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   Enemas Are you sure?  Have you tried oral disimpaction over days? No phosphate enemas for children less than 2. Saline enemas are generally safe for all ages 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. Audio Player       00:00   00:0