|Review position/seating||Ensure child is adequately supported in an upright position to allow optimal defecation. Time in a standing table may help with evacuation. If indicated, obtain adapted toilet seat with adequate support.|
|Address behavioral issues||Positively reinforce all passage of stool. For children who are toilet trained, ensure adequate time and privacy for defecation (e.g., it isn't going to happen in a public school bathroom stall). Treat accidents with a neutral approach.|
|Dietary alterations||Increase fluid/fiber if possible. Decrease dairy products. If using an enteral formula, consider switching to one with fiber. Refer to a nutritionist as needed: see all Nutrition/Dietary services providers (53) in our database.|
|Clean-out program||Consider several days of enemas to remove all impacted stool. (If standard enemas don't work well, consider an oil retention enema to soften the impacted stool.) Oral clean out procedures may also be used (e.g., high dose Miralax™ See Bowel management algorithm( 47 KB)). Follow by starting on an oral agent to keep stool soft to loose.|
|Maintenance program||Miralax, now available over the counter and prescription. It may take time working with the parent to find an optimal regimen. The need for chronic therapy should be carefully explained.|
|Emptying program||Even when stool is maintained soft, many children with special health care needs may need help with evacuation. Consider using oral senna or suppositories as needed to ensure every other day regular emptying. (Editor's Comment: "I have found many parents like Theravac enemas for this purpose. These are little vials with essentially a liquid suppository that do not require a finger be inserted into the rectum. They can be prescribed with or without lidocaine.")|
- While the cost of over-the-counter laxatives may be relatively low, when used chronically the cost adds up quickly. If possible, use an agent that will be covered by the families medical insurance. If the family has no medical card, then use the cheapest agent available.
- Diapers are a huge health care expense. Generally Medicaid will cover the cost of diapers for the incontinent child after age three through a home care company with a clinicians prescription and letter of medical necessity. Rarely private payers can be convinced to do this.
|High-dose Glycolax (PEG 3350, Miralax)||may be used at 2-3 times dosage discussed below for an oral clean out alternative.|
|Fleets Phosphate Enema:||30ml/5kg, adult size if > 20 Kg. For clean-out give one per day for 3-5 days.|
|Mineral Oil (oral clean out alternative)||15-30 ml/year of age/day to max of 240 ml/day -- 98% success rate with in 4 days according to clinical trial -- do not use in kids with significant aspiration risk.|
|Glycolax (PEG 3350, Miralax)||1/2 - 1 cap full sprinkled on food or in formula q day. Higher doses are often used for chronic constipation (e.g., 1 capful BID).|
|Mineral Oil||1-2 ml/kg/dose bid, adolescents 60 ml/dose bid, max 8 oz/day or 15 ml per year of age to max of 90ml/day given at bedtime (note decrease dose if child having anal leakage of mineral oil, do not use mineral oil in children with significant aspiration risk). Emulsified preparations are more palatable (e.g. Kondremul).|
|Lactulose||0.5-1.0 ml/kg/dose bid, adolescents 15 ml bid, max 3 oz/day.|
|Milk of Magnesia (regular strength)||1ml/kg/dose bid, adolescent 60 ml bid (note: 10ml MOM concentrate = 30 ml of regular MOM = 5 MOM tablets).|
|Senekot||For children under 5 years of age 1-2 tsp, for those over 5 years 2-3 tsp per day, adolescent 3 tsp per day, Note: if dosing is too high children will experience abdominal cramping. (Note 1 tablet = 5 ml of liquid senekot).|
|Dulcolax||5-12 years one tablet (5mg), > 12 years 2 tabs (10mg), maximum daily dose 4 tablets (20mg).|
Constipation evaluation tool( 84 KB)
Provides a format for evaluation of chronic constipation in children.
Bowel management algorithm( 47 KB)
Algorithm for management of chronic constipation developed in collaboration with pediatric gastroenterology.
Over-the-Counter Drug list, Medicaid, Utah, 2006( 41 KB)
Medications available over the counter and paid for by Utah medicaid, last updated summer 2006.