactulose Lactulose
• 1-2g/kg/day (=1.5-3 ml/kg) in 1-2 doses (max 60mL/day)
Magnesium hydroxide Milk of Magnesia
• 2-5 years: 0.4-1 g/day in 1-2 doses
• 6-11 years: 1-2.4 g/day in 1-2 doses
• 12-18 years: 2.4-4.8 g/day in 1-2 doses
Lubricant laxative – if defecation is painful
Mineral oil
Mineral Oil
Lansoyl
• 1-18 years: 1-3 ml/kg/day, in 1-2 doses (max 90ml/day)
*do not use in children <1 year or children unable to protect their airways or with GERD
Stimulant laxatives – add if insufficient effect of osmotic laxatives alone (choose based on patient preference)
Bisacodyl Dulcolax
Bisacodyl
• 3-10 years: 5 mg/day
• 10-12 years: 5-10 mg/day
• > 12 years: 5-15 mg/day
4
Benninga, M. A., Hussain, S. Z., Sood, M. R., Nurko, S., Hyman, P., Clifford, R. A., O’Gorman, M., Losch-Beridon, T., Mareya, S.,
Lichtlen, P., & Di Lorenzo, C. (2022). Lubiprostone for pediatric functional constipation: Randomized, controlled, double-blind study
with long-term extension. Clinical Gastroenterology and Hepatology, 20(3).
5
Hyman, P. E., Di Lorenzo, C., Prestridge, L. L., Youssef, N. N., & Ueno, R. (2014). Lubiprostone for the treatment of functional
constipation in children. Journal of Pediatric Gastroenterology & Nutrition, 58(3), 283–291.
6
Medina-Centeno, R. (2020). Medications for constipation in 2020. Current Opinion in Pediatrics, 32(5), 668–673.
7
Mugie, S. M., Korczowski, B., Bodi, P., Green, A., Kerstens, R., Ausma, J., Ruth, M., Levine, A., & Benninga, M. A. (2014).
Prucalopride is no more effective than placebo for children with functional constipation. Gastroenterology, 147(6), 1285–1295.
8
Winter, H. S., Di Lorenzo, C., Benninga, M. A., Gilger, M. A., Kearns, G. L., Hyman, P. E., Vandeplassche, L., Ausma, J., &
Hoppenbrouwers, M. (2013). Oral Prucalopride in children with functional constipation. Journal of Pediatric Gastroenterology &
Nutrition, 57(2), 197–203.
Last Updated: October 2022 10 of 17 Back to Algorithm
Generic name Trade name
Dosage
*adjust to meet the goal of at least 1 soft stool/day that is easy to pass – Bristol 4/5
Senna Senokot or Exlax
• 2 to < 6 years:
1
/
2
tablet (4.3 mg sennosides) at bedtime, not to exceed 1
tablet (8.6 mg sennosides) twice daily
• 6 to < 12 years: 1 tablet (8.6 mg sennosides) at bedtime, not to exceed 2
tablets (17.2 mg sennosides) twice daily
• ≥ 12 years: 2 tablets (17.2 mg sennosides) at bedtime, not to exceed 4
tablets (34.4 mg sennosides) twice daily
*Senokot syrup is 8.8mg/5ml
Sodium picosulfate/
Magnesium
oxide/citric acid
Pico-Salax
Purg-Odan
Only use on advice of a specialist (mainly used for bowel cleanout/bowel
prep).
• 1/4 sachet for kids aged 1-5
• 1/2 sachet 6-12 years
• 1 sachet for > 12 years.
Start with one dose and repeat if necessary.
Rectal therapies
Bisacodyl
Dulcolax or
Bisacodyl
suppository
• 2-10 years: 5 mg once/day
• > 10 years: 5-10 mg once/day
Mineral oil
Fleet Oil
• 2-10 years: 30-60 ml once/day
• > 10 years: 60-150 ml/day
Sodium phosphate Fleet Enema
• 2-12 years: 65 ml
• > 12 years: 130ml
NaCl
Fleet Saline
Enema
• > 1 year: 6 ml/kg once or twice per day
Fluid intake
• Ensure the child has adequate fluid intake as per below.
Table 4. Fluid intake guidelines
9
Age
Water obtained from drinks per day* from breast milk, formula, milk, juices, drinking water
7-12 months
• 600 ml (20 oz)
• If drinking formula, range is 480-1110 ml (16-37 oz)
• Review How Much Infant Formula to Prepare for Baby
1-3 years
900 ml (30 oz)
4-8 years
1200 ml (40 oz)
9-13 years
1600-1800 ml (54-60 oz)
14-18 years
1800-2600 ml (60-88 oz)
*Recommended average daily intake to meet the needs of apparently healthy individuals. Does not take into account potential
additional requirements for other conditions (e.g. environmental conditions, physical activity, and medical conditions).
9
Institute of Medicine. Water. In: Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Washington, DC:
National Academy of Sciences; 2005. p.73-185.
Last Updated: October 2022 11 of 17 Back to Algorithm
9. Maintenance therapy for 6-12 months
• After regular, soft stools have been re-established through laxatives and fluid, maintenance therapy for an
extended period of time is essential to long-term treatment success.
• The length of treatment must be of sufficient duration for behaviour modification, and return of rectal tone
and sensation. This can range from a few months to several years.
• A long-term effective therapeutic relationship in the patient’s medical home is necessary for a successful
treatment outcome; periodic patient follow up and coaching improves the chance of a long-term successful
outcome.
• If relapse occurs at any stage, see #11 to reassess/adjust interventions.
• Over time, soft stools allow children to lose the fear of defecation.
Laxatives
• This stage represents a long-term continuation of laxatives initiated previously.
• It is common for families to discontinue laxatives too soon; confirm family understanding of management
concepts and the importance of long-term therapy.
• The approach to treatment must be individualized. Stool consistency should be maintained at type 4-5,
without encopresis, to prevent pain and withholding, and to promote bowel retraining – at least 1-2 months.
• With time, when behavioural modifications are established, slowly taper laxatives by 25% every 2-3 months,
over a 6-12 month period, while maintaining daily, soft bowel movements (Bristol stool 3-5).
Diet interventions
10
• Low dietary fibre intake in children may contribute to constipation; however, adequate fibre should not be
used as the initial treatment, especially in younger children. It is not feasible to increase fibre sufficiently to
resolve constipation/fecal impaction in a timely manner, without also causing gas, bloating, and/or other
symptoms that may be uncomfortable for the child.
• Dietary fibre may be used for maintenance of a healthy bowel routine once constipation is resolved.
• Fibre should be introduced gradually to allow the body to adjust. A sudden increase in fibre intake can cause
discomfort, bloating, and gas.
• Increased fluid and fibre, in the form of vegetables, fruits, and whole grains, may prevent recurrence of
constipation.
• Diets high in sugar, fat, protein, or milk products are generally low in fibre. See
Constipation in Babies and
Children for suggestions on adding more fibre to the diet.
• Diet changes are most successful when the entire family makes these healthy choices.
• Consider referral to dietitian for additional support and/or education. Visit the Alberta Referral Directory
and
search for nutrition counselling.
10. Wean and observe for 6-12 months
• If child continues to respond after 6-12 months of maintenance therapy, wean from laxatives by decreasing
laxative dose by 25% every 1-2 months. Monitor to ensure Bristol stools 3-4 are maintained at lower dosage.
o If there is a relapse, return to last successful dose of laxatives.
• Dietary fibre should replace laxatives to increase the content of water in the stool and stimulate the colon.
Fibre should be introduced or increased and then maintained throughout this stage to prevent relapse.
• Families should be reminded of the high risk of recurrence at susceptible periods (dehydration associated
with fever, hot weather vacation, hospital admissions, sports, physical activity; change of the life routines).
Remind families of the importance of preventative strategies such as ensuring adequate dietary fibre and
implementing early intervention at these susceptible periods.
10
Healthy Infants and Young Children: Management of Constipation. https://www.albertahealthservices.ca/assets/info/nutrition/if-
nfs-ng-healthy-infants-gi-function-management-constipation.pdf
Last Updated: October 2022 12 of 17 Back to Algorithm
Provide Feedback ˃
11. Optimize management
• In situations where the child does not respond to treatment as expected or experiences a relapse, consider
these strategies to optimize management
o Reassess for fecal impaction/functional retention and address if required (#6-7)
o Re-educate on behaviour modification strategies (#4)
o Review adherence to laxatives; adjust dosage if indicated (#8)
o Consider behavioural/mental health concerns and whether a referral to a pediatrician and/or mental
health supports is warranted.
o Encourage positive diet interventions (fluid and fibre); consider referral to dietitian (#8-9)
BACKGROUND
About this Pathway
•
Primary care pathways for adult were originally developed in 2015 as part of the Calgary Zone’s Specialist
LINK initiative. They were co-developed by the Department of Gastroenterology and the Calgary Zone’s
specialty integration group, which includes medical leadership and staff from Calgary and area Primary Care
Networks, the Department of Family Medicine and Alberta Health Services.
•
The pathways were intended provide evidence-based guidance to support primary care providers in caring
for patients with common digestive health conditions within the medical home.
•
Based on the successful adoption of the primary care pathways within the Calgary Zone, and their impact on
timely access to quality care, in 2017 the Digestive Health Strategic Clinical Network (DHSCN)led an
initiative to validate the applicability of the pathways for Alberta and to spread availability and foster adoption
of the pathways across the province.
Authors & Conflict of Interest Declaration
This pathway was developed through the DHSCN in 2022 by a multi-disciplinary team comprised of family
physicians, pediatricians, pediatric gastroenterologists, and allied health professionals.
Pathway Review Process
Primary care pathways undergo scheduled review every three years, or earlier if there is a clinically significant
change in knowledge or practice. The next scheduled review is May 2025. However, we welcome feedback at any
time. Click on the Provide Feedback button to provide your feedback.
Copyright Information
This work is licensed under a Creative Commons Attribution-Non-commercial-Share Alike 4.0 International license.
You are free to copy, distribute, and adapt the work for non-commercial purposes, as long as you attribute the work to
Alberta Health Services and Primary Care Networks and abide by the other license terms. If you alter, transform, or
build upon this work, you may distribute the resulting work only under the same, similar, or compatible license. The
license does not apply to content for which the Alberta Health Services is not the copyright owner.
Disclaimer
This pathway represents evidence-based best practice but does not override the individual responsibility of health
care professionals to make decisions appropriate to their patients using their own clinical judgment given their
patients’ specific clinical conditions, in consultation with patients/alternate decision makers. The pathway is not a
substitute for clinical judgment or advice of a qualified health care professional. It is expected that all users will seek
Last Updated: October 2022 13 of 17 Back to Algorithm
advice of other appropriately qualified and regulated health care providers with any issues transcending their specific
knowledge, scope of regulated practice or professional competence.
PROVIDER RESOURCES
Advice Options
Non-urgent advice is available to support family physicians.
• Non-urgent advice is available through Alberta Netcare eReferral Advice Request (responses are received
within five calendar days). View the Referring Provider – FAQ document for more information.
o Community pediatrics advice is available in the Calgary Zone
o Pediatric gastroenterology advice is available in the Edmonton Zone
• Non-urgent telephone advice connects family physicians and specialists in real time via a tele-advice line.
Family physicians can request non-urgent advice from a pediatrician:
o In the Edmonton and North Zones by calling 1-844-633-2263 or visiting pcnconnectmd.com
. This
service is available from 9:00 a.m. to 6:00 p.m. Monday to Thursday and 9:00 a.m. to 4:00 p.m.
Friday (excluding statutory holidays and Christmas break). Calls are returned within two (2)
business days.
o In the Calgary Zone at specialistlink.ca or by calling 403-910-2551. This service is available from
8:00 a.m. to 5:00 p.m., Monday to Friday (excluding statutory holidays). Calls are returned within
one (1) hour.
Nutrition Services
To refer your patient to a Registered Dietitian, visit the Alberta Referral Directory
and search for nutrition counselling.
Last Updated: October 2022 14 of 17 Back to Algorithm
PATIENT RESOURCES
Information
Description
Website
Website with handouts, videos, and other resources about
childhood constipation
http://fcrc.albertahealthservices.ca/health-
information/library/information-prescriptions/constipation/
Handout from the Children’s Hospital of Eastern Ontario
about childhood constipation, including detailed
dosing/mixing information on PEG 3350
https://www.cheo.on.ca/en/resources-and-
support/resources/P5593E.pdf
“Poo Diary” for tracking bowel movements
https://www.eric.org.uk/Handlers/Download.ashx?IDMF=0e6
361d4-b887-43c9-8793-85eb00f1686c
Food, Lifestyle, and Symptom Diary
https://www.albertahealthservices.ca/assets/info/nutrition/if-
nfs-bowel-symptom-journal.pdf
AHS Nutrition Services handout on dietary approaches to
address constipation in babies and children
https://www.albertahealthservices.ca/assets/info/nutrition/if-
nfs-constipation-in-babies-and-children.pdf
A variety of handouts on healthy diet for infants, children,
and families
https://www.healthyparentshealthychildren.ca/resources/prin
tables-healthy-eating
Resource page with a variety of videos and articles on toilet
training
https://www.eric.org.uk/Pages/Category/potty-training
Videos for parents that describe what leads to childhood
constipation and provide general information about what is
needed for successful treatment.
How to Make It Happen
Fibre FAQs
Educational video for children, that explains constipation
and encopresis
The Poo in You
https://www.youtube.com/watch?v=SgBj7Mc_4sc
Book – The Ins and Outs of Poop by Thomas R. Duhamel Available at some libraries, and for purchase online
Services Available
Description
Website
Health Link has Registered Dietitians available to answer nutrition
questions. Call 8-1-1 and ask to talk to a Dietitian.
Visit Health Link
for more information.
Alberta Health Services has a variety of programs available across
Alberta. To learn more about programs and services offered in your
area, visit the AHS Nutrition Services Website.
www.ahs.ca/nutrition
Last Updated: October 2022 15 of 17 Back to Algorithm
APPENDIX A – Organic etiology of childhood constipation
Anatomic Neuromuscular Systemic Drugs Toxins
• Anal stenosis
• Imperforated anus
• Pelvic mass
• Hirschsprung’s
disease
• Spinal cord
anomalies/trauma
• Colonic dysmotility
• Abnormal abdominal
musculature
• Celiac disease
• Hypothyroidism
• Hypercalcemia/
hypokalemia
• Diabetes
• Dietary protein allergy
• Multiple endocrine
neoplasia (rare)
• Cystic fibrosis
• Antidepressants
• Chemotherapy
• Opiates
• Anticholinergics
• Vitamin D
intoxication
• Lead poisoning
• Botulism
Medical conditions presenting with constipation or inability to pass normal stools:
More likely in a neonate/infant, especially with clinical presentation of bowel obstruction (abdominal distention,
failure to pass meconium, bilious vomiting):
• Imperforated anus indicates congenital anorectal malformation, possible urogenitary tract and other
congenital anomalies.
• Hirschsprung’s disease due to absence of ganglion cells in the rectum that are responsible for relaxation
of the internal anal sphincter, diagnosed by rectal biopsy.
• Spinal cord anomalies, with/without associated anorectal anomalies, like spina bifida occulta, tethered
cord, spinal tumor may be asymptomatic or lead to sensory-motor abnormalities, including neurogenic bowel
and bladder. It is extremely rare for dysraphism to result in soiling or constipation in the absence of
abnormal bladder control. See Physical exam paragraph.
• Cystic fibrosis presenting with meconium ileus (the obstruction of the terminal ileum with inspissated
meconium).
• Dietary protein allergy may present with straining, hematochezia, and mucosy stools in an infant. The role
of dietary protein allergy in constipation continues to be disputed but a 4-week trial off dairy in cases of
unresponsive functional constipation can be considered.
• Botulism – constipation typically is an initial symptom followed by progressive weakness (weak cry, poor
feeding, dehydration, hypotonia, hyporeflexia)
More likely in young children
• Celiac disease – the “classic” presentation with weight loss, malnutrition, diarrhea and abdominal distention
in toddlers has been mostly replaced by later and less severe presentation with a variety of gastrointestinal
and non-gastrointestinal symptoms. Although diarrhea still happens more frequently, constipation may be
present in less than 10% of older children, who may also have short stature, poor weight gain, iron
deficiency anemia and other non-gastrointestinal symptoms.
• Hypothyroidism presenting with constipation alone in children is very unlikely unless associated with
concomitant growth failure and/or obesity and short stature, or genetic predisposition (trisomy 21).
• Constipation is common in patients with cystic fibrosis presenting with malnutrition, pulmonary disease,
steatorrhea, abdominal distention, and rectal prolapse. Lack of stools with abdominal distention, poor
appetite, nausea and/or vomiting associated with RLQ mass may indicate distal ileal obstruction in a CF
patient.
• Diabetes of any type (mellitus, nephrogenic, central) can be associated with constipation in childhood
secondary to dehydration.
• Hypokalemia must reach level 2.5- 3 mEq/L to cause constipation and will likely be accompanied by muscle
weakness, cramps and myalgia.
Last Updated: October 2022 16 of 17 Back to Algorithm
• Hypercalcemic disorders in children may present with hypotonia, poor feeding, vomiting, constipation,
abdominal pain, lethargy, polyuria, dehydration, failure to thrive, and seizures. In severe cases renal failure,
pancreatitis and reduced consciousness may also occur and older children and adolescents may present
with psychiatric symptoms. In children (especially infants), they are more likely due to genetics than acquired
causes.
• Patients with inherited multiple endocrine neoplasia (MEN) develop parathyroid tumors (and other
endocrine tumors) resulting in hypercalcemia. MEN3 causes intestinal autonomic ganglion dysfunction
instead leading to dysmotility and megacolon.
• Lead poisoning is generally asymptomatic but can present with abdominal pain, constipation, anemia,
fatigue, hearing loss, neuropathy, neurotoxicity, encephalopathy, or renal disease.
More likely in adolescents:
• Celiac disease, hypercalcemic disorders, slow transit constipation, spinal cord trauma, drugs
APPENDIX B – Stool frequency
11
1 – 4 weeks after
birth
• Average of 2–3/day for formula fed infants.
• Average of 4/day for breastfed infants from one to two weeks of age.
• Expected range from once every two days to 6/day at 4 weeks of age
1 – 2 months
• Frequency tends to decrease with age in both breastfed and formula fed infants, for term
and preterm infants, especially after one month of age.
• Expect exclusively breastfed infants continue to stool more frequently than formula-fed
infants until 8 weeks of age.
• Some healthy exclusively breastfed babies > 2 weeks may have infrequent soft stool
occurring once in 1-2 weeks or even longer. This is probably normal but requires an
assessment for red flags if there is no stool for 2 weeks.
2 -6 months
• ~1 – 2 stools/day, but many infants have fewer than that.
6 months – 3
years
• Once solids are introduced (after 6 months), stool frequency decreases to an average of
2/day (with a range of 1-3).
3+ years
• ~1/day is usual but it can be as few as 3/week as long as stools are soft and easy to pass.
Range once every two days to 3/day.
APPENDIX C – Rome diagnostic criteria for Irritable Bowel Syndrome
Must include all of the following for at least two months before diagnosis:
1. Abdominal pain at least 4 days per month associated with one or more of the following:
a. Related to defecation
b. A change in frequency of stool
c. A change in form (appearance) of stool
2. In children with constipation, the pain does not resolve with resolution of the constipation (children in whom
the pain resolves have functional constipation, not irritable bowel syndrome)
3. After appropriate evaluation, the symptoms cannot be fully explained by another medical condition
11
Steer CD, Emond, AM Golding, J, Sandhu, B. The variation in stool patterns from 1 to 42 months: a population-based
observational study. Arch Dis Child. 2009;94:231-4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/18676434
Last Updated: October 2022 17 of 17 Back to Algorithm
APPENDIX D – Bristol Stool Chart
12
12
Reproduced with no changes from Figure 1 in Heidelbaugh, Joel & Andino, Nicole & Pineles, David & Poppers, David. (2021).
Diagnosing Constipation Spectrum Disorders in a Primary Care Setting. Journal of Clinical Medicine. 10. 1092.
10.3390/jcm10051092.
Licensed under Creative Commons attribution license
.
