Pediatric Constipation Management

Aka: Pediatric Constipation Management

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II. Indications

  1. Constipation in Children over age 1 year

III. Prevention: Behavioral and Dietary Management

  1. See Pediatric Constipation Dietary Management
  2. Sit, practice pushing on toilet 5-10 minutes per day
  3. Sit on toilet after meals
    1. Makes use of gastrocolic reflex
  4. Keep a calendar and bring to clinic appointments
    1. Record Bowel Movements
    2. Soiling (Encopresis)
    3. Enema use
    4. Pushing and relaxing Exercises

IV. Management: Approach

  1. Step 1: Disimpaction procedure
    1. See protocol below
    2. In contrast to adults, digital, manual disimpaction is rarely performed in children (risk of perforation)
  2. Step 2: Maintenance protocol follows disimpaction
    1. See protocol below (osmotic agents are preferred)
    2. Continue maintenance for first several months to 6 months
    3. Adjust doses to result in 1 soft stool per day
    4. Make behavior and lifestyle changes
      1. See Pediatric Constipation Dietary Management
      2. Sitting on toilet twice daily after meals
      3. Maintain high Dietary Fiber

V. Management: Acute Disimpaction Procedure

  1. Indications
    1. Children over age 12 to 18 months (Glycerin Suppository may be used in infants)
    2. Severe Constipation with hard stool in Rectum
  2. Rectal agents
    1. Glycerin Suppository
      1. Preferred agent in age under 1 year
      2. Dose: 1/2 to 1 infant suppository (adult suppository for age 6 years and older)
    2. Bisacodyl (10 mg suppository)
      1. Indicated for age 2 years and older
      2. Give one half to one suppository (5 to 10 ml) every 12-24 hours
      3. Use as part of combination protocol for impaction
      4. May also be used in maintenance program
    3. Enema
      1. Consider Polyethylene Glycol (PEG, Miralax) instead for first-line disimpaction (see below)
      2. Avoid in age <1 year
      3. Dosing
        1. Dose: 6 ml/kg (up to 135 ml)
        2. May repeat every 12-24 hours for 1-3 doses
        3. First dose often given 1 hour before bedtime
      4. Normal Saline (less effective than fleets)
        1. Dose: 5-10 ml/kg
        2. Administer in evening
      5. Mineral Oil (indicated in hard impaction)
        1. Dose: 15-30 ml per year of age up to 240 ml
        2. Consider saline or Fleets Enema 1-3 hours before
      6. Fleets Enema (Hypertonic phosphate, Sodium phosphate, Fleets Phosphasoda)
        1. Dose given on 2 to 3 consecutive evenings
          1. Avoid under age 2 years
          2. Age 2 to 4 years old: 30 ml enema (1 oz)
          3. Age 5 to 11 years old: 66 ml enema (2.25 oz)
          4. Age 12 years and older: 133 ml enema (4.5 oz)
        2. Avoid in under age 2 years (some avoid use in under age 4 years)
        3. Risk of Electrolyte disturbance
          1. Hyperphosphatemia
          2. Hypokalemia
          3. Hypocalcemia
      7. Milk with molasses (1:1 concentration)
        1. Used in refractory impaction
  3. Oral agents used for disimpaction (slower than rectal)
    1. See Maintenance medications as listed below
    2. Polyethylene Glycol (PEG)
      1. Considered preferred first-line agent for disimpaction
      2. As effective as enemas and digital disimpaction and better tolerated
      3. May be used in infants under age 1 year
      4. Miralax (PEG 3350 powder) 1 to 1.5 g/kg/day in 6-8 oz water or juice for 3 to 6 days
      5. Golytely (PEG solution) 25 ml/kg/hour via nasogastric lavage (inpatient management, see below)
    3. Magnesium Citrate
      1. Dose: 1 oz per age in years (or 4 ml/kg/day up to 300 ml) OR
        1. Age <6 years: 2-4 ml/kg/day
        2. Age 6-12 years: 100-150 ml/day
        3. Age >12 years: 150-300 ml/day
      2. May repeat daily for 2-3 days
  4. Other oral agents for disimpaction that are largely replaced by agents above
    1. Senna (Senokot)
      1. Age 2-6 years: 2.5 to 7.5 ml (8.8 mg/5 ml) or 0.5 to 1.5 tablets (8.6 mg/tablet)
      2. Age 6-12 years: 5 to 15 ml (8.8 mg/5 ml) or 1 to 2 tablets (8.6 mg/tablet)
      3. May repeat every 12 hours for 3 doses
    2. Bisacodyl (Dulcolax)
      1. Age 2 to 10 years: 5 mg (1 tab) orally each morning for 3 days
      2. Age 10-18 years: 10 mg (2 tabs) orally each morning for 3 days
    3. Lactulose
      1. Dose: 1 ml/kg twice daily for up to 12 weeks
    4. Mineral Oil (caution due to aspiration risk)
      1. High dose: 15-30 ml per age in years up to 240 ml
      2. Much lower dose used in maintenance below
      3. May repeat daily for 3-4 days
    5. Combination Protocol: 3 day cycle
      1. Day 1: Enema and consider repeating every 12-24 hours
      2. Day 2: Bisacodyl suppository 10 mg every 12-24 hours
      3. Day 3: Bisacodyl tablet 5 mg PO every 12-24 hours
      4. Repeat as needed x1-2 cycles
  5. Inpatient protocol (usually given via Nasogastric Tube)
    1. Polyethylene Glycol Solution (Golytely) - see above
      1. Dose: 25 ml/kg/hour (up to 1 Liter/hour) for 4 hour
      2. Start at 10 ml/kg/hour and increase by 10-20 ml every 1 to 2 hours (max: 40 ml/kg/hour)

VI. Management: Maintenance with Osmotic Agents

  1. Polyethylene Glycol 3350 (PEG, Miralax, GoLytely)
    1. Dissolve PEG powder 17 grams in 240 ml water or juice
    2. Dose: 0.4 to 0.8 g/kg/day, up to 1.5 g/kg/day (15 ml/kg/day) to maximum of 17 g/day divided twice daily
      1. Adjust dose until 1-2 soft painless stools per day
      2. Taper dose over time
    3. Efficacy
      1. Safe, well tolerated and effective
      2. More effective and better tolerated than Lactulose
    4. References
      1. Gremse (2002) Clin Pediatr 41:225-9 [PubMed]
      2. Pashankar (2003) Arch Pediatr Adolesc Med 157:661-4 [PubMed]
      3. Voskuijl (2004) Gut 53:1590-4 [PubMed]
  2. Lactulose
    1. Dose: 1 to 3 ml/kg/day (10 mg/15 ml) divided twice daily
    2. Easier to administer to young children (may be used in infants under 1 year of age)
    3. May cause abdominal cramping and Flatus
    4. Miralax is preferred as it is better tolerated
  3. Milk of Magnesia (Magnesium Hydroxide 800 mg/ml)
    1. Exercise caution in infants due to risk of Hypermagnesemia
    2. Age <2 years old: 0.5 cc/kg/day divided daily at bedtime to twice daily
    3. Age 2-5 years old: 5-15 ml/day divided daily at bedtime to twice daily
    4. Age 6-11 years old: 15-30 ml/day divided daily at bedtime to twice daily
    5. Age >12 years old: 30-60 ml/day divided daily at bedtime to twice daily
    6. May cause abdominal cramping in higher doses
  4. Mineral Oil
    1. Dose: 1-3 cc/kg/day divided daily to twice daily
      1. Children: 5-15 ml/day
      2. Teens: 15-45 ml/day
    2. Contraindicated if aspiration risk (risk of lipoid Pneumonia)
    3. Not recommended under age 18 months
    4. Give chilled in juice to maximize tolerability
    5. Coadminister Multivitamin daily if used chronically
  5. Lactitol
    1. As effective as Lactulose with less pain and Flatus
    2. Pitzalis (1995) Pediatr Med Chir 17(3):223-6 [PubMed]
  6. Pediatric Fleets Enema
    1. Give 1 enema every 48 hours absence of normal stool
  7. Sorbitol (e.g. prune juice, apple juice or pear juice)
    1. Indicated in infants
    2. Dose: 1-3 ml/kg/day diluted in 1 to 2 ounces fluid divided twice daily

VII. Management: Maintenance with stimulant agents

  1. Senna syrup (8.8 grams per 5 ml) or tablets
    1. Risk of hepatitis, Melanosis coli, Hypertrophic Osteoarthropathy, Analgesic nephropathy
    2. Age <2 years: 1.25 to 2.5 ml syrup (2.2 to 4.4 mg) at bedtime to twice daily
      1. Maximum up to <5 ml or 8.8 mg/day
    3. Age 2-6 years: 2.5 to 3.75 ml syrup (4.4 to 6.6 mg) or 0.5 tab (4.3 mg) at bedtime to twice daily
      1. Maximum up to 7.5 ml or one 8.6 mg tab per day
    4. Age 6-12 years: 5 to 7.5 ml syrup (8.8 to 13.2 mg) or 1 tab (8.6 mg) at bedtime to twice daily
      1. Maximum up to 15 ml or two 8.6 mg tabs per day
    5. Age >12 years: 10-15 ml syrup (17.2 to 26.4 mg) or 2 tabs (17.2 mg) at bedtime to twice daily
      1. Maximum up to 30 ml or four 8.6 mg tabs per day
  2. Bisacodyl 5 mg tablets
    1. Risk of abdominal cramps, Diarrhea, Hypokalemia
    2. Avoid in under age 2 years
    3. Start at 1 tablet once daily orally after breakfast
    4. Advance to up to 2 tablets (age 3-12 years) or 3 tablets (age >12 years) orally daily

VIII. References

  1. Felt (2003) Univ Michigan Constipation Guidelines
  2. Baker (1999) J Pediatr Gastroenterol Nutr 29:612-26 [PubMed]
  3. Biggs (2006) Am Fam Physician 73:469-82 [PubMed]
  4. Mulhem (2022) Am Fam Physician 105(5): 469-78 [PubMed]
  5. Nurko (2014) Am Fam Physician 90(2): 82-90 [PubMed]
  6. Rubin (2004) Clin Evid 11:385-90 [PubMed]

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