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INTRODUCTION — Constipation is common among children, accounting for an estimated 3 to 5 percent of all visits to pediatricians. Functional constipation is an umbrella term that encompasses a group of disorders associated with persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of a structural or biochemical explanation (table 1) .
Fecal incontinence, also known as encopresis or soiling, refers to the repetitive (voluntary or involuntary) passage of stool in children four years of age and older, at which time a child may be reasonably expected to have completed toilet training and to exercise bowel control. Fecal incontinence is usually associated with chronic constipation and functional fecal retention. However, it may occur in the absence of fecal retention, in which case it is termed non-retentive fecal incontinence. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations and evaluation", section on 'Functional fecal incontinence'.)
The treatment of chronic functional constipation and fecal incontinence in infants and children will be discussed here. Related material is presented in the following topic reviews:
TREATMENT OF INFANTS — Constipation is treated somewhat differently in infants as compared with children. When constipation presents early in life, the clinician should be particularly alert for evidence of organic disease, including cystic fibrosis and Hirschsprung disease. Guidelines and an algorithm for diagnosing and treating constipation in infants were developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), and are included in a clinical guideline at the NASPGHAN website (www.naspghan.org) . The functional and organic causes of constipation in infants are discussed in a separate topic review. (See "Functional constipation in infants and children: Clinical features and differential diagnosis", section on 'Differential diagnosis'.)
Infants with functional constipation frequently respond to treatment with nondigestible osmotically active carbohydrates, such as sorbitol-containing juices (eg, apple, prune, or pear). Dark corn syrup has been used in the past. However, preparations of dark corn syrup may not contain the glycoproteins that are fermented into osmotically active particles in the colon, so the syrup may be ineffective for treating constipation. If these measures are unsuccessful, addition of osmotic laxatives and/or occasional disimpaction with glycerin suppositories can be useful. However, glycerin suppositories should be used with caution because they can enhance anal irritation and cause the symptoms to become chronic. (See "Prevention and treatment of acute constipation in infants and children", section on 'Infants' and 'Laxatives' below.)
The choice of medications for treatment of functional constipation in infants is similar to that in children (see 'Treatment of children' below).
However, there are some important differences in treatment decisions for infants:
●Osmotic laxatives such as lactulose or sorbitol are frequently used and are usually effective in infants. The use of polyethylene glycol without electrolytes (PEG-3350, or Miralax) for infants and toddlers <24 months of age was reported in two small case series [3,4]. The treatment was generally effective and no adverse effects were noted in either study. The mean effective maintenance dose was approximately 0.8 g/kg body weight per day. Thus, experience with polyethylene glycol is increasing in infants, although the safety is less well established than with older age groups.
●Mineral oil is not recommended in infants, or in other children prone to gastroesophageal reflux, because of potential risks of pneumonitis if aspirated.
TREATMENT OF CHILDREN
Overview — Treatment of chronic functional constipation and fecal incontinence typically requires a comprehensive program, including the use of laxatives, behavior changes, and dietary changes [2,5-10]. Multimodal therapy is particularly helpful for children who have gone several days between bowel movements, have an anal fissure with bleeding, or have very large-diameter stools with marked straining. The type and intensity of the intervention should be tailored to the severity of constipation and the child's developmental stage, and close follow-up is often necessary.
Treatment for chronic constipation is based on the concept that chronic constipation causes the colon to be unresponsive to stool burden, due to distension. It follows that effective treatment requires consistent and complete emptying of the colon, so that it becomes conditioned to work on its own, a concept known as "bowel retraining". There are four general steps in bowel retraining:
●Prolonged laxative treatment and behavior therapy to achieve regular evacuation and avoid recurrent constipation
●Dietary changes (primarily increasing fiber content) to maintain soft stools
●Gradual tapering and withdrawal of laxatives as tolerated
The goal of therapy is the passage of soft stools, ideally once per day, and no less than every other day. This goal of frequent defecation is important to overcome constipation, although less frequent defecation patterns are common and acceptable in children without a history of constipation. Weeks to months, and sometimes years, of laxative and behavior therapy may be necessary before this goal is achieved. The child's parents or caretakers must be effectively educated about bowel retraining and behavior modification so that they can carry out the sustained treatment. Ultimately, improvement can be expected in most patients. (See 'Prognosis' below.)
The combined laxative and behavioral approach has been used since the 1960s . It has been evaluated in only a few controlled studies [12-14] but is largely supported by cohort studies, case-control studies, and clinical experience [15-22]. Analysis of intervention trials is complicated by the varied methods used for laxative and behavioral treatments. Consequently, conclusions also vary, but generally support the use of combination therapy with both of these modalities. As an example, a large study found that the combination of behavioral intervention and laxative therapy was more effective than behavioral therapy alone (achievement of remission: 63 versus 43 percent, respectively) . Another study showed that combination therapy was more effective than laxative therapy alone (improvement rates: 78 versus 45 percent, respectively) , whereas a similar randomized study did not show such an effect . A systematic review concluded that combined behavioral and laxative treatment was more effective than either intervention alone . Evidence supporting biofeedback was lacking [10,13].
Guidelines for management of infants and children with constipation were developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) . These guidelines include a management algorithm, and are available at the society's website (www.naspghan.org).
The following tables summarize a typical treatment plan for children with chronic constipation; details are provided in the remainder of this topic review:
●For children with chronic constipation but without overflow fecal incontinence (table 2)
●For children with chronic constipation and fecal incontinence (table 3)
Parental education — Effective education of the parents and child with regard to constipation is crucial in changing chronic behavior patterns [2,24]. Treatment requires a team approach involving the patient, family, and healthcare provider . A primary goal is to remove negative attributions. The parent or caretaker must understand that soiling due to overflow incontinence does not constitute willful and defiant behavior by the child but represents physiologic loss of continence. The child should therefore not be scolded, or otherwise punished, for soiling episodes [25,26]. In toddlers with constipation, toilet training should be postponed since it will not be successful until rectal awareness is restored and defecation is pain free . (See "Functional constipation in infants and children: Clinical features and differential diagnosis", section on 'Etiology'.)
The child's parent or caretaker should be provided with verbal and printed information. Printed information should be written in easy-to-understand lay language, with descriptions of the problem and the methods that will be used to solve it. The following diagram can be used to explain how and why the constipation became chronic, how constipation can cause encopresis, and the concept of bowel retraining (figure 1). The clinician can use this to explain that once the constipation has been relieved, it may be some time before the nerves in the colon readjust and the child learns to sense stool in the rectum and to properly coordinate the newly conditioned muscles. The predominant theme of the management program is that of rebuilding the rectal muscles to control the bowels . Parents should be advised that this process can take as long as six months to several years. Because parents are often concerned about the safety of long-term laxative use, it is important to explain the need for laxatives and the safety of the type of laxative that will be prescribed. Regular follow-up and ongoing support and encouragement to the parents and child during periodic office visits or phone conversations are essential. (See 'Overview' above and 'Follow-up' below.)
In severe cases, the parents and/or clinician may need to enlist the help of the school and teacher . Some children may benefit from access to a private bathroom. The teacher should be sensitive to the child's problem, permitting him or her to use the bathroom whenever requested (often by a prearranged, unobtrusive signal to avoid drawing attention). In addition, it may be helpful to have a change of clothing available in case a soiling episode occurs.
Disimpaction — "Fecal impaction" is a term used to describe markedly increased amounts of stool in the colon, which is a subjective judgement based on clinical findings.
The majority of children who come to medical attention because of chronic constipation have fecal impaction, and will benefit from a regimen to disimpact the rectum before beginning maintenance therapy [2,24,27]. This step is sometimes described as a "clean-out" in discussions with patients and their family. We suggest a disimpaction step for children with any of the following characteristics:
●Constipation-associated fecal incontinence
●Significant stool mass palpable on digital rectal or abdominal examination, or on abdominal radiograph
●History of incomplete or infrequent evacuation
Disimpaction and catharsis can be effectively accomplished with oral or nasogastric medications, rectal medications, or a combination. The parents and child should be involved in the decision regarding the appropriate route . Disimpaction can usually be performed in the outpatient setting . It is important to assess the response to the regimen as soon as possible after it is completed. Successful disimpaction is usually indicated by abundant fecal production and decreased episodes of soiling, as reported by the parents .
Hospitalization may be necessary if several attempts of outpatient management have failed to yield abundant stool. Inpatient regimens may include nasogastric administration of a balanced electrolyte solution (eg, GoLYTELY) to flush out the colon . If the there is a large impaction by exam or radiograph, it is prudent to first remove some stool distally by digital disimpaction, rectal softening (mineral oil retention enema), stimulant rectal suppositories, and/or enemas. In this setting, beginning nasogastric solutions first may result in vomiting. Pulsed irrigation enhanced-evacuation systems  and enemas with Gastrografin are other techniques that have been successfully used for disimpaction when standard oral and rectal disimpaction regimens described above have not been successful [30-32]. These enemas can be administered in or out of the hospital. Consultation with a pediatric gastroenterologist should be considered if disimpaction is unsuccessful or if hospitalization is necessary .
Oral medications — For children with fecal impaction, we generally suggest oral medications for disimpaction because this method is noninvasive and may help the child feel in control . Oral medications also are particularly valuable for children with a history of painful defecation, perineal trauma, or difficulty tolerating enemas [5,28]. However, adherence with the necessary volume may be difficult, and two to three days (up to a maximum of six days, sometimes split between two weekends) of treatment are often needed to achieve complete disimpaction .
Polyethylene glycol (PEG) without electrolytes, PEG-electrolyte solutions, or high-dose mineral oil have all been shown to be effective for initial disimpaction [28,34-39]. The PEG without electrolytes is generally the most palatable of these options and better accepted by children . The doses are as follows:
●Polyethylene glycol 3350 (PEG without electrolytes; Miralax and others) – 1 to 1.5 g/kg/day by mouth for up to six days. The daily dose is dissolved in approximately 10 mL/kg of water or flavored beverage. In a randomized placebo-controlled study, these doses successfully disimpacted 95 percent of children with chronic constipation . For patients with inadequate disimpaction using six days of PEG-based treatment at home, rectal medications or PEG-electrolyte cleanout in the hospital should be considered. Of note, PEG 3350 was found to be as effective as enemas in treating impaction, but children treated with PEG had more fecal incontinence . Further safety studies are needed before this approach can be recommended in infants.
●Polyethylene glycol-electrolyte solution (eg, GoLYTELY) – 25 mL/kg per hour to a maximum of 1000 mL/hr by nasogastric tube until stool appears clear, or 20 mL/kg per hour for four hours per day . We suggest nasogastric administration because most children are not able to take sufficient quantities of this solution by mouth. The rate of the PEG-electrolyte infusion should be slowed if the child develops vomiting or abdominal distension. Bowel perforation has been reported in children undergoing bowel disimpaction with nasogastric PEG-electrolyte solutions, especially in patients with previous bowel surgeries, who may have unrecognized sub-acute bowel obstruction due to a stricture or an adhesion.
●Mineral oil – 15 to 30 mL per year of age, up to 240 mL per day by mouth. Mineral oil should not be used for infants, neurologically impaired children, and others at high risk for gastroesophageal reflux, because of risks of pneumonitis if the oil is aspirated [40,41].
Other oral agents that have been used successfully for disimpaction, but for which controlled trials are lacking, include magnesium hydroxide , magnesium citrate , lactulose , sorbitol, senna, and bisacodyl .
Rectal medications — For patients with severe impaction, we prefer to use rectally administered medications rather than oral medications because stimulants can cause intense discomfort and may not be effective in this setting. In addition, rectal medications are more rapidly effective than oral medications for disimpaction and may be a powerful motivator for toilet sitting [2,16]. However, enemas are invasive and may be difficult to administer to an uncooperative or fearful child . (See 'Behavior modification' below.)
●Sodium phosphate enema – 1.13 ounce (33 mL) enema for children 2 to <5 years; 2.25 ounce (66 mL) enema for children 5 to 12 years; and 4.5 ounce (133 mL) enema for children ≥12 years. These enemas should not be used in children younger than two years of age. This dose may be repeated once within 12 to 24 hours, if necessary. More frequent dosing should be avoided because there are several case reports of life-threatening hyperphosphatemia and hypocalcemic tetany, particularly in young children, those with colonic dysmotility, and/or with repeated administration of enemas [45-48]. Phosphate-based enemas should be avoided in children with renal insufficiency. Because these are small-volume enemas, the caregiver should be instructed to point the tip of the enema device toward the child's back after it is inserted, to direct the contents toward the bowel wall where it will be effective, rather than into the fecal mass.
●Saline enema –This can be administered using a dose of 10 to 15 mL per kg.
●Mineral oil enema – 2.25 ounce (66 mL) enema for children 2 to 12 years of age, and 4.5 ounce (133 mL) enema for children ≥12 years.
Bisacodyl suppositories may be used for older children, and glycerin suppositories for infants [2,49]. These approaches are generally not as effective as enemas but are well tolerated. We do not recommend the use of enemas made of soapsuds [50,51], tap water [52,53], milk and molasses , magnesium (ie, Epsom salt) [55-57], or herbal formulations  because of potential complications, which include colitis, water intoxication, bowel perforation, and bowel necrosis [2,6].
Oral and rectal — Combination treatment with oral and rectal medications is often the most effective approach for moderate or severe fecal impaction. A protocol that combines polyethylene glycol 3350 (PEG without electrolytes), mineral oil, and sodium phosphate enemas is outlined in the table (table 3). In this case, the initial treatment is with oral medication to soften the stool, and rectal medication is added on day two to help evacuate the impacted stool. An alternative combination approach consists of three to four consecutive three-day cycles in which a phosphate sodium enema is administered on day one, a bisacodyl suppository on day two, and bisacodyl tablet (10 mg) on day three [5,24].
Laxatives — After disimpaction, patients should be treated with a maintenance regimen of oral laxatives to "retrain" the bowel and avoid reimpaction, which could restart the constipation cycle. Adequate doses of medication should be given to maintain a pattern of soft bowel movements once or twice a day. It is important to start this maintenance regimen of laxatives immediately after disimpaction to avoid reaccumulation of stools.
The practice of prolonged treatment with osmotic laxatives is supported by extensive clinical experience and a few randomized controlled trials. The best studied medication is PEG without electrolytes, which appears to be efficacious and safe, although based on low quality evidence . Expert opinion and guidelines encourage aggressive treatment; early intervention appears to lead to more rapid recovery [2,27].
The laxatives that are considered safe and are used most often for children include polyethylene glycol 3350, magnesium hydroxide (milk of magnesia), lactulose, and mineral oil. The type of laxative is not as important as using an adequate dose and ensuring compliance; the choice should be individualized according to circumstances, familiarity, and the child's acceptance [16,27]. The dose should be based upon age, body weight, and severity of constipation (table 4). There is no evidence that tolerance develops to osmotic or lubricant laxatives, and very little evidence that this is a problem for stimulant laxatives such as senna or bisacodyl . However, in the author's personal experience, children treated with senna seem to have more difficulty weaning off of medication as compared with those treated with bisacodyl or other medications.
Parents should be advised to adjust the laxative dose according to the response, and to increase the dose every two days until the child has one or two soft stools each day, or to decrease it if the patient develops diarrhea. Parents should be warned that some leaking or soiling may continue at first, especially if the child fears or continues to resist having a bowel movement.
After starting the laxative treatment, parents should be advised to encourage the child to use the toilet for 5 to 10 minutes at the same time each day, preferably after breakfast or dinner. In children who are not fully toilet trained, we delay this toileting plan until the child has had at least two to four weeks of effective laxative treatment, to make sure that he or she is not experiencing any pain or hard stools when using the toilet. However, the toileting regimen can be started sooner or later, depending on the child's readiness. If the child fails to have a bowel movement for several days, it may be necessary to use an enema to empty the rectum and then increase the laxative dose. If soiling recurs, disimpaction, as described above, may be necessary . (See 'Behavior modification' below and 'Disimpaction' above.)
Polyethylene glycol — PEG without electrolytes (polyethylene glycol 3350; eg, MiraLax, Glycolax, or Restoralax) is an osmotic laxative. Because it is more palatable and has fewer adverse effects than other agents, PEG without electrolytes is preferred by most experts for disimpaction and treatment of chronic constipation, although it is not yet labeled for this use . It is approved for short-term management of constipation in adults and is available without prescription in the United States. Adverse effects include diarrhea (10 percent), bloating or flatulence (6 percent), and abdominal pain (2 percent) . These symptoms tend to be mild, transient, and responsive to dose reduction . Short- and long-term studies revealed no significant changes in serum electrolytes or other laboratory tests during treatment with PEG [4,62]. A study is in progress to address questions raised about whether there are any adverse effects of PEG 3350 metabolites in children. In the interim, NASPGHAN has published a statement with frequently asked questions about the use of PEG in children .
The typical dose is 0.4 to 0.8 g/kg per day (up to 17 g) (table 4) [61,64-66]. In a dose-ranging trial, the dose of 0.4 g/kg/day was most likely to give high success rates (74 percent) while generating fewer complaints of abdominal pain or fecal incontinence than higher doses . The effective dose in an individual patient is not predictable, and many patients require relatively high doses for initial treatment of constipation, with somewhat lower maintenance doses. Therefore, we suggest an empiric approach to dosing. In our practice, we use an initial dose of 4 tsp (17 g = approximately 3.5 tsp) for patients weighing 20 kg or more, increased or decreased by 1/2 tsp to 1 tsp every other day until the consistency of the stools is soft to loose. We have rarely had to use more than 6 to 7 tsp per day. For patients weighing less than 20 kg, it is reasonable to use a slightly lower initial dose (0.4 to 0.8 g/kg/day), with dose adjustments up or down to achieve soft stools. Further dose-ranging trials are needed to determine optimal dosing, especially in children requiring long-term PEG treatment .
Clinical trials indicate that PEG without electrolytes has efficacy greater than or similar to that of lactulose and magnesium hydroxide with fewer adverse effects and greater acceptance [36,62,68,69]. In particular, a systematic review concluded that PEG is superior to either lactulose or milk of magnesia, for outcomes of higher frequency of bowel movements and reduced need for additional therapy, although the difference was small and the quality of the evidence was weak . Patients tolerated PEG as well or better than the other therapies, suggesting the possibility that PEG is associated with improved treatment adherence (eg, 95 versus 65 percent in one study) .
Oral preparations of PEG with electrolytes (Transipeg, Movicol, Movicolon) are available outside the United States. The addition of electrolytes offers the theoretical benefit of avoiding electrolyte depletion, but this also alters the taste, which may decrease palatability. One trial from the Netherlands compared the efficacy of PEG with electrolytes (Transipeg) to lactulose in 100 children with functional constipation . Compared with the pretreatment period, defecation frequency increased, and episodes of fecal incontinence decreased in both groups after eight weeks of therapy. However, success (defined as ≥3 bowel movements per week and ≤1 episode of fecal incontinence every two weeks) occurred more frequently in the PEG group (56 versus 29 percent). Children in the PEG group reported less abdominal pain, straining, and pain at defecation, but complained of bad taste more often than those in the lactulose group. Similar results were reported in a smaller study .
Mineral oil — Mineral oil is a lubricant laxative that was the mainstay of therapy for chronic constipation and fecal incontinence in the past. It has largely been replaced by osmotic laxatives, which are more palatable and easier to administer, and are at least as effective as mineral oil. There is a theoretic concern that chronic use of mineral oil may interfere with the absorption of fat soluble vitamins, but any effects are probably clinically insignificant. In addition, this effect can be minimized by administering it in the mid-afternoon and at bedtime, and/or by prescribing a daily multivitamin [5,11,60,71].
Mineral oil, particularly in large amounts, may not be palatable in children. It may be more palatable if served chilled and mixed in a 1:1 ratio with a fat-containing food that the child likes (eg, pudding, yogurt, chocolate syrup) . Families should be warned about the possibility of anal leakage of mineral oil, which may stain clothing or furniture. Typical doses are 1 to 3 mL/kg daily, with dose adjustment to achieve soft stools (table 4). If anal leakage of oil occurs, this usually indicates a need for disimpaction, or that the dose of mineral oil is excessive.
In one randomized trial in 37 children (3 to 13 years) with chronic functional constipation, mineral oil compared favorably to senna concentrate (a stimulant laxative) in symptom control, frequency of recurrence, and duration of therapy .
Mineral oil can cause a dangerous lipoid pneumonia if aspirated. Therefore, it should not be used in patients at risk for aspiration, including infants (<12 months of age), children with neurodevelopmental abnormalities, or those with gastroesophageal reflux.
Magnesium hydroxide — Magnesium hydroxide (milk of magnesia) is an osmotic laxative that has a long history of success but has been largely replaced by PEG because of palatability, and possibly lower efficacy . It releases cholecystokinin, which stimulates gastrointestinal motility and secretion. Magnesium hydroxide should be avoided in infants or patients with renal insufficiency since they are susceptible to hypermagnesemia [73-76]. Typical doses are 1 to 2 mL/kg, once daily (table 4).
Lactulose — Lactulose is an osmotic laxative and is usually well tolerated in the long-term . Lactulose is not absorbed by the small intestine. Some patients report loss of effectiveness over time, presumably due to altered degradation by the colonic bacteria. Side effects include flatulence and abdominal cramps, which occur when the sugar is metabolized by colonic flora. Typical doses are 1 mL/kg (up to 30 mL), once or twice daily (table 4).
Stimulant laxatives — Stimulant laxatives, such as senna and bisacodyl, are sometimes used for brief periods to avoid recurrence of impaction ("rescue" therapy), and their use for this purpose is supported by extensive clinical experience and expert guidelines , although controlled trials on the use of these agents for constipation in children are lacking . Traditionally, concerns were raised about the possible development of tolerance or physical dependence with chronic use of stimulant laxatives. The issue has not been systematically studied in humans, but it appears that most patients remain responsive to these drugs with chronic use . Nonetheless, most pediatric providers reserve stimulant laxatives for patients with severe constipation who do not respond to osmotic laxatives and dietary changes, preferably under supervision from a pediatric gastroenterologist . These laxatives are often used in conjunction with a stool softener such as docusate (Colace) or lubricant such as mineral oil. Stimulant laxatives also may be helpful for patients with anorectal malformations or other disorders that affect anorectal innervation, which can affect sensory and motor function and predispose to both constipation and fecal incontinence .
Newer pharmacological agents — Newer drugs that are used for adults with chronic constipation include the secretory agents linaclotide (Linzess), a guanylate cyclase receptor agonist, and lubiprostone (Amitiza), a chloride channel activator. One pediatric study reported that the side effects of lubiprostone were similar to those in adults, however, this study was not specifically designed to evaluate efficacy . Studies to evaluate efficacy of lubiprostone to treat functional constipation in children are ongoing. These drugs are approved in the United States for chronic constipation in adults but are second-line agents (bulk-forming and osmotic laxatives are preferred). Prucalopride (Resotran, Resolor), a serotonin receptor agonist that enhances bowel motility, is approved and available in Europe and Canada, but not in the United States. Although clinical trials have suggested that prucalopride is efficacious in adults, a large randomized study in children found no efficacy compared with placebo . These findings do not exclude the possibility that prucalopride may be effective for subsets of children, such as those who are older (≥12 years of age) or perhaps those who have slow-transit constipation . (See "Management of chronic constipation in adults", section on 'Pharmacologic therapy'.)
Behavior modification — Behavior modification is used to recondition the child to normal bowel habits. It is important to educate the child's parents about the pathogenesis of constipation, including the cycle of pain, stool withholding, and encopresis, as discussed above (figure 1). This will help the parents understand the treatment process and improve their adherence to the protocol. (See 'Parental education' above.)
The typical behavior modification program for chronic constipation includes :
●Toilet-sitting – The child's parents or caretakers should organize, encourage, and supervise a program of regular toilet-sitting. The child should sit on the toilet shortly after a meal, for 5 to 10 minutes, two to three times per day . Toilet sitting episodes should occur at the same time each day and be timed with a timer or stopwatch . The routine should be followed every day, particularly during times of transition (eg, holidays, vacations, or weekends) . The child's adherence to the program should be encouraged with positive reinforcers as described below, rather than negative reinforcers (criticism or punishment). For children whose feet do not touch the floor sitting on a regular toilet seat, it is helpful to use a stool for foot support. (See "Prevention and treatment of acute constipation in infants and children", section on 'Toilet training'.)
●Reward system – The parents or caretakers should implement a reward system that is tailored to the child [5,84] and in which the reward is provided for effort (ie, toilet sitting) rather than success (ie, evacuation in the toilet) [17,85,86]. Rewards for preschoolers may include stickers or small sweets, reading books or singing songs while sitting, or special toys that are only used during toilet sitting . Rewards for school-aged children may include reading books together, activity books, or hand-held computer games that are only used during sitting time, or coins that can be redeemed for small drug-store items .
●Monitoring – The parents or caretaker should use a diary or log to record bowel movements, the use of medication, and episodes of fecal incontinence, abdominal pain, and wetting. A sample of such a diary and a blank one that can be printed out for use by patients are shown in the following figures (figure 2A-B).
Dietary changes — During the treatment of fecal incontinence and/or chronic constipation, it is important to ingest a diet that is conducive to fecal regularity [2,24]. Increased intake of fruit and raw vegetables, bran, and whole-grain breads and cereals is commonly recommended, as is adequate intake of fluids other than milk. However, the evidence supporting these interventions is weak, especially in moderate to severe constipation.
Fiber — Increasing the intake of fiber, through dietary changes or fiber supplements, is often recommended for acute and chronic constipation. However, the evidence base for this practice is weak and somewhat conflicting [2,87-91]. This may be because dietary fiber can have either beneficial or adverse effects in children with constipation, especially in the setting of chronic constipation and recurrent impactions. On the one hand, fiber adds bulk and water content to the stool; this can make the stool softer and easier to release. On the other hand, the increased stool bulk also may cause greater distension of the rectum and colon in children with fecal retention, and interfere with the child's ability to sense the need to defecate. Moreover, if there is inadequate accompanying fluid intake, impactions can occur.
Therefore, we suggest a balanced diet that includes whole grains, fruits, and vegetables as a component of the treatment of constipation in children (table 5A-B). Dietary changes should not be forced, nor should they replace the other interventions described above. It is reasonable to avoid dietary changes in the initial management in order to limit the battle fronts to medications and toileting behaviors. For children with acute or mild chronic constipation, a reasonable target for dietary fiber can be calculated as the child's age plus 5 to 10 grams/day (ie, 11 to 16 grams/day for a six year old child). Giving more than this fiber goal has no proven benefit for management of constipation in children  (see "Prevention and treatment of acute constipation in infants and children", section on 'School entry'). For children with a history of fecal impaction, extra fiber intake should be encouraged only after colorectal tone has been restored, eg, after several months of successful treatment with laxatives .
Adequate intake of fiber may be particularly important during the time that laxative therapy is discontinued, when the increased stool bulk may raise the child's awareness of the need to evacuate . Supplementation with glucomannan was a useful adjunct to disimpaction and behavioral interventions in a small, randomized trial . If necessary, a variety of fiber products are available over the counter (table 6). These include powdered fiber that can be mixed in juice (and frozen into popsicles), wafers, or tablets .
Fluid intake — There is no evidence that constipation can be successfully treated by increasing fluid intake unless the patient is clinically dehydrated. To ensure adequate hydration, children with chronic constipation or fecal incontinence should be encouraged to consume at least 32 to 64 ounces (960 to 1920 mL) of water or other non-milk liquids per day, particularly if they are using fiber supplements.
Whether increasing fluids beyond the usual intake affects constipation is unclear. In one study, 108 prepubertal children (2 to 12 years of age) with moderate to severe simple constipation were randomly assigned to one of three groups: one was instructed to increase daily water intake by 50 percent; the second was asked to ingest additional hyperosmolar liquids such as juices; and the third to make no changes . There were no changes regarding stool frequency, consistency, or ease of defecation with either intervention.
Cow's milk — In children whose constipation is unresponsive to other measures, and especially in those with atopic symptoms, we suggest a trial for at least two-weeks of eliminating all cow's milk protein from the diet [2,15,93]. If the constipation improves substantially, the diet should be continued. A non-dairy form of milk (eg, soy) can be used as a substitute.
We suggest this approach because eliminating cow's milk from the diet improves constipation in some children. This is particularly true in children with atopic symptoms, probably because of an occult cow's milk intolerance [93,94]. In one double-blind crossover study in 65 constipated children who were refractory to laxative therapy, 68 percent of children improved while receiving soy milk compared with cow's milk [95,96]. Constipation recurred within days of reintroduction of cow's milk. Another study suggested that constipation can be a delayed clinical manifestation of cows' milk protein intolerance, particularly in children with a personal or family history of atopy .
Although not clinically proven, it is also possible that excessive consumption of milk may contribute to constipation in some children, even in the absence of cow's milk protein intolerance. The proposed mechanism is that cow's milk slows intestinal motility and satiates the child, thereby diminishing the intake of other fluids and fiber-containing foods. This mechanism may be most relevant for toddlers, who are most likely to have a high intake of milk and low intake of dietary fiber. Therefore, we recommend limiting the intake of cow's milk to 24 fluid ounces (720 mL) per day. (See "Prevention and treatment of acute constipation in infants and children", section on 'Toilet training'.)
Probiotics — The evidence available from controlled trials in children and adults is insufficient to support a recommendation about use of probiotics to treat constipation in children, let alone identify the most effective strain, dose, or treatment duration .
Probiotics, defined as live microorganisms which when administered in adequate amounts confer a health benefit on the host, are being evaluated in the management of constipation in adults and children. The most widely studied organisms are within the genera Bifidobacterium and Lactobacillus. (See "Probiotics for gastrointestinal diseases", section on 'Constipation'.)
The hypothesis that probiotics may have therapeutic potential for the treatment of constipation is supported by data demonstrating differences in the intestinal microbiota between healthy individuals and patients with chronic constipation . Administration of Bifidobacterium or Lactobacillus has also been shown to improve colonic transit times in constipated patients [99,100]. Only a few clinical trials have addressed the use of probiotics for constipation, with mixed results. A randomized trial in 60 children found that the addition of Lactobacillus sporogenes to mineral oil increased stool frequency and reduced straining and soiling as compared with children treated with mineral oil alone . A smaller randomized trial found a significantly higher defecation frequency in patients receiving Lactobacillus casei rhamnosus Lcr35 (n = 18) compared with placebo (n = 9) . Furthermore, a large trial found that Lactobacillus reuteri given prophylactically to young infants helped to prevent the development of constipation during the first three months of life . However, negative results were reported in another randomized trial, in which 84 children were randomized to lactulose plus Lactobacillus rhamnosus GG or a lactulose-containing placebo for 12 weeks . There were no differences between the experimental and control groups in terms of spontaneous bowel movements or fecal soiling at 12 or 24 weeks of follow-up.
Follow-up — The management of chronic constipation requires monitoring by the clinician or clinician's staff to prevent recurrences. Planned follow-up is particularly important during the first few days of treatment, especially if disimpaction was warranted. The initial discussion can be by telephone, but the child may need to return to the office if he or she is still passing hard stools. Patients who require disimpaction also should have an office visit soon after completing the disimpaction protocol to review the details of maintenance therapy.
After entering the maintenance phase, the child should have regular follow-up visits, initially on a monthly basis and then less frequently (eg, every three to four months). The clinician should review the child's stool records (figure 2A-B) and repeat the abdominal and rectal examinations [16,105]. The follow-up visits provide opportunities to evaluate progress, adjust medication regimens, anticipate challenges, and celebrate successes . As laxative therapy is gradually discontinued, the importance of dietary and behavioral interventions should be reinforced.
TREATMENT FAILURE — Failure of treatment, manifested by continued soiling and recurrent impaction, suggests the need to review education and other treatment components. Most treatment failures are caused by inadequate medication or premature discontinuation . Poor adherence with the treatment program is another important cause of treatment failure. In some children, adherence to the medication or behavioral program may be impaired by behavior problems (eg, oppositional behavior, poor attention span, high activity level) [16,24,106]. Such patients and their families may benefit from individual or group psychotherapy and a more rigorous behavioral approach .
Repeated failure despite adequate compliance requires reconsideration of the diagnosis and the possibility of further testing . Patients with ongoing chronic constipation despite adherence to an optimal medical and behavioral intervention should be evaluated by anorectal manometry and/or balloon expulsion testing. Colon transit studies using Sitzmarkers or radioisotopes can help evaluate oro-anal transit and colon manometry studies and identify regional or pancolonic dysmotility. Slow transit or regional and pancolonic dysmotility have been associated with chronic refractory symptoms. These tests can help identify patients with internal anal sphincter achalasia or other anatomic causes of constipation, or dyssynergic defecation, which is a functional disorder characterized by the incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate. (See "Constipation in infants and children: Evaluation", section on 'Motility testing'.)
Biofeedback therapy is occasionally added as an adjunct to medical and behavioral therapy for the subset of patients with dyssynergic defecation, but it requires a highly motivated patient and its efficacy in the pediatric age group is uncertain. For patients with dyssynergic defecation, biofeedback therapy teaches patients how to relax pelvic floor muscles when defecating, by converting measurements of anal pressure or electromyographic activity into a simple visual and/or auditory signal. Because biofeedback requires serial learning sessions with an anal probe and exercises, it is only practical for use in highly motivated older children and adolescents. Biofeedback has been used with some success in adults with constipation , but studies in children have not shown any added benefit of biofeedback over laxatives alone [109-111]. (See "Management of chronic constipation in adults", section on 'Biofeedback'.)
DISCONTINUATION OF LAXATIVES — The goal of therapy is passage of soft normal caliber stools every one to two days, without fecal incontinence. In many cases, laxatives need to be taken for months and sometimes years [7,112] to induce daily soft stools . Once the child has achieved regular bowel habits (and independently uses the toilet), the frequency of mandatory toilet sitting and the use of laxatives can be reduced . The laxative dose is gradually decreased to a dose that will prevent soiling, and maintain one to two bowel movements per day .
We typically wait until optimal bowel habits are achieved and stable for at least six months before laxative use is further decreased or discontinued. Some children require ongoing laxative treatment for one or more years. Parents must be warned not to stop the laxative without consulting the child's clinician. Stopping laxatives too soon will lead to a prompt recurrence and disrupt the treatment program .
As laxative therapy is discontinued, it is particularly important to encourage compliance with the behavioral and dietary regimens . In addition, the parents and child should have a "rescue" plan if the child goes more than three days without a stool or has other indications of recurrence (ie, hard stools, abdominal pain, smears in the underwear) . The rescue plan may involve the use of an enema or suppository followed by an increase in the laxative dose. The development of such a plan empowers the child and family to anticipate, tolerate, and treat recurrences .
INDICATIONS FOR REFERRAL — Consultation with a pediatric gastroenterologist should be considered in children in whom oral or rectal medications are ineffective for disimpaction, and in whom dietary changes and laxative therapy are ineffective . Additional evaluation before or after consultation should include T4, TSH, calcium, celiac disease antibodies, and lead. For children with atypical features or constipation that is refractory to optimal medical and behavioral therapy, diagnostic testing may include tests of colonic transit and anorectal and colon manometry. (See "Constipation in infants and children: Evaluation".)
Anal sphincter release — Some children with constipation refractory to medical therapy may respond to an intervention to release the internal anal sphincter through injection of botulinum toxin or myectomy. The effect of the botulinum toxin treatment is temporary (lasting up to several months). For patients that respond to initial treatments, additional injections may be given every few months, as needed, to maintain efficacy over the long term. Limited information is available to guide selection of patients for surgical approaches .
●Internal anal sphincter (IAS) achalasia – IAS achalasia is characterized by lack of rectoanal inhibitory reflex on anal manometry with a rectal biopsy that demonstrates the presence of ganglion cells, thus excluding Hirschsprung disease. The clinical presentation is similar to functional constipation. Patients typically do not respond to optimal and persistent medical and behavioral regimen, prompting further workup with anorectal manometry.
For patients with IAS achalasia, both anal sphincter botulinum toxin or myectomy treatment are effective in 60 to 80 percent of patients. In a meta-analysis of studies comparing these treatments for IAS achalasia, patients undergoing myectomy reported more frequent bowel movements, and there were no significant differences in long-term laxative use between the two treatment modalities . Interestingly, short term fecal incontinence was more common with botulinum toxin injection compared with myectomy. Thus, myectomy appears to be more effective than botulinum toxin for some patients.
●Idiopathic constipation – Interestingly, patients without IAS achalasia (ie, no demonstrable abnormalities on anorectal manometry) also may respond to sphincter release. A systematic review reported good efficacy for both botulinum toxin injection and myectomy, but most of the included studies were small and had only brief follow up . The only randomized trial compared these treatments in 42 children with idiopathic chronic constipation unresponsive to laxative treatment . All patients had normal findings on anorectal manometry, with no evidence of IAS achalasia. Botulinum toxin and myectomy and yielded improvement in symptom severity score in 80 and 55 percent of patients, respectively. Thus, both groups showed improvement, but the symptom severity score and other measures of constipation were not significantly different between the two treatment groups.
Other — The rare patient with intractable constipation and normal anorectal manometry (or one who fails to respond to botulinum toxin injection) may be considered sacral nerve stimulation, or for other surgical approaches:
●Sacral nerve stimulation (SNS) appears to be a promising new treatment option for children with chronic constipation, especially those who are not responding to intensive medical management . Since it also helps to improve urinary incontinence, this treatment may be especially suitable for patients with combined fecal and urinary incontinence. Larger randomized studies with long-term follow-up are required. The experience with SNS in adults is described separately. (See "Fecal incontinence in adults: Management", section on 'Sacral nerve stimulation'.)
●Other surgical procedures include antegrade continence enema (ACE) [117-121], intestinal diversion (ileostomy or colostomy) [117,122], or colonic resection [117,123,124], as summarized in a systematic review . ACE provides a conduit for daily colonic irrigation, and is also used for patients with myelomeningocele and bowel dysfunction. (See "Overview of the management of myelomeningocele (spina bifida)", section on 'Bowel management'.)
A retrospective series of 44 patients reported the following outcomes :
•ACE was performed in 16 patients and had a satisfactory outcome in 10 (63 percent). These patients generally required ongoing ACE treatment throughout the follow-up period, but displayed some improvement in colonic motility after one year of treatment.
•Diversion procedures (with ileostomy or colostomy) were performed in 19 patients and had satisfactory outcomes in 18 (95 percent); intestinal continuity was reestablished in 14 (74 percent) at a mean of 27 months post diversion. Those with colonic dysmotility as documented by manometry underwent resection of the dysfunctional segment at the time of reanastomosis.
•Colonic resection was performed in nine patients and yielded satisfactory outcome in only two (22 percent), either because of persistent constipation or fecal incontinence. Four of the nine patients (44 percent) required a second surgical procedure. Somewhat better outcomes were reported in a separate systematic review .
Based on this and other anecdotal reports, we feel that colonic resection should not be offered as a treatment for refractory constipation. Rarely, ACE procedures and diversion via colostomy or ileostomy with subsequent resection and reanastomosis may be appropriate. A systematic review provides a summary of studies using these techniques, concluding that there is insufficient evidence to support one technique over the others .
PROGNOSIS — Improvement can be expected in virtually all patients who cooperate with the type of comprehensive approach described above [9,15,83,125,126]. On the other hand, complete recovery, defined as three or more bowel movements weekly with no or minimal soiling while off laxatives, is seen less often [15,16,18,127]. A systematic review was unable to identify factors that predict which patients would fail to respond to treatment .
Recovery rates increase significantly over time; they are approximately 30 to 50 percent after one year, and 48 to 75 percent after five years [15,18,126,129]. As an example, a follow-up evaluation of 97 patients treated in an encopresis clinic showed that 43 percent of a total of 97 patients (all of whom had been treated with milk of magnesia, a high-fiber diet, and bowel-training techniques) recovered by one year . Severe constipation and abnormal anorectal manometry and/or balloon expulsion testing were significantly related to treatment failure.
Recovery rates are higher in populations in primary care practices, presumably because this population includes children with less severe or refractory constipation as compared with children referred for specialty care. In a retrospective review of children younger than two years of age who were treated for acute or chronic constipation in a general pediatric clinic, the following results were noted :
●116 children were initially treated with dietary changes, corn syrup, or both. Constipation resolved in 25 percent.
●100 children were treated with laxatives (magnesium hydroxide or polyethylene glycol without electrolytes); 44 of these had failed dietary interventions, corn syrup, or both. Laxative therapy was successful in 92 percent.
Most children with functional constipation will have good clinical outcomes in adulthood if they are adequately treated during childhood. In a study of 401 children treated with a six- to eight-week treatment protocol in the Netherlands, and followed for a median of 11 years, 25 percent still had symptoms as adults . Risk factors for lack of long-term recovery included older age at onset, longer delay before referral to a pediatric gastroenterologist, and fewer bowel movements per week at presentation.
TREATMENT OF NONRETENTIVE FECAL INCONTINENCE — Non-retentive fecal incontinence is the term used to describe fecal incontinence that occurs in the absence of constipation or other organic disease. Children with this disorder usually have full bowel movements in their clothing rather than just soiling. Treatment requires an approach similar to that described above but without laxative therapy . It is important to distinguish this disorder from constipation-associated fecal incontinence, which is far more common (in 80 percent of children, fecal incontinence is associated with constipation). Children with fecal incontinence should have a careful evaluation for underlying constipation, including a digital rectal examination, because constipation is not always recognized by the child or caregiver. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations and evaluation".)
No widely effective treatments have been established for non-retentive fecal incontinence, but most approaches focus on behavior modification and psychosocial diagnosis and support . The behavioral protocol generally includes a highly structured toilet training protocol designed to encourage frequent and sustained efforts at defecation and supported by behavior modification techniques including a reward system. Laxatives, enemas, and biofeedback are not helpful in these children (provided that constipation has been carefully excluded) [111,132,133]. In our practice, we find that many of these children benefit from referral to a therapist for behavioral intervention and support.
Only one study has reported long-term outcomes in patients with non-retentive fecal incontinence, and this suggested very slow resolution of the problem . Among children who had intensive medical and behavioral treatment for two years, only 29 percent had resolved after two years of treatment, 65 percent after five years, and about 90 percent after ten years.
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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Constipation in infants and children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS — The treatment of chronic functional constipation and/or fecal incontinence requires a comprehensive approach that includes education of the parent and child, pharmacotherapy, a program of regular toileting, dietary changes, and frequent, close follow-up. The goal of therapy is the achievement of one soft stool per day. Improvement can be expected in the majority of such patients, although it may be gradual.
Functional constipation with or without fecal incontinence
●Treatment of infants may include nondigestible osmotically active carbohydrates, with osmotic laxatives and/or occasional glycerin suppositories, if necessary. However, glycerin suppositories should be used with caution because they can enhance anal irritation and cause the symptoms to become chronic. Mineral oil, enemas, and stimulant laxatives should NOT be used in infants, due to safety concerns. (See 'Treatment of infants' above.)
●Treatment of constipation in children typically includes four general steps for bowel retraining. It is essential to educate parents about each of these steps, including the need for prolonged therapy to "retrain" the bowel (figure 1). (See 'Overview' above and 'Parental education' above.)
•Prolonged laxative treatment and behavior therapy to achieve regular evacuation and avoid recurrent constipation
•Dietary changes (primarily increasing fiber content) to maintain soft stools
•Gradual tapering and withdrawal of laxatives as tolerated
●Disimpaction can be accomplished with oral medications, rectal medications, or a combination. We suggest using oral rather than rectal medications for most children, and particularly in those with a history of painful defecation, or perineal trauma (Grade 2C). Enemas or brief hospitalization for disimpaction may be necessary for children with severe constipation or when rapid disimpaction is desired. (See 'Disimpaction' above.)
●After disimpaction, we suggest treating children with chronic constipation (with or without fecal incontinence) with a combination of daily laxatives and behavior modification rather than either therapy alone (Grade 2B).
•The goal of therapy is to achieve about one soft normal caliber stool daily. The choice of laxative is less important than using an adequate dose and assuring compliance. The dose should be based upon age, body weight, and severity of constipation (table 4). (See 'Laxatives' above.)
•We suggest use of polyethylene glycol (PEG), as the initial choice for maintenance therapy rather than other laxatives (Grade 2C). This drug is safe and effective, and is usually better accepted by children than other laxatives. High doses of PEG also may be effective for initial disimpaction of children with mild to moderate constipation. (See 'Polyethylene glycol' above and 'Disimpaction' above.)
•A behavior modification scheme to support regular toileting habits and encourage a child's cooperation is an important part of treatment for functional constipation. Components include toilet-sitting after meals under the supervision and encouragement of a caregiver, a reward system to enhance the child's cooperation, and keeping a record of stooling (figure 2A). (See 'Behavior modification' above.)
•The parents and child should have a "rescue" plan if the child goes more than three days without a stool or has other indications of recurrence (ie, hard stools, abdominal pain, smears in the underwear). The rescue plan may involve administration of a stimulant laxative, enema, or suppository followed by an increased laxative dose. (See 'Laxatives' above.)
•Regular and frequent follow-up is necessary to reinforce the need for continuation of laxative therapy, toilet sitting, and dietary changes. The laxative dose can be titrated and the rescue plan reviewed at follow-up visits. (See 'Follow-up' above.)
●Once the child has achieved regular bowel habits, the frequency of toilet sitting and laxative use can be reduced. We typically wait until optimal bowel habits are achieved and stable for at least six months before laxative use is further decreased. Some children require ongoing laxative treatment for one or more years. Behavioral and dietary interventions increase in importance as laxative therapy is discontinued. (See 'Discontinuation of laxatives' above.)
Non-retentive fecal incontinence
●Treatment of children with functional non-retentive fecal incontinence (encopresis without evidence of constipation) is similar, but laxatives are not used. It is important to distinguish this disorder from constipation-associated fecal incontinence, which is far more common. Children with fecal incontinence should have a careful evaluation for underlying constipation, including a digital rectal examination, because constipation is not always recognized by the child or caregiver. (See 'Treatment of nonretentive fecal incontinence' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge George Ferry, MD, who contributed to an earlier version of this topic review.
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