When to refer a constipated child to a pediatric gastroenterologist

The following pediatric constipation referral guidelines and recommended outpatient treatments were developed by John T. Stutts, M.D., pediatric gastroenterologist at Norton Children’s Gastroenterology, affiliated with the UofL School of Medicine.

Dr. Stutts practices at the Novak Center for Children’s Health downtown and at Norton Medical Plaza II – Brownsboro on Norton Brownsboro Hospital/Norton Children’s Medical Center campus.

Primary care providers can perform recommended outpatient treatments for patients presenting with constipation due to functional conditions. In the event that evaluation and/or intervention determine that the constipation is not due to a functional condition, a referral to a gastroenterology specialist should be made.

Recommended evaluations prior to referral

• Patient history and physical exam. In general, a history of skipping days between bowel movements indicates a lack of need for kidneys, ureters and bladder (KUB) view and a need for intervention, which can be performed by a primary care provider (see recommended outpatient treatments below).
• Abdominal film (AP view with kidneys, ureters and bladder) to assess colonic stool burden. In general, a film interpretation of “mild,” “moderate” or “large” stool burden indicates need for intervention, which can be performed by a primary care provider (see recommended outpatient treatments below).
• Thyroid function tests
• Celiac panel (total IgA and tissue transglutaminase IgA). If positive, do not begin gluten-free diet prior to gastrointestinal evaluation/endoscopy to prevent false negatives on histology.

When to refer

Providers can submit a referral to Norton Children’s Gastroenterology after evaluations are complete that  rule out a functional condition and if patients present with symptoms such as:

• Chronic abdominal pain (lasting more than one month) not responsive to bowel clean out and maintenance interventions detailed below
• Encopresis not responsive to bowel clean out and maintenance interventions detailed below
• Weight loss or growth failure
• Failure to pass stool in the first 48 hours after birth
• Sacral dimple
• Abdominal distention with vomiting

Recommended documentation to include with referral:

• Current growth chart
• Laboratory and radiology results
• Relevant clinical notes that include information that led to referral

Recommended outpatient treatments

Two steps to intervention

1. Colonic evacuation of accumulated stool (bowel clean out)
2. Maintenance medications to prevent re-accumulation of stool

Outpatient bowel clean out — four options

• Fleet enemas
  1. Ages 1 to 3: Use pediatric/children’s-size Fleet enemas
  2. Over age 3: Use adult-size Fleet enemas

Use one enema every day (at approximately the same time each day) for a minimum of four days. If stool output still has brown specks/brown liquid after fourth enema, continue for two additional days (total of six days).

OR

• Magnesium citrate
• Usually reserved for older children who can ingest despite its poor taste (ages 10 and older).
• Give 1 ounce per year of age, maximum 10 ounces, every day for a minimum of four days. It should be ingested in less than 15 minutes. If stool output still has brown specks/brown liquid, continue for two additional days (total of six days).
• Do not mix the magnesium citrate with any other liquid.

OR

• GoLytely (polyethylene glycol electrolyte lavage solution)
• Usually reserved for older children who can ingest despite its poor taste (ages 10 and older).
• Total of 1 gallon: Take 3 to 4 ounces every 20 minutes until 1 gallon is ingested.
• Flavoring such as Crystal Light can be added (yellow lemonade flavor recommended).

OR

• Miralax clean-out

Children under 40 kilograms:

Do not use in children younger than 1 year old.

• Give 5 milligram tablet of Dulcolax (bisacodyl) by mouth, then one hour later begin drinking the following:

Mixture of seven capfuls (119 grams) of Miralax powder in 32 ounces of Gatorade or other clear liquid. This mixture should be ingested over four hours.

• Then give an additional 5 milligram tablet of Dulcolax by mouth.

Children over 40 kilograms:

Do not use in children younger than 1 year old.

• Give two 5 milligram tablets of Dulcolax (bisacodyl) by mouth, then one hour later begin drinking the following:

Mixture of 14 capfuls (238 grams) of Miralax powder in 64 ounces of Gatorade or other clear liquid. This mixture should be ingested over four hours.

• Then give two additional 5 milligram tablets of Dulcolax by mouth.

The patient’s bowel should be completely cleaned out before starting the maintenance medications below. The following should start the day after the clean out is complete.

Post-bowel clean out maintenance options (starting doses):

Maintenance options will need to be in place for a minimum of six months prior to starting the weaning process. The goal is two to four pudding-consistency stools daily.

• Miralax (polyethylene glycol): 1 capful = 17 grams
  1. Ages 1 to 3: ½ capful by mouth once a day
  2. Ages 4 to 6: ¾ capful by mouth twice a day
  3. Ages 7 to 10: 1 capful by mouth twice a day
  4. Ages 11 to 17: 1½ capfuls by mouth twice a day

OR

• Milk of Magnesia
  1. Age 1 or younger: 1 to 2 teaspoons by mouth twice a day
  2. Ages 2 to 6: 2 teaspoons by mouth twice a day
  3. Ages 7 to 8: 1 tablespoon by mouth twice a day
  4. Age 9 and older: 2 tablespoons by mouth twice a day

PLUS

• Fiber and fluids
  1. Ages 1 to 3: 15 grams/day plus increase fluids
  2. Ages 4 to 8: 20 grams/day plus increase fluids
  3. Ages 9 to 12: 25 grams/day plus increase fluids
  4. Agea 13 and older: 30 grams/day plus increase fluids