Constipation is a common problem throughout childhood and affects up to 30 percent of children and accounts for an estimated 3 to 5 percent of all visits to pediatricians.¹ Early intervention is key to avoid complications such as anal fissures, stool withholding, fecal incontinence (encopresis), and psychosocial consequences. This guideline represents a collaboration of several specialties including pediatric emergency medicine, urgent care, and gastroenterology with the goals of:

• Understanding the diagnostic criteria for functional constipation
• Being aware of red flags that may indicate organic causes of constipation
• Establishing a uniform process for the evaluation and management of constipation
• Decreasing utilization of abdominal x-rays to diagnose constipation

Patients >1 month of age who meet the diagnostic criteria for functional constipation are included in the guideline.

Diagnostic criteria for functional constipation must include TWO or more of the following:

1. Two or fewer defecations per week
2. At least one episode per week of incontinence after the acquisition of toileting skills
3. History of retentive posturing or excessive stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large diameter stools which may obstruct the toilet

Functional constipation is responsible for more than 95% of cases of constipation in healthy children one year and older.² Although constipation is common, it is still important to evaluate children and be diligent to identify the few that have organic causes of constipation. Some red flags that should raise your suspicion to a possible organic cause include:

• Midline dimple; Tuft of hair over lower back
• New onset lower limb weakness/motor delay
• Signs of systemic illness: fevers, mouth sores, joint pain, rash
• Weight loss
• First passage of meconium after 48 hours of life
• Persistent abdominal distension/vomiting
• Bloody diarrhea
• Bilious emesis
• Failure to thrive, Malabsorption
• Tight rectum gripping finger; explosive stool/air from rectum upon withdrawal of examining finger
• Family history of Hirschsprung’s disease

The treatment of functional constipation begins with determining whether the patient has fecal impaction. If fecal impaction is determined by a digital rectal exam it recommended the patient receive a glycerin suppository for children <1 year of age and a soap suds enema for children >1 year of age. Enema dosing can be found in the guideline.

Upon discharge the patient will receive education on appropriate dose and home use of miralax to continue the treatment of constipation as an outpatient. These recommendations are included below:

1-3 years old

Cleanout: Take 1 capful (17 grams) Miralax every day for 3 days in 8 oz. of juice

Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking  

4-5 years old

Cleanout: Take 2 capfuls (34 grams) Miralax every day for 3 days in 16 oz. of juice Maintenance: On day 4 take ¼ capful (4.25 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/8 capful but do not stop taking

6-11 years old

Cleanout: Take 7 capfuls (119 grams) Miralax for 1 day in 32 oz. Gatorade

Maintenance: On day 2 take ½ capful (8.5 grams) Miralax daily in at least 4 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/4 capful but do not stop taking

12 years and older

Cleanout: Take 14 capfuls (238 grams) Miralax for 1 day in 64 oz. Gatorade

Maintenance: On day 2 take 1 capful (17 grams) Miralax daily in at least 8 oz. of any liquid

If stools are too liquid, decrease Miralax to 1/2 capful but do not stop taking

• Encourage fluid intake (especially during cleanout)
• Referral to PCP in 2 weeks. Continue maintenance dosing until seen by PCP

The constipation guideline can be accessed on CHOA Physician Portal: md.choa.org

Under clinical excellence clinical practice guidelines

1. Epidemiology of childhood constipation: a systematic review.

Van den Berg MM, Benninga MA, Di Lorenzo C

Am J Gastroenterol. 2006;101(10):2401.

2. Prevalence, symptoms and outcome of constipation in infants and toddlers.

Loening-Baucke V

J Pediatr. 2005;146(3):359