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Updated by: Denise Kilway, APNP
Update on: 10/26/2020


Signs and symptoms

2 or more present for 1 month

  • 2 or less Bowel Movements(BMs) per week
  • Painful or hard stools
  • Large diameter stools
  • Presence of large fecal mass in rectum (if potty-trained or 4 yrs old)
  • At least one episode of fecal incontinence per week and/or
  • History of retentive postures

Alarming signs/symptoms

  • Constipation starting before 1 month of age
  • Meconium passed > 48 hours
  • Family history of Hirschprungs disease
  • Ribbon stools
  • Blood in stools without anal fissures
  • Failure to thrive
  • Fever
  • Bilious vomiting
  • Abnormal thyroid gland
  • Severe abdominal distention
  • Perianal fistula
  • Abnormal position of anus
  • Absent anal or cremasteric reflex
  • Decreased lower extremity strength and done or reflexes
  • Sacral dimple or hair tuft
  • Gluteal cleft deviation
  • Extreme fear during anal inspection
  • Anal scars

Referring provider's initial evaluation and management:

Diagnosis and treatment

If breast fed infant:

  • Reassurance that infrequent stools can be normal.
  • If infant dyschezia can reassure infant will learn to defecate on own, or can do tummy massage, bicycle the legs and rectal stimulation with thermometer daily for a 2-3 weeks until infant has developed good pattern of elimination.

For infant < 6 months with constipation:

  • Suppository to clean out the rectum.
  • Do not use liquid glycerin suppositories.
  • Give 0.5 to 1 oz of prune or pear juice in bottle daily or as needed to soften stools.
  • Change formula, consider whey based formula, or hydrolysate formula for 2 week trial.
  • If no improvement after 2 weeks consider hypoallergenic formula.
  • Tummy massage, bicycle legs, rectal stimulation as needed.
  • If retentive postures hold infant in squatting position.
  • Dark karo syrup, although safe, is no longer consistently effective and may not work.

For infant >6 months:

  • Suppository to clean out the rectum
  • Lactulose syrup 1 mL/kg 1-2 times/day
  • Milk of Magnesia 1-3 mL/kg/day

For toddler and young child not yet potty-trained:

  • Education about potty training should be introduced early and repeated often to avoid unrealistic expectations of child. If constipated toilet training should be delayed until child is having regular pain free stools and is interested in potty training.
  • For toddler and preschool child who are withholding stools:
    • Relief of fecal impaction with oral or rectal medications:
      • Liquid glycerin suppository every 48 hours until oral medications are working (no longer than 2 weeks)
      • Or Miralax 1.5 gm/kg/day for 3 days for oral clean out. Then child can be maintained on Miralax 0.4-0.8 gm/kg/day. If parent has concerns about using Miralax can use different osmotic laxative or refer to:
  • Lactulose 1 mL/kg 1-2 times a day
  • Milk of magnesia 1-3 mL/kg/day
  • Mineral oil 1-3 mL/kg/day
  • Most children who are volitionally holding back stool will also need stimulant for at least a few months:
    • Senna syrup 1-2.5 mL 1-2 times/day
    • Chocolate laxative (Exlax) 0.5 to 1 chew tab/day

Educate parents about:

  • The need for balanced diet, containing adequate fiber, fluids and avoiding excessive dairy. They also need to know about the medication and how it is to be administered, and that it is not to be stopped until they are instructed to wean the child off of it.
  • Parents need to know how to recognize signs of readiness for potty training and how to proceed.

When to initiate referral/ consider refer to GI Clinic:

  • If any of the alarm signs and symptoms are present.
  • Those with abnormal thyroid: refer to Endocrine.
  • Those with abnormalities of spine or muscle tone and reflexes: refer to neurology
  • If the anus has an unusual size, shape or position: refer to surgery
  • If one or more cleanouts were attempted and not successful.
  • If treatment was initially successful but always relapses.
  • (see algorithm for infants <6 months and for children >6 months)

What can referring provider send to GI Clinic?

  1. Using Epic referral form, please complete:
  • Urgency of the referral
  • What is the patient's chief complaint
  • Describe details
  • Pertinent past medical history
  • What is the key question you want addressed

In addition, please include the following in your note when you recommend an appt to our clinic:

  • Growth charts
  • Any lab tests that have been done.
  • Any abdominal films should be sent on CD or uploaded into CHW radiology if possible.
  • Office records indicating the treatment that has been recommended so far and the child's response to treatment.

• Indicate if you want consult only, or consult and management of the constipation.

2. Not using Epic referral form:

Please fax to Central Scheduling (414- 607-5288) the above information and include:

  • Chief complaint, onset, frequency
  • Recent progress notes
  • Labs and imaging results
  • Other Diagnoses

Contact Number: (414) 266-3690

Specialist's workup will likely include:

After referral to GI Clinic:

  • Child will receive testing only if it is warranted and if it has not already been done.
  • You will receive consultation letter with assessment and plan within a week of the clinic visit.
  • You will receive updates any time the child returns for follow up. You may also receive a phone call if there are any additional concerns.

Model of care

Patient-centered care

Constipation figure 1 for infants less than 6 months

Constipation figure 2 for infants greater than 6 months

Source for algorithms:

Tabbers, M., DiLorenzo, C, Berger, M, Faure, C., Langendam, M., Nurko, S, Staiano, A., Vandenplas, Y, Benninga, M. (2014).  Evaluation and Treatment of functional constipation in Infants and Children: Evidence-Based recommendations from ESPGHAN and NASPGHAN. It is in JPGN vol 58 (2) pp 260-261.  Retrieved from