Updated Pediatric Expert Constipation Guidelines

Updated guidelines for the diagnosis and treatment of constipation by NASPGHAN and ESPGHAN have undergone formal peer review are likely to be published soon (available online with the following link: bit.ly/1geLxrk).  “Evidence-Based Recommendations from ESPGHAN and NASPGHAN for Evaluation and Treatment of Functional Constipation in Infants and Children” by Merti Tabbers, Carlo DiLorenzo et al. The following are some of their recommendations.

Diagnostic recommendations:

  • The ROME III criteria are recommended for the definition of functional constipation for all age  groups.
  • Diagnosis of functional constipation is based on history and physical examination.
  • There is no role for the routine use of an abdominal X-ray to diagnose functional constipation.
  • A plain abdominal  radiography may be used in a child in whom fecal impaction is  suspected but in whom physical examination is unreliable/not possible.
  • Based on expert opinion, a 2-4 weeks trial of avoidance of cow’s milk protein may be indicated in the child with intractable constipation.
  • Routine laboratory testing to screen for hypothyroidism, celiac disease and hypercalcemia is not recommended in children with constipation in the absence of alarm symptoms. 

Treatment Recommendations:

  • We do not recommend the use of biofeedback as additional treatment in childhood constipation.
  • Polyethylene glycol (PEG) with or without electrolytes orally 1-1.5 gr/kg/day for 3-6 days is recommended as first-line treatment for children presenting with fecal impaction
  • An enema once a day for 3-6 days is recommended for children with fecal impaction if PEG is not available.
  • PEG with or without electrolytes is recommended as first-line maintenance treatment. A starting dose of 0.4 gr/kg/day is recommended and the dose should be adjusted according to the clinical response.
  • Addition of enemas to the chronic use of PEG is not recommended.
  • Based on expert opinion, use of milk of magnesia, mineral oil and stimulant laxatives may be considered as additional or second line treatment.
  • Antegrade enemas are recommended in the treatment of selected children with intractable constipation.

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19 thoughts on “Updated Pediatric Expert Constipation Guidelines

  1. thanx,
    i appreciate your outlook towards the subject.i read with interest the observations and recommendations. sharing herewith Our central India Pedgihep registry notes following observation :
    1.Defecation dyssynergia is the most common cause of childhood constipation .
    2.There is a definite role of biofeedback therapy.Without proper toliet training its difficult to taper off laxatives and stool softeners.
    3.We could diagnose subtle hypothyroidism , neurotuberculosis , celiac , hypocalcemia only after
    investigation in such cases where defecation dyssynergia have significant component in constipation.
    4.its very rare to have cow’ milk causing constipation in India at least .The evidence basis of the same have you noted ? please send reference if possible.

    Yogesh Waikar
    Pediatric Gastroenterologist .
    email: pedgihep@yahoo.com

    • Dr. Walker,

      Thank you for your comments. The soon-be-published guidelines will have references to support the recommendations. As I did not write these guidelines, I do not have their references on hand.


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  15. Does this suppose enemas are superior to liquid glycerin suppositories for treating pediatric constipation? If so, why?

    • These recommendations from an expert group do not comment on glycerin suppositories. These guidelines recommend enemas for disimpaction if polyethylene glycol is not available/effective.

      In general (not addressed in this report), enemas are more potent than glycerin; though, glycerin may be effective in some populations, especially infants.

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