laxatives (and doses) for disimpaction in childhood constipation

Last reviewed 11/2023

• offer the following oral medication regimen for disimpaction if indicated:
  • polyethylene glycol 3350 + electrolytes e.g. Movicol, using an escalating dose regimen, as the first-line treatment
  • polyethylene glycol 3350 + electrolytes may be mixed with a cold drink
  • add a stimulant laxative e.g. Senna, if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks
  • substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if polyethylene glycol 3350 + electrolytes is not tolerated
  • inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.
• start maintenance therapy if the child or young person is not faecally impacted

Laxatives Recommended doses for Disimpaction

• Macrogols Polyethylene glycol 3350 + electrolytes
  • Paediatric formula: Oral powder: macrogol 3350 (polyethylene glycol 3350)a 6.563 g; sodium bicarbonate 89.3 mg; sodium chloride 175.4 mg; potassium chloride 25.1 mg/sachet (unflavoured)
    • disimpaction
      • child under 1 year: ½-1 sachet daily (non-BNFC recommended dose)
      • child 1-5 years: 2 sachets on 1st day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily (non-BNFC recommended dose)
      • child 5-12 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to maximum of 12 sachets daily (non-BNFC recommended dose)
    • ongoing maintenance (chronic constipation, prevention of faecal impaction)
      • child under 1 year: ½-1 sachet daily (non-BNFC recommended dose)
      • child 1-6 years: 1 sachet daily; adjust dose to produce regular soft stools (maximum 4 sachets daily) (for children under 2, non-BNFC recommended dose)
      • child 6-12 years: 2 sachets daily; adjust dose to produce regular soft stools (maximum 4 sachets daily)
  • Adult formula: Oral powder: macrogol 3350 (polyethylene glycol 3350) 13.125 g; sodium bicarbonate 178.5 mg; sodium chloride 350.7 mg; potassium chloride 46.6 mg/sachet (unflavoured)
    • disimpaction
      • child/young person 12-18 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to maximum of 8 sachets daily (non-BNFC recommended dose)
    • ongoing maintenance (chronic constipation, prevention of faecal impaction)
      • child/young person 12-18 years: 1-3 sachets daily in divided doses adjusted according to response; maintenance, 1-2 sachets daily
• Osmotic laxatives Lactulose
• child 1 month to 1 year: 2.5 ml twice daily, adjusted according to response
• child 1-5 years: 2.5-10 ml twice daily, adjusted according to response (non-BNFC recommended dose)
• child/young person 5-18 years: 5-20 ml twice daily, adjusted according to response (non-BNFC recommended dose)
• Stimulant laxatives
  • Sodium picosulfate ***b
    • Non-BNFC recommended doses Elixir (5 mg/5 ml)
      • child 1 month to 4 years: 2.5-10 mg once a day
      • child/young person 4-18 years: 2.5-20 mg once a day
    • Non-BNFC recommended dose Perlesc (1 tablet = 2.5mg)
      • child/young person 4-18 years: 2.5-20mg once a day
  • Bisacodyl Non-BNFC recommended doses
    • By mouth
      • child/young person 4-18 years: 5-20 mg once daily
    • By rectum (suppository)
      • child/young person 2-18 years: 5-10 mg once daily
  • Sennad Senna syrup (7.5 mg/5 ml)
    • child 1 month to 4 years: 2.5-10 ml once daily
    • child/young person 4-18 years: 2.5-20 ml once daily
  • Senna (non-proprietary) (1 tablet = 7.5 mg)
    • child 2-4 years: ½-2 tablets once daily
    • child 4-6 years: ½-4 tablets once daily
    • child/young person 6-18 years: 1-4 tablets once daily
  • Docusate sodiume
    • child 6 months-2 years: 12.5 mg three times daily (use paediatric oral solution)
    • child 2-12 years: 12.5-25 mg three times daily (use paediatric oral solution)
    • child/young person 12-18 years: up to 500 mg daily in divided doses

All drugs listed above are given by mouth unless stated otherwise. Unless stated otherwise, doses are those recommended by the British National Formulary for Children (BNFC) 2009.***Informed consent should be obtained and documented whenever medications/doses are prescribed that are different from those recommended by the BNFC.

• a At the time of publication (May 2010) Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that includes electrolytes. It does not have UK marketing authorisation for use in faecal impaction in children under 5 years, or for chronic constipation in children under 2 years. Informed consent should be obtained and documented. Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that is also unflavoured
• b Elixir, licensed for use in children (age range not specified by manufacturer). Perles not licensed for use in children under 4 years. Informed consent should be obtained and documented
• c Perles produced by Dulcolax should not be confused with Dulcolax tablets which contain bisacodyl as the active ingredient
• d Syrup not licensed for use in children under 2 years. Informed consent should be obtained and documented
• e Adult oral solution and capsules not licensed for use in children under 12 years. Informed consent should be obtained and documented

Notes:

• do not use rectal medications for disimpaction unless all oral medications have failed and only if the child or young person and their family consent
• administer sodium citrate enemas only if all oral medications for disimpaction have failed
• do not administer phosphate enemas for disimpaction unless under specialist supervision in hospital/health centre/clinic, and only if all oral medications and sodium citrate enemas have failed
• do not perform manual evacuation of the bowel under anaesthesia unless optimum treatment with oral and rectal medications has failed
• review children and young people undergoing disimpaction within 1 week

Reference:

• 1) NICE (May 2010). Constipation in chidren