PEM Playbook – Constipation and the way out

Originally published at Pediatric Emergency Playbook on March 1, 2021 – Visit to listen to accompanying podcast. Reposted with permission.

Follow Dr. Tim Horeczko on twitter @EMTogether

Constipation as a diagnosis can be dangerous, mainly because it is a powerful anchor in our medical decision-making.

Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed.

We’re not here for “chances are“; we’re here for “why isn’t it?

Ask yourself, could it be:

Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma

Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy

Neuropathic: spinal cord abnormalities, trauma, tethered cord

Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome

Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome

Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics

Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance


Red Flags

Failure to thrive

Abdominal distention

Lack of lumbosacral curve

Midline pigmentation abnormalities of the lower spine

Tight, empty rectum in presence of a palpable fecal mass

Gush of fluid or air from rectum on withdrawal of finger

Absent anal wink




You gotta push the boat out of the mud before you pray for rain.


— Coach



Medications for disimpaction

(do this first!)

Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days.  Maximum daily dose: 100 g/day PO.  Follow-up with maintenance dose (below) for at least 2 months (usually 6 months)

Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days

Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days


Medications for Maintenance

(do this after disimpaction!)

Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO.  Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance.

Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily.  Maximum daily dose: 60 mL/day in adults.

Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day

Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID)

Senna, Bisocodyl — complicated regimens; use your local reference



  1. Are you sure?  Have you tried oral disimpaction over days?
  2. No phosphate enemas for children less than 2.
  3. Saline enemas are generally safe for all ages
  4. Be careful with the specific dose — please use your local reference


Selected References

Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13.

Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.

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