Consider cause:

• Inactivity
• Metabolic: dehydration; hypercalcaemia; hypokalaemia
• Cystic fibrosis
• Reduced oral intake
• Spinal cord/cauda equina compression
• Bowel obstruction
• Fear of pain on defaecation: secondary to hard stools, rectal/anal grazes and tears
• Drugs: opioids; anticholinergics; anticonvulsants; 5HT₃ antagonists; vincristine chemotherapy
• Social: shy about using toilets away from home. Not knowing where the toilets are etc.

Liaise with parents:

What are child’s usual bowel habits? - what is constipation for one may be a normal pattern for another.

Has there been a change in the usual pattern?

Management

General measures

• Treat underlying cause if appropriate/possible
• Co-prescribe prophylactic laxatives with drugs that commonly cause constipation
• Try oral medication first, then proceed to rectal preparations
• Check for bowel obstruction, faecal impaction and rectal/anal grazes/tears
• A plain abdominal X-ray may be helpful if the clinical picture is unclear.
  Explain cause and discuss treatment options with child and family; ensuring they understand that results from treatment will not be immediate. Their co-operation is essential in successful management.

Medication

Bisacodyl

Form

Tablet: 5mg
Suppository: 5mg, 10mg

Dose

Give tablets at night, suppositories in the morning.

By mouth:

Child 4–18 years: 5-20mg once daily; adjust according to response.

By rectum (suppository):

Child 2–18 years: 5-10mg once daily; adjust according to response.
Acts in 12h orally, 20-60 minutes rectally. Stimulant laxative.

Senna

Form

Syrup: 7.5mg in 5mL

Tablets: 7.5mg

Dose (oral)

Initial doses which can be adjusted according to response and tolerance

Child 1 month –2 years: 0.5mL/kg (maximum 2.5mL) of syrup once a day,
Child 2 –6 years: 2.5-5mL of syrup a day,
Child 6–12 years: 5-10mL a day of syrup or 1-2 tablets at night or 2.5-5mL of granules,
Child 12–18 years: 10-20mL a day of syrup or 2-4 tablets at night or 5-10mL of granules.

Stimulant laxative. Acts in 8-12h

Licence: Syrup licensed in children >2yr, tablet not recommended in children <6yr.

Movicol®

Form

Sachet: oral powder

Dose and routes (Movicol® paediatric for those less than 12 years of age; Movicol® from 12 years of age)

By mouth for constipation or prevention of faecal impaction:

Child under 1 year: ½-1 sachet daily,
Child 1–6 years: 1 sachet daily (adjust dose according to response; maximum 4 sachets daily),
Child 6–12 years: 2 sachets daily (adjust dose according to response; maximum 4 sachets daily),
Child 12–18 years: 1–3 sachets daily of adult Movicol®.

By mouth for faecal impaction:

Child under 1 year: ½-1 sachet daily,
Child 1–5 years: 2 sachets on first day and increase by 2 sachets every 2 days (maximum 8 sachets daily). Treat until impaction resolved then switch to maintenance laxative therapy,
Child 5–12 years: 4 sachets on first day and increase by 2 sachets every 2 days (maximum 12 sachets daily). Treat until impaction resolved then switch to maintenance laxative therapy,
Child 12–18 years: 4 sachets daily of adult Movicol® then increase by 2 sachets daily to a maximum of 8 adult Movicol sachets daily. Total daily dose should be drunk within a 6 hour period. After disimpaction switch to maintenance laxative therapy.

Dantron (Co-danthramer)

By mouth

Co-danthramer 25/200 suspension 5mL = one co-danthramer 25/200 capsule (Dantron 25mg poloxamer ‘188’ 200mg):

Child 2–12 years: 2.5–5mL at night,
Child 6–12 years: 1 capsule at night,
Child 12–18 years: 5–10mL or 1–2 capsules at night. Dosage can be increased up to 10-20mL twice a day.

Strong co-danthramer 75/1000 suspension 5mL = two strong co-danthramer 37.5/500 capsules:

Child 12–18 years: 5mL or 1–2 capsules at night.

Combined softener and stimulant laxative. Acts in 8-12h. Makes urine red (inform child and carers). Can cause superficial burns in children who are incontinent / in nappies, in which case use an alternative laxative.

Licence: only licensed for use in children with prognosis expected to be less than a year due to theoretical cancer risk from studies in animals.

Docusate sodium

Form

Elixir: 12.5mg in 5mL; 50mg in 5mL. Dilute with milk or orange juice.
Capsule: 100mg
Enema: Fletcher’s Enemette: 90mg in 5mL
Norgalax micro enema: 120mg in 10g

By mouth

Child 6 months–2 years: initial dose of 12.5mg 3 times daily; adjust dose according to response,
Child 2–12 years: initial dose of 12.5mg 3 times daily. Increase to 25mg 3 times daily as necessary and then further adjust dose according to response,
Child 12–18 years: initial dose 100mg/dose 3 times daily. Adjust as needed according to response up to 500 mg/day in divided doses.

By rectum

Child 12–18 years: 1 enema as single dose.

Oral preparation acts in 24-48h, rectal within 20 minutes

Softener and stimulant.

Licence: capsule not licensed for children. Norgalax microenema licensed for children >12yr. Fletcher’s Enemette licensed for children >3yr.

Lactulose

Form

Solution: 3.1 - 3.7g in 5mL

By mouth: initial dose twice daily then adjusted to suit patient

Neonate: 2.5mL/dose twice a day
Child 1 month to 1 year: 2.5mL/dose 1-3 times daily,
Child 1year to 5 years: 5mL/dose 1-3 times daily,
Child 5-10 years: 10mL/dose 1-3 times daily,
Child 10-18 years: 15mL/ dose 1-3 times daily.

Mild osmotic laxative

Acts in 36-48h

May cause bloating/flatulence.

Sodium Citrate enema (3 preparations)

Micolette Micro-enema sodium citrate 450mg, sodium lauryl sulfoacetate 45mg, glycerol 625mg, together with citric acid, potassium sorbate, and sorbitol in a viscous solution, in 5mL

By rectum: Child 3–18 years: 5–10 mL as a single dose

Micralax Micro-enema sodium citrate 450mg, sodium alkylsulfoacetate 45mg, sorbic acid 5mg, together with glycerol and sorbitol in a viscous solution in 5mL

By rectum: Child 3–18 years: 5mL as a single dose

Relaxit Micro-enema sodium citrate 450mg, sodium lauryl sulfate 75mg, sorbic acid 5mg, together with glycerol and sorbitol in a viscous solution in a 5mL single dose pack with nozzle.

By rectum: Child 1 month–18 years: 5mL as a single dose (insert only half nozzle length in child under 3 years).

Phosphate enema

Form

Enema sodium acid phosphate 21.4g/ sodium phosphate 9.4g in 118mL

Dose (rectal)

Child 3–7 years: 45-65mL once daily, Child 7-12 years: 65-100mL once daily, Child 12–18 years: 100-128mL once daily

Not more than 1 in 24h. Osmotic laxative.