Maintenance therapy
- start maintenance therapy as soon as the child or young person's bowel is disimpacted.
- reassess children frequently during maintenance treatment to ensure they do not become reimpacted and assess issues in maintaining treatment such as taking medicine and toileting. Tailor the frequency of assessment to the individual needs of the child and their families (this could range from daily contact to contact every few weeks). Where possible, reassessment should be provided by the same person/team
- offer the following regimen for ongoing treatment or maintenance therapy:
- polyethylene glycol 3350 + electrolytes as the first-line treatment
- adjust the dose of polyethylene glycol 3350 + electrolytes according to symptoms and response. As a guide for children and young people who have had disimpaction the starting maintenance dose might be half the disimpaction dose (see disimpaction doses below)
- add a stimulant laxative (see disimpaction doses below) if polyethylene glycol 3350 + electrolytes does not work
- substitute a stimulant laxative if polyethylene glycol 3350 + electrolytes is not tolerated by the child or young person. Add another laxative such as lactulose or docusate (see doses used for disimpaction below) if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established - this may take several months. Children who are toilet training should remain on laxatives until toilet training is well established. Do not stop medication abruptly: gradually reduce the dose over a period of months in response to stool consistency and frequency. Some children may require laxative therapy for several years. A minority may require ongoing laxative therapy.
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
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