Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Constipation

Cystic Fibrosis patients are excluded from this pathway
Red Flags
  1. First passage meconium after 48 hours of life
  2. Symptom onset < 1 month
  3. Persistent abdominal distention, vomiting
  4. Bloody diarrhea
  5. Bilious emesis
  6. Family history Hirschsprung’s disease
  7. Failure to thrive
  8. Tight rectum gripping finger; explosive stool and air from rectum upon withdrawal examining finger
  9. Midline dimple, tuft of hair over lower back
  10. Lower limb weakness, motor delay
  11. Signs of systemic illness: fever, mouth sores, joint pain, rash
  12. Weight loss

1-8 Concern Hirschprung, 7 Malabsorption

No Red Flags, Low Concern for Underlying Disease
Functional Constipation Likely
  • Acute Surgical Abdomen
  • Hirschprung Disease
  • Medical Disease - GI, Metabolic
  • Neurologic Disease
Child < 6 Months
Child > 6 Months
Consider Glycerin
No Fecal
Fecal Impaction and
Significant pain, vomiting or
Family desire for enema
Not Effective
After 1 Hour
Consider further
Inpatient Constipation Pathway
Diagnostic Criteria for Constipation
At least 2 criteria present
(symptoms present for at least 2 weeks)
  1. ≤ 2 defecations per week
  2. At least 1 episode of incontinence per week after the acquisition of toileting skills
  3. History of 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 that may obstruct the toilet
Fecal Impaction
  • History of no stool passage > several days
  • History of encopresis
  • Stool in rectum on digital rectal exam or in the descending colon/rectum on imaging
  • Palpable abdominal stool mass on physical exam
Initial Treatment Options for Constipation Enema Administration
Age Medication Dose
< 1 yr Glycerin (pediatric) 1 suppository if no stool in previous 24 hrs
≥ 1 yr
to < 2 yrs
NS enema 10 mL/kg
Max dose of 120 mL
≥ 2 yrs Sodium Phosphate (Fleet) 2-11 yrs: Pediatric preparation 66 mL
> 12 yrs: Adult preparation 133 mL
Mineral oil enema 2-11 yrs: 60 mL
≥ 12 yrs: 133 mL
Posted: February 2015
Revised: November 2020
Authors: E. Kane, MD; M. Mittal, MD; K. Fiorino, MD; C. Jacobstein, MD; X. Morgan, CRNP; J. Crawford, CNS; A. Shah, MD; L. Utidjian, MD; J. Lavelle, MD; A. Moore, PharmD