Gastroenterology Book

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Pediatric Constipation Management

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  1. Indications
    1. Constipation in Children over age 1 year
  2. See Also
    1. Pediatric Constipation Dietary Management
    2. Constipation in Infants
  3. 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
  4. 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
      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
  5. 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. 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)
        3. Mineral Oil (indicated in hard impaction)
          1. Consider saline or Fleets Enema 1-3 hours before
        4. Fleets Enema (Hypertonic phosphate)
          1. Risk of increased phosphate, decreased K+, Ca++
          2. Avoid in under age 2 years (some avoid use <4 yo)
        5. Milk with molasses (1:1 concentration)
          1. Used in refractory impaction
    3. Oral agents used for dismpaction (slower than rectal)
      1. See Maintenance medications as listed below
      2. Senna 15 ml every 12 hours for 3 doses
      3. Magnesium Citrate
        1. Dose: 1 oz per age in years up to 300 ml
        2. May repeat daily for 2-3 days
      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. Bisacodyl (Dulcolax)
        1. Age 1.5 to 10 years: 5 mg orally qam for 3 days
        2. Age 10-18 years: 10 mg orally qam 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
        1. Dose: 25 ml/kg/hour (up to 1 Liter/hour) for 4 hour
  6. 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: 0.8 - 1.0 g/kg/day (15 ml/kg/day) divided bid
        1. Adjust dose until two 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
        2. Pashankar (2003) Arch Pediatr Adolesc Med 157:661
        3. Voskuijl (2004) Gut 53:1590
    2. Mineral Oil
      1. Dose: 1-3 cc/kg/day divided daily to twice daily
      2. Contraindicated if aspiration risk
      3. Not recommended under age 18 months
      4. Give chilled in juice to maximize tolerability
      5. Coadminister multivitamin daily if used chronically
    3. Lactulose (10 mg/15 ml) 1-3 cc/kg/day divided qd-bid
      1. Easier to administer to young children
      2. May cause abdominal cramping and flatus
    4. Lactitol
      1. As effective as Lactulose with less pain and flatus
      2. Pitzalis (1995) Pediatr Med Chir 17(3):223
    5. Milk of Magnesia (Magnesium Hydroxide)
      1. Concentration 400 mg/5ml: 1-3 cc/kg/day divided bid
      2. Concentration 800 mg/5 ml: 0.5 cc/kg/day divided bid
      3. May cause abdominal cramping in higher doses
    6. Pediatric Fleets Enema
      1. Give 1 enema every 48 hours absence of normal stool
    7. Sorbitol
      1. Dose: 1-3 ml/kg/day divided twice daily
  7. Management: Maintenance with stimulant agents
    1. Senna syrup (8.8 grams per 5 ml)
      1. Age 2-6 years: 2.5 to 7.5 ml per day divided bid
      2. Age 6-12 years: 5 to 15 ml per day divided bid
    2. Bisacodyl 5 mg tablets
      1. Start at 1 tablet once daily orally after breakfast
      2. Advance up to 3 tablets orally twice daily
  8. References
    1. Felt (2003) Univ Michigan Constipation Guidelines
      1. http://cme.med.umich.edu/pdf/guideline/peds03.pdf
    2. Baker (1999) J Pediatr Gastroenterol Nutr 29:612
    3. Biggs (2006) Am Fam Physician 73:469
    4. Rubin (2004) Clin Evid 11:385

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