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Pediatric Constipation Management

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Pediatric Constipation Management

  • Indications
  1. Constipation in Children over age 1 year
  • 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
  • Management
  • Approach
  1. Step 1: Disimpaction procedure
    1. See protocol below
  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
  • Management
  • Acute Disimpaction Procedure
  1. Indications
    1. Children over age 12 to 18 months
    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 over 6 years)
    2. Bisacodyl 10 mg suppository
      1. Give one half to one suppository every 12-24 hours
      2. Use as part of combination protocol for impaction
      3. May also be used in maintenance program
    3. Enema
      1. 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
      2. Normal Saline (less effective than fleets)
        1. Dose: 5-10 ml/kg
      3. 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
      4. Fleets Enema (Hypertonic phosphate, Fleets Phosphasoda)
        1. Avoid in under age 2 years (some avoid use in under age 4 years)
        2. Dose: 66 ml enema for 2-12 years old and 133 ml enema for those over 12 years old
        3. Risk of electrolyte disturbance
          1. Hyperphosphatemia
          2. Hypokalemia
          3. Hypocalcemia
      5. 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. As effective as enemas and digital disimpaction and better tolerated
      2. May be used in infants under age 1 year
      3. Miralax (PEG 3350 powder) 1 to 1.5 g/kg/day for 3 days
      4. 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 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. 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
    5. 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
    6. 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
  4. 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
  • 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: 0.5 - 0.8 g/kg/day (15 ml/kg/day) up to 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 ml/kg/day (10 mg/15 ml) divided daily to 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 to twice daily
    3. Age 2-5 years old: 5-15 ml/day divided daily to twice daily
    4. Age 6-11 years old: 15-30 ml/day divided daily to twice daily
    5. Age >12 years old: 30-60 ml/day divided daily 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)
    1. Dose: 1-3 ml/kg/day divided twice daily
  • 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 (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 (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 (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 (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 up to 3 tablets orally twice daily