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Constipation in children may seem mundane, but it’s no joke. Here are the tried-and-true treatment options for kids who are all jammed up.
 
You’ve seen this presentation a thousand times. Child comes in with intermittent, severe bouts of abdominal pain that cause the child to double over. Often the latest episode is gone by the time the patient arrives in the ED. If asked, the parents will sometimes tell you the belly looks bigger. The child will have a history of prior constipation, or infrequent stooling, straining to stool, small hard stools sometimes with a streak of bright red blood. You ask if there was delay in the first passage of meconium (screening for a late presentation of Hirschsprungs disease. All but a tiny number of healthy, term infants pass their first stool in the first 24 hours of life). You examine the kid and find a soft, perhaps slightly distended abdomen, sometimes with fullness or palpable fecal mass, particularly on the left. You check the back for midline tufts or dimples and the DTRs to rule-out the rare (but important to spot) tethered cord as a cause of constipation. You do your rectal exam and perhaps find a dilated vault with hard stool present, perhaps not. You get a KUB just to confirm your suspicions and there you have it – non-obstructed bowel gas pattern and stool throughout. OK, so you knew the kid was constipated. Now what are you going to do about it?

First of all, what’s the goal? You have 3 aims here: You want to soften the stools without producing diarrhea. You want to prevent fecal soiling (which is socially devastating to the school-aged child). You want to get them in a routine so they stool every 1-2 days. You’ll be referring them back to their regular physician to make sure that they achieve these goals. But you’re the one who gets to launch this ship and explain to the parents what it is you are recommending and why.

A run-down of treatment options:
 
Stool softeners. They don’t stimulate stooling, they just make it easier to go. They aren’t habit forming and can be used safely for years. Meds in this group include milk of magnesia, lactulose, mineral oil, and miralax. Miralax seems to be the most effective of the lot. Have the parents add one capful to 8 ounces of liquid once or twice per day for constipated children over the age of 6 months. The error most folks make is not using enough or stopping too soon. Don’t be shy, go for it.

Senekot. Only use this for a week at a time because it does have the potential to be habit forming. Use this with miralax to give that extra push to get the poop out. It is not as helpful when used alone. Our GI service recommends 1 tsp daily for 3-4 year olds, working up to 1 tsp twice daily for 8-12 year olds. (Ex-Lax is senakot. 1 chocolate square = 1 tsp).

Laxatives. Several days of this can be helpful with the child with a large fecal mass.   Then transition them to a stool softener. Options here include Mag citrate which is dosed at 4cc/kg/dose, given 3 times in a 24 hour period. Another favorite option of our residents in the miralax home clean-out regimen.

Miralax home clean-out. Make sure you tell the parents this is off-label. It is available over the counter. Miralax does not dissolve well in cold liquids, so tell them to mix it at room temperature. Once it is dissolved, you can refrigerate it and it will be OK. Tell the folks to do this on a week-end, since the child will miss school to do this. For a child 4-10 years old, have them take 1 Dulcolax tablet in the afternoon. Then mix 8 caps of miralax in 32 ounces of Gatorade and start drinking it about 2 hours later. Aim for 4 ounces every 30 minutes, it’s OK if the child goes slower. Just get it all in. For a child older than 10 years old, double everything. That is, have them take 2 dulcolax, and mix an entire 14 ounce bottle of miralax in 64 ounces of Gatorade, taking 8 ounces every 30 minutes. Once the child is finished, have them continue to take clear liquids until bedtime. Then the next day the child should be started on maintenance miralax.

This is a chronic problem. The colon took a long time to get so backed up and one clean-out shouldn’t mean you’re done. Keep on the miralax.

Have the child sit on the potty 3 times daily, after meals. If they are small, make sure they have a stool to rest their feet on. They only need to sit for 5-10 minutes. This will take advantage of the gastro-colic reflex and help get them back on track. 

Hospital admission for a NG Go-Lytely clean-out is indicated for a child with  significant abdominal pain or continued fecal soiling, despite your best efforts.

Now you’re ready to do some spring cleaning.

Amy Levine, MD, is an associate professor of pediatric EM at UNC Chapel Hill  
 

Comments   

# A moving topicTom Richardson, M.D. 2009-06-16 20:09
Thanks for the suggestions! Acutely, one of our peds GI docs also uses "Milk and Molasses" enemas--while parents do look at you rather odd, they really do work!
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