The following is an informative leaflet from our hospital (Greenville Health System)

Guidelines for Treatment of Pediatric Constipation

Pediatric constipation is very common. Most children have functional constipation and do not have any organic pathology or require any type of evaluation other than a careful history and physical examination.

Typical signs and symptoms of functional constipation:

• 2 or less stools per week
• Rectal fecal impaction
• Stool withholding/ posturing (often perceived by parents as straining)
• History of hard or excessively large BMs
• At least one episode on incontinence per week in child who was previously toilet trained.

Warning signs of organic pathology:

• Failure to pass meconium in first 48 hours of life
• Vomiting
• FTT
• Blood in absence of anal fissures
• Abnormal position of the anus
• Decreased lower extremity strength/tone/reflexes

Treatment of functional constipation:

• Clean out

*If there is significant impaction, it can be helpful to give an enema or two prior to oral cleanout.

Enemas:

• Phosphate: 5 ml/kg up to 133 ml
• Mineral oil:           2-11 years 30-60 ml

>11 years 60-150 ml once per day

Oral:

• Miralax in Gatorade over 4-6 hours: (can give bisacodyl or senna 1-2 hours before oral cleanout)

8-10 kg:  2 capfuls /12 ounces                       11-13 kg: 3 capfuls/16 ounces

35-39 kg: 9 capfuls/40 ounces                       40-43 kg: 10 capfuls/48 ounces

14-18 kg: 4 capfuls/20 ounces                       44-47 kg: 11 capfuls/52 ounces

19-22 kg: 5 capfuls/24 ounces                       48-51 kg: 12 capfuls/56 ounces

23-26 kg: 6 capfuls/28 ounces                       52-56 kg: 13 capfuls/60 ounces

27-30 kg: 7 capfuls/32 ounces                       57-60 kg: 14 capfuls/64 ounces

31-34 kg: 8 capfuls/36 ounces                       61 + kg:    15 capfuls/64 ounces

• Magnesium Citrate 1 ounce per year of age up to 10 ounces 2-3 days in a row

Maintenance therapy:

Osmotic laxatives

• Polyethylene glycol: 2-0.8 g/kg/day
• Lactulose:            1-2 g/kg once or twice a day
• Mineral oil: 1-3 ml/ kg/ day once or divided , max 90 ml/ day
• Milk of Magnesia: 2-5 years: 2-5 ml once daily or divided/ 6-11 years: 5 ml-15 ml once or divided/ 12-18 years: 10 ml- 30 ml once or divided

Stimulant laxatives: (if needed to meet goal of producing soft good size BM most days with minimal soiling)

• Bisacodyl   3-10 years: 5 mg once a day;  >10 years: 5-10 mg once a day
• Senna          2-6 years : 2.5-5 mg once or twice a day; 6-12 years: 7.5-10 mg once / day; >12 years: 15-20 mg once / day

3) Structured toilet sitting for children who have previously been toilet trained or do not having toilet refusal. Sit for 1 minute per year age twice a day after meals. Use a stool if feet don’t reach the floor or consider a Squatty Potty.

4) normalize fluid and fiber intake. Use a fiber goal of age in years + 5 grams of fiber per day

5) In resistant cases, consider trial of milk free diet.

Indications for pediatric GI referral:  Warning signs of organic pathology or failure of multiple maintenance medication regimens.