-History and physical exam, above.
-No red flags.
-Non-pharmacological and pharmacological therapies discussed.
“Oral osmotics such as polyethylene glycol–based solutions are recommended as an appropriate initial approach to constipation in children because they are effective, easy to administer, noninvasive, and well tolerated (SOR C). Rectal therapies are similar in terms of effectiveness but are more invasive and less commonly used as first-line treatment (SOR A). Oral stimulants and bisacodyl rectal suppositories are not recommended for children under 2 years of age. Enemas are sometimes used as second-line therapy, but the addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation (SOR B). Manual disimpaction is a more invasive option and is not recommended as first-line treatment in young children.” ABFM
“Most childhood constipation is functional, which appears to be the case with this patient. She has no evidence of organic disease, and she had a change in lifestyle that caused her to retain stool, resulting in a cycle of constipation. Polyethylene glycol is easily tolerated, safe, and easy to use. For this reason, it is the first-line therapy. A daily dose should resolve this issue, although it is likely that the child will need another course of treatment, as functional constipation is likely to recur. It is not reasonable in this case to provide no treatment, as the child is uncomfortable. An enema would be unnecessary since oral therapies are very likely to be effective. Behavioral therapies have not been shown to be as effective as laxatives for functional constipation, and stringent therapy that is not related to food intake is likely to increase the stress surrounding going to the toilet. There is no role for imaging in a case where the suspicion of an organic cause is so low.” ABFM critique 2017
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*** Medical disimpaction vs. manual disimpaction.
Medical disimpaction with laxatives like Miralax always comes first and manual disimpaction is last.
Reference
Pediatrics 2009;124(6):e1108-e1115. http://pediatrics.aappublications.org/content/124/6/e1108.short
Archives of Disease in Childhood. 2009;94(2):156-160. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2614562/
Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev 2012;(7):CD009118.
Evaluation and treatment of constipation in children and adolescents. Am Fam Physician 2014;90(2):82-90.