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Pediatric Constipation Management
Aka: Pediatric Constipation Management
- Indications
- Constipation in Children over age 1 year
- See Also
- Pediatric Constipation Dietary Management
- Constipation in Infants
- Prevention: Behavioral and Dietary Management
- See Pediatric Constipation Dietary Management
- Sit, practice pushing on toilet 5-10 minutes per day
- Sit on toilet after meals
- Makes use of gastrocolic reflex
- Keep a calendar and bring to clinic appointments
- Record Bowel Movements
- Soiling (Encopresis)
- Enema use
- Pushing and relaxing Exercises
- Management: Approach
- Step 1: Disimpaction procedure
- See protocol below
- Step 2: Maintenance protocol follows disimpaction
- See protocol below (osmotic agents are preferred)
- Continue maintenance for first several months to 6 months
- Adjust doses to result in 1 soft stool per day
- Make behavior and lifestyle changes
- See Pediatric Constipation Dietary Management
- Sitting on toilet twice daily after meals
- Maintain high Dietary Fiber
- Management: Acute Disimpaction Procedure
- Indications
- Children over age 12 to 18 months
- Severe Constipation with hard stool in Rectum
- Rectal agents
- Glycerin suppository
- Preferred agent in age under 1 year
- Dose: 1/2 to 1 infant suppository (adult suppository for age over 6 years)
- Bisacodyl 10 mg suppository
- Give one half to one suppository every 12-24 hours
- Use as part of combination protocol for impaction
- May also be used in maintenance program
- Enema
- Dosing
- Dose: 6 ml/kg (up to 135 ml)
- May repeat every 12-24 hours for 1-3 doses
- First dose often given 1 hour before bedtime
- Normal Saline (less effective than fleets)
- Dose: 5-10 ml/kg
- Mineral Oil (indicated in hard impaction)
- Dose: 15-30 ml per year of age up to 240 ml
- Consider saline or Fleets Enema 1-3 hours before
- Fleets Enema (Hypertonic phosphate, Fleets Phosphasoda)
- Avoid in under age 2 years (some avoid use in under age 4 years)
- Dose: 66 ml enema for 2-12 years old and 133 ml enema for those over 12 years old
- Risk of Electrolyte disturbance
- Hyperphosphatemia
- Hypokalemia
- Hypocalcemia
- Milk with molasses (1:1 concentration)
- Used in refractory impaction
- Oral agents used for disimpaction (slower than rectal)
- See Maintenance medications as listed below
- Polyethylene glycol (PEG)
- As effective as enemas and digital disimpaction and better tolerated
- May be used in infants under age 1 year
- Miralax (PEG 3350 powder) 1 to 1.5 g/kg/day for 3 days
- Golytely (PEG solution) 25 ml/kg/hour via nasogastric lavage (inpatient management, see below)
- Magnesium Citrate
- Dose: 1 oz per age in years up to 300 ml OR
- Age <6 years: 2-4 ml/kg/day
- Age 6-12 years: 100-150 ml/day
- Age >12 years: 150-300 ml/day
- May repeat daily for 2-3 days
- Senna (Senokot)
- 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)
- Age 6-12 years: 5 to 15 ml (8.8 mg/5 ml) or 1 to 2 tablets (8.6 mg/tablet)
- May repeat every 12 hours for 3 doses
- Mineral Oil (caution due to aspiration risk)
- High dose: 15-30 ml per age in years up to 240 ml
- Much lower dose used in maintenance below
- May repeat daily for 3-4 days
- Bisacodyl (Dulcolax)
- Age 2 to 10 years: 5 mg (1 tab) orally each morning for 3 days
- Age 10-18 years: 10 mg (2 tabs) orally each morning for 3 days
- Combination Protocol: 3 day cycle
- Day 1: Enema and consider repeating every 12-24 hours
- Day 2: Bisacodyl suppository 10 mg every 12-24 hours
- Day 3: Bisacodyl tablet 5 mg PO every 12-24 hours
- Repeat as needed x1-2 cycles
- Inpatient protocol (usually given via Nasogastric Tube)
- Polyethylene glycol Solution (Golytely) - see above
- Dose: 25 ml/kg/hour (up to 1 Liter/hour) for 4 hour
- Management: Maintenance with Osmotic Agents
- Polyethylene glycol 3350 (PEG, Miralax, GoLytely)
- Dissolve PEG powder 17 grams in 240 ml water or juice
- Dose: 0.5 - 0.8 g/kg/day (15 ml/kg/day) up to 17 g/day divided twice daily
- Adjust dose until 1-2 soft painless stools per day
- Taper dose over time
- Efficacy
- Safe, well tolerated and effective
- More effective and better tolerated than Lactulose
- References
- Gremse (2002) Clin Pediatr 41:225-9 [PubMed]
- Pashankar (2003) Arch Pediatr Adolesc Med 157:661-4 [PubMed]
- Voskuijl (2004) Gut 53:1590-4 [PubMed]
- Lactulose
- Dose: 1 ml/kg/day (10 mg/15 ml) divided daily to twice daily
- Easier to administer to young children (may be used in infants under 1 year of age)
- May cause abdominal cramping and Flatus
- Miralax is preferred as it is better tolerated
- Milk of Magnesia (Magnesium Hydroxide 800 mg/ml)
- Exercise caution in infants due to risk of Hypermagnesemia
- Age <2 years old: 0.5 cc/kg/day divided daily to twice daily
- Age 2-5 years old: 5-15 ml/day divided daily to twice daily
- Age 6-11 years old: 15-30 ml/day divided daily to twice daily
- Age >12 years old: 30-60 ml/day divided daily to twice daily
- May cause abdominal cramping in higher doses
- Mineral Oil
- Dose: 1-3 cc/kg/day divided daily to twice daily
- Children: 5-15 ml/day
- Teens: 15-45 ml/day
- Contraindicated if aspiration risk (risk of lipoid Pneumonia)
- Not recommended under age 18 months
- Give chilled in juice to maximize tolerability
- Coadminister Multivitamin daily if used chronically
- Lactitol
- As effective as Lactulose with less pain and Flatus
- Pitzalis (1995) Pediatr Med Chir 17(3):223-6 [PubMed]
- Pediatric Fleets Enema
- Give 1 enema every 48 hours absence of normal stool
- Sorbitol (e.g. prune juice)
- Dose: 1-3 ml/kg/day divided twice daily
- Management: Maintenance with stimulant agents
- Senna syrup (8.8 grams per 5 ml) or tablets
- Risk of hepatitis, Melanosis coli, Hypertrophic Osteoarthropathy, Analgesic nephropathy
- Age <2 years: 1.25 to 2.5 ml syrup (2.2 to 4.4 mg) at bedtime to twice daily (up to <5 ml or 8.8 mg/day)
- 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 (up to 7.5 ml or one 8.6 mg tab per day)
- 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 (up to 15 ml or two 8.6 mg tabs per day)
- Age >12 years: 10-15 ml syrup (17.2 to 26.4 mg) or 2 tabs (17.2 mg) at bedtime to twice daily (up to 30 ml or four 8.6 mg tabs per day)
- Bisacodyl 5 mg tablets
- Risk of abdominal cramps, Diarrhea, Hypokalemia
- Avoid in under age 2 years
- Start at 1 tablet once daily orally after breakfast
- Advance up to 3 tablets orally twice daily
- References
- Felt (2003) Univ Michigan Constipation Guidelines
- Baker (1999) J Pediatr Gastroenterol Nutr 29:612-26 [PubMed]
- Biggs (2006) Am Fam Physician 73:469-82 [PubMed]
- Nurko (2014) Am Fam Physician 90(2): 82-90 [PubMed]
- Rubin (2004) Clin Evid 11:385-90 [PubMed]