How Much Milk of Magnesia for 25 Pound Baby

Managing functional constipation in children

Posted: December 1, 2011 | Reaffirmed: Feb 28, 2018

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Principal writer(south)

A Rowan-Legg; Canadian Paediatric Society, Community Paediatrics Committee

Paediatr Kid Health 2011;16(10):661-five

Abstruse

Constipation is a common babyhood problem, with both somatic and psychological effects. The etiology of paediatric constipation is probable multifactorial, and seldom due to organic pathology. Children benefit from prompt and thorough direction of this disorder. The goal of treatment is to produce soft, painless stools and to forbid reaccumulation of feces. Education, behavioural modification, daily maintenance stool softeners and dietary modification are all of import components of therapy. Fecal disimpaction may be necessary at the offset of treatment. Investigations are rarely necessary. Polyethylene glycol is a safe, effective and well-tolerated long-term treatment for constipation. Regular follow-up for children with constipation is of import. Referral to a gastroenterologist should be made in refractory cases or when there is a suspicion of organic pathology.

Primal Words: Constipation; Encopresis; Laxative; Paediatric

Constipation is a common childhood complaint [1][2]. Despite its prevalence, it remains a challenging illness for paediatric patients, their families and wellness intendance providers. The etiology of paediatric constipation is likely multifactorial, and is very seldom due to organic pathology. It has been shown that childhood constipation is undertreated [3]. If constipation is unrecognized or inadequately treated, its effects can be far reaching – in children, it tin can lead to significant intestinal pain, appetite suppression, fecal incontinence with lowered self-esteem, social isolation and family unit disruption. Children with constipation benefit from prompt and thorough treatment intervention.

Definition

Constipation is defined variably, but involves infrequent, difficult, painful or incomplete evacuation of difficult stools. The term 'functional constipation' describes all children in whom constipation does not have an organic etiology. Functional constipation is usually the issue of withholding of feces in a child who wants to avert painful defecation. Frequently, children with constipation will also experience recurrent episodes of fecal incontinence due to overflow acquired by fecal impaction (known equally encopresis).

The Rome II paediatric criteria for functional gastrointestinal disorders were established in 1999, and were to be used as a diagnostic assistance and to provide categorization for inquiry purposes [four]. The updated Rome III criteria for functional constipation were published in 2006 [v]:

Rome 3 diagnostic criteria for functional constipation (criteria fulfilled at least once per calendar week for at least two months before diagnosis):

Must include ii or more of the following in a child with a developmental age of at least four years, with bereft criteria for the diagnosis of irritable bowel syndrome:

1. Ii or fewer defecations in the toilet per week.
2. At least i episode of fecal incontinence per calendar week.
3. History of retentive posturing or excessive volitional stool retentivity.
4. History of painful or hard bowel movements.
5. Presence of a big fecal mass in the rectum.
6. History of large diameter stools that may obstruct the toilet.

Objective

The current practice bespeak focuses on the management of functional constipation in children, rather than its differentiation from organic pathology. The reader is referred to other resources for a diagnostic discussion [6][7].

Management

The goals in treating constipation are to produce soft, painless stools and to prevent the reaccumulation of feces. These outcomes are achieved through a combination of didactics, behavioural modification, daily maintenance stool softeners and dietary modification. Fecal disimpaction may be necessary at the outset of treatment.

Initial laboratory and radiographical investigations are not necessary unless history and examination suggest organic disease [viii][9].

Education

Parents and older children will benefit from a brief description of the mechanism of functional constipation. This should be the outset step in treatment.

When stool enters the normal rectum, the involuntary smooth muscle of the internal anal sphincter is relaxed. The urge to defecate is signaled when the stool reaches the external anal sphincter. If the child voluntarily relaxes the external sphincter accordingly, the rectum is evacuated. If, however, the child tightens the external sphincter and the gluteal muscles, the fecal mass is pushed back in the rectal vault and the urge to defecate subsides. Parents will likely recognize examples of these characteristic withholding behaviours: squatting, rocking, stiff walking on tiptoes, crossing the legs or sitting with heels pressed against the perineum. Withholding leads to stretching of the rectum and lower colon, and retention of stool. The longer the stool remains in the rectum, the more water is removed and the harder the stool becomes, to the point of impaction. Involuntary overflow soiling and then occurs around this mass of impacted stool.

Loss of control over defecation confuses the child and angers the parents, who may believe that the kid is intentionally soiling his/her underwear. It is very of import to remove these negative attributions, and to have parents understand that soiling is not a willful or defiant behaviour.

Ii transition periods in which the developing kid is particularly prone to functional constipation are at the time of toilet learning, and during the start of school [6]. Toilet learning should non be a struggle, and the clinician may have a role in aiding parents to make up one's mind the child's readiness [x].

Past the time a child is referred to a clinician, constipation may have been a problem for a long period. Thus, it is very important to instill promise and positivity in the frustrated child and her/his parents. Positive messaging is aided by education and a articulate direction program to foster a sense of command. In improver, it is crucial to admit that proper direction of constipation is a long-term partnership, necessitating patience and realistic goals for improvement.

Parents often worry (but may not ask) about the potential for medications to render the bowel 'lazy' or 'fond to laxatives'. Misconceptions must be anticipated and dispelled through teaching nigh stool softeners, which practise not make the bowel contract or spasm, are absorbed minimally (if at all) from the gut, and are condom for long-term use.

Fecal disimpaction

Fecal impaction is identified past the presence of a large and hard mass in the abdomen or dilated vault filled with stool on rectal examination, and ofttimes substantiated by a history of overflow incontinence. (An abdominal radiograph is non needed to diagnose fecal impaction.) It is important to recognize the presence of fecal impaction because maintenance stool softeners tin worsen overflow incontinence if the impaction is left untreated [8].

Disimpaction can be accomplished past either oral or rectal medication. In a double-blind uncontrolled study, Youssef et al [11] showed that the 3-day administration of polyethylene glycol (PEG) 3350 at a dose of 1 k/kg/day to i.5 yard/kg/day (maximum dose 100 yard/day) successfully disimpacted 95% of children, and was well tolerated [11]. Another study showed that a regimen of daily enemas for six days was equally as constructive as PEG 3350 (1.v g/kg/solar day) in relieving disimpaction, merely may be less well tolerated [12]. High-dose mineral oil has likewise been shown to exist constructive [xiii].

Children with severe impaction may need to be admitted to infirmary or an outpatient medical unit of measurement for nasogastric lavage with PEG solution if the volume required is intolerable orally. This is commonly continued until the rectal effluent is clear.

Digital disimpaction cannot exist recommended based on available information, and may accept harmful furnishings [6][14].

Maintenance therapy

One time the impacted stool has been removed, the focus of the handling should exist on preventing recurrence with use of laxatives. Refer to Table 1 for a listing of medications used to treat constipation. Medications have been shown to be more constructive than behavioural change alone in the treatment of constipation [15]. A systematic review of laxative treatments for childhood constipation has been recently published, and acknowledges the relative paucity of well-designed trials for laxatives in children and the resultant difficulty in establishing first-line therapy [16].

TABLE i Medications for the handling of paediatric constipation
Laxative	Dosage	Side effects
Lactulose	1 mL/kg/24-hour interval – 3 mL/kg/day in divided doses	Flatulence, intestinal cramps
Milk of magnesia (Magnesium hydroxide)	1 mL/kg/day – 3 mL/kg/twenty-four hours of 400 mg/5 mL available equally liquid	Magnesium poisoning (infants). In overdose, hypermagnesemia, hypophosphatemia and secondary hypocalcemia
Polyethylene glycol 3350	Disimpaction: ane g/kg/twenty-four hour period – 1.five g/kg/day for 3 days Maintenance: Starting dose at 0.four g/kg/day – 1 g/kg/day	Limited. Occasional abdominal pain, bloating, loose stools
Polyethylene glycol-electrolyte solution (lavage)	Disimpaction: 25 mL/kg/h (to 1000 mL/h) by nasogastric tube until clear effluent Maintenance: 5 mL/kg/day – 10 mL/kg/solar day (older children)	Nausea, bloating, abdominal cramps, vomiting and anal irritation
Mineral oil	Disimpaction: 15 mL/year – 30 mL/year of age (upwardly to 240 mL daily) Maintenance: ane mL/kg/day – three mL/kg/mean solar day <1 year of age: Not recommended	Lipid pneumonia if aspirated. Theoretical interference with absorption of fat-soluble substances, but no show
Senna	2–6 years: 2.v mL/solar day – 7.5 mL/day 6–12 years: v mL/day – 15 mL/day	Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy
Bisacodyl	Oral: 3–12 years: v mg – 20 mg Rectal: <two years: five mg/twenty-four hours 2–xi years: five mg/mean solar day – 10 mg/day	Abdominal cramping, nausea, diarrhea, proctitis (rare)
Docusate sodium	five mg/kg/day divided three times a solar day or as a single dose	Intestinal pain, cramping, diarrhea
Glycerin suppositories	–	None
Phosphate enemas	<2 years onetime: Not recommended >two years: 6 mL/kg (up to 135 mL)	Run a risk of mechanical trauma to rectal wall Abdominal distention or airsickness Hyperphosphatemia, hypocalcemia
Adapted from references [6] and [42]

At that place is growing prove to support the efficacy and safety of PEG 3350 in the maintenance treatment of children with constipation [17]. PEG 3350 without electrolytes (Lax-A-Mean solar day [Pendopharm, Canada] or RestoraLAX [Merck Canada Inc]) is a tasteless, odourless, osmotic laxative. It is available in powder course, and dissolves well when mixed in juice or h2o. It is absorbed only in trace amounts from the gastrointestinal tract and, unlike other colonic lavage solutions, carries no gamble of electrolyte imbalance. The effects of PEG 3350 starting time within the first calendar week of treatment.

Compared with placebo, PEG 3350 was more effective in increasing defecation frequency [18][xix]. PEG 3350 has been shown to be more effective (with increment in bowel movement frequency and subtract in fecal incontinence) than lactulose [20]-[23], and as as constructive equally milk of magnesia, although better tolerated [24]. A contempo study showed no additional consequence of regular enemas compared with PEG 3350 lonely in children with severe constipation [25].

Dose-finding studies for PEG 3350 used starting doses of 0.4 1000/kg/solar day to 0.8 g/kg/day as either a single or twice-daily dose and, when tailored to effect, a range of doses from 0.27 grand/kg/24-hour interval to 1.iv 1000/kg/day [26], and 0.3 yard/kg/solar day to ane.eight m/kg/day [27] was reported. Maintenance doses of 0.four g/kg/day to 1.0 g/kg/day have been shown to exist effective and well tolerated [26]-[28]. A common reason for the lack of response to stool softening therapy is inadequate dosing; physicians should non hesitate to get-go PEG therapy at a higher dose of 1.0 g/kg and then decrease as necessary.

The safe profile for PEG 3350 has been favourable. Clinical agin effects are minor and can include bloating, flatulence, abdominal pain and loose stools [17][18][26]-[28]. In none of the aforementioned trials was PEG 3350 discontinued due to side furnishings related to the medication.

At that place is no evidence that docusate is effective in paediatric constipation. There is no testify to recommend mineral oil in jelly course (Lansoyl [Aurium Pharma Inc, Canada]) over standard mineral oil, other than the issue of palatability. Sennosides have been shown to be inferior to lactulose, with respect to symptom control, relapse charge per unit and side effects in two trials [29][thirty].

With any stool softener, parents should be advised to adjust the dose co-ordinate to the response, increasing the dose every two days until the child has ane to ii soft stools per mean solar day, or decreasing the dose if the kid has loose stools. Parents should be warned that some leaking or soiling might persist at the start of handling. Physicians should besides hash out an 'emergency plan' with the parents, to be used if at that place is indication that impaction is recurring (eg, increasing the dose of stool softener or using a suppository).

Behavioural modification

A toileting regimen that dedicates fourth dimension for defecation is valuable. About people who have normal stooling habits tend to defecate at the same time each day [eight]. This conditioned reflex tends to occur within i h of eating, and usually in the morning. A constipated child should have a routine scheduled toilet sitting for 3 min to 10 min (age dependent), once or twice a day. Ensure that the child has a footstool on which they can support their legs to effectively increment intra-abdominal pressure (valsalva). In that location should be no punishment for not stooling during the toileting time; praise and advantage for stooling and the behaviour of toilet sitting can exist offered.

Information technology is helpful to have children and their caregivers go along a diary of stool frequency to review at the next appointment. A copy of the Bristol chart can exist helpful for standardizing stool descriptions [31].

Regular physical activity can be recommended, although its role in treating constipation remains unclear [32].

Dietary modification

A balanced diet that includes whole grains, fruits and vegetables is recommended equally part of the handling of constipation in children [6].

Carbohydrates (peculiarly sorbitol) establish in clip, pear and apple juices tin cause increased frequency and water content in stools [6].

Fibre intake below the minimum recommended value has been shown to be a run a risk factor for chronic constipation in children [33][34]. The American Academy of Pediatrics recommends a fibre intake of 0.five grand/kg/twenty-four hours (to a maximum of 35 chiliad/day) for all children [35]. There is piddling evidence supporting fibre supplementation (higher up the recommended daily intake) in children with constipation. In that location are no published studies regarding the use of wheat dextrin (Benefiber [Novartis Consumer Health Inc, USA]) or psyllium fibre (Metamucil [Procter & Gamble, USA]) supplements for treating childhood constipation. Acceptable fluid intake must be ensured with a bulking agent such every bit fibre.

Although excessive milk intake can exacerbate constipation, at that place is insufficient evidence that eliminating it from the diet improves refractory constipation [19]. For children unresponsive to acceptable medical and behavioural management, consideration could be given to a time-limited trial of a cow's milk-free nutrition [6]. Intolerance to cow's milk, particularly in children with atopy, has been associated with chronic constipation [36].

Two studies accept addressed the use of probiotics in treating constipation in children [37][38]. In the first study, the improver of Lactobacillus rhamnosus GG was not an effective adjunct to lactulose in treating constipation [37]. The second study'south sample size was likewise modest to draw whatsoever meaningful determination [38].

Constipation in infants

In infancy, constipation is generally functional, but a heightened vigilance for identifying ruby flags suggestive of an organic disorder in this historic period group is necessary. Information technology is known that breastfed infants can have greater variability than formula-fed infants in stool frequency. (Some normal breastfed newborns may stool with each feeding or may not take a bowel motion whatever more often than every vii to 10 days.) [6]. Mineral oil is contraindicated in infants because of uncoordinated swallowing and the take a chance of aspiration and subsequent pneumonitis. Increased intake of fluids and reducing excess cow'due south milk intake may exist helpful for constipation in older infants [6]. Recommendations to add brown saccharide to formula or water for infant constipation are anecdotal and not evidence based, besides as pose a chance of caries evolution. Lactulose and glycerin suppositories may be used [vi]. Two retrospective chart reviews examining the safety of PEG 3350 in infants have been reported [39][twoscore]. Both showed that at doses of 0.viii g/kg/day, PEG was well tolerated, effective and safe in the direction of constipation in infants younger than xviii months of age.

Follow-Up

Regular follow-ups with ongoing support and encouragement to the child and caregivers at scheduled part visits or through phone conversations are essential. In many cases, stool softeners need to be taken for months or years to promote soft daily stools [41]. Children with constipation should be treated for at to the lowest degree six months, and should take regular bowel movements without difficulty before because a trial of weaning maintenance therapy. The relapse rate for constipation can be quite high, and problems with stooling may persist into adulthood [8].

Referral to a gastroenterologist

Consultation with a gastroenterologist should be sought when adequate therapeutic measures fail or there is a concern that organic illness exists [six]. Further investigations may be warranted at this time.

Summary of recommendations

• A thorough history and physical examination are required to dominion out organic causes of constipation.
• Investigations (laboratory and radiography) are seldom required.
• Educational activity is critical at the initial visit and should exist regularly reinforced at subsequent visits.
• Disimpaction tin be achieved with either oral or rectal medication.
• A balanced and varied diet with requisite fibre intake is recommended.
• Behavioural management should be used in conjunction with medication therapy.
• PEG 3350 is a safety, constructive and well-tolerated long-term treatment for constipation.
• Regular follow-up is very important.
• Referral to a gastroenterologist should be made in refractory cases or when at that place is a suspicion of organic disease.

Acknowledgements

This practice signal was reviewed past the Canadian Paediatric Society's Nutrition and Gastroenterology Committee.

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Customs PAEDIATRICS Committee

Members: Minoli Amit MD (Lath Representative); Carl Cummings MD; Marking Feldman MD (Chair); Barbara Grueger MD; Anne Rowan-Legg Dr.
Liaison: Peter Nieman Doc, Canadian Paediatric Social club, Community Paediatrics Department
Consultants: Mia Lang MD; Hema Patel MD
Master author: Anne Rowan-Legg Doc

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of handling or process to exist followed. Variations, taking into business relationship private circumstances, may exist appropriate. Net addresses are electric current at time of publication.

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