Consistency key to managing pediatric constipation

Treating pediatric constipation requires more than prescribing a stool softener or recommending dietary changes. Long-term success depends on clearing retained stool, maintaining regular bowel movements, and building sustainable toileting habits, according to Justin Wheeler, MD.

Wheeler, a pediatric gastroenterologist at Primary Children's Hospital in Salt Lake City, Utah, specializes in neurogastroenterology and motility at the University of Utah, with a focus on children with severe constipation. At the American Academy of Pediatrics (AAP) 2026 National Conference & Exhibition, he discussed practical strategies pediatricians can use to help families manage constipation and prevent recurrence.

"Just like many parts of many aspects of medicine, care depends largely on consistency," Wheeler said.

Why is disimpaction an important first step?

For children with significant stool retention or fecal impaction, Wheeler emphasized that effective treatment typically begins with a bowel cleanout.

"In constipation, there are for sure two major things that you have to do. The first is you need to disimpact or get an effective cleanout, where you just kind of clear the slate, clean out the colon, and start fresh," Wheeler said.

Without adequate disimpaction, small amounts of stool-softening medication may cause softer stool to leak around retained stool without resolving the underlying problem. Families may subsequently conclude that the treatment is ineffective.

Wheeler explained that disimpaction can often be completed at home using an institution-specific protocol. Depending on the regimen, treatment may involve oral polyethylene glycol or magnesium citrate, sometimes combined with a stimulant laxative.

After successful disimpaction, the next step is maintenance therapy aimed at producing soft, regular bowel movements.

"The goal is for a child to have a soft poop every single day," Wheeler said.

Consistent evacuation allows the rectum to gradually recover tone and sensation while helping children overcome the fear associated with painful defecation.

How can behavioral strategies improve treatment?

Medication alone may not be sufficient, particularly for children with longstanding constipation or stool withholding.

Wheeler recommended pairing maintenance therapy with scheduled toilet sitting, positive reinforcement, and positioning that facilitates stool passage.

Children may benefit from placing their feet on a small stool or box to elevate their knees while sitting on the toilet. Immediate rewards, such as a small treat, temporary tattoo, or special time with a caregiver, can reinforce participation in toileting routines.

Importantly, Wheeler encouraged families to reward behaviors children can control, including taking medication and completing scheduled toilet sits, rather than focusing exclusively on whether a bowel movement occurs.

"The best outcomes really do occur when medical treatment is paired with consistent behavioral interventions," Wheeler said.

Adequate hydration, fruits, vegetables, and soluble fiber can also support bowel health. However, Wheeler cautioned that increasing fiber alone is rarely sufficient for children with significant constipation, particularly those experiencing fecal soiling.

How long should constipation treatment continue?

One of the most important messages pediatricians can communicate is that recovery often takes considerably longer than families anticipate.

"It's not going to get better overnight if they've been constipated for six years. It's not going to get better in six weeks," Wheeler said.

Children with severe or longstanding constipation may require months or even years of consistent bowel management before gradually discontinuing treatment.

Wheeler also encouraged pediatricians to help families prepare for setbacks associated with travel, school transitions, changes in household routines, or inconsistent medication use.

Written bowel management plans can help families respond when symptoms recur. Wheeler described a green-, yellow-, and red-light approach in which families maintain treatment when stooling is consistent and follow predetermined escalation steps when bowel movements are missed, pain develops, or accidents return.

Such plans may reduce delays in treatment adjustments and help families feel more confident managing symptoms.

How can pediatricians support long-term success?

Beyond medication and toileting routines, Wheeler emphasized the importance of addressing barriers that affect adherence and quality of life.

Some children may benefit from behavioral health or occupational therapy support, particularly when toileting difficulties have affected confidence or become associated with distress.

Schools can also play an important role. Pediatricians may provide documentation requesting unrestricted bathroom access or access to a more private restroom, helping children maintain toileting routines throughout the school day.

Wheeler encouraged clinicians to recognize improvements beyond stool frequency, including fewer accidents, greater confidence, and improved participation in daily activities.

"The success really isn't simply having a bowel movement," Wheeler said. "I think success is when kids get their confidence back, when they prevent recurrence, when they have that improvement in quality of life."

For pediatricians, Wheeler's message was that successful constipation management requires a sustained partnership with families. Combining appropriate medical treatment, behavioral support, and realistic expectations can help children regain normal bowel function while reducing the burden of constipation on everyday life.

Reference

Wheeler J. Constipation and Encopresis: Evaluation and Management. Presented at: American Academy of Pediatrics 2026 National Conference & Exhibition; October 6, 2026; San Diego, CA.