First of all, what’s the goal? You have 3 aims here: You want to soften the stools without producing diarrhea. You want to prevent fecal soiling (which is socially devastating to the school-aged child). You want to get them in a routine so they stool every 1-2 days. You’ll be referring them back to their regular physician to make sure that they achieve these goals. But you’re the one who gets to launch this ship and explain to the parents what it is you are recommending and why.
Stool softeners. They don’t stimulate stooling, they just make it easier to go. They aren’t habit forming and can be used safely for years. Meds in this group include milk of magnesia, lactulose, mineral oil, and miralax. Miralax seems to be the most effective of the lot. Have the parents add one capful to 8 ounces of liquid once or twice per day for constipated children over the age of 6 months. The error most folks make is not using enough or stopping too soon. Don’t be shy, go for it.
Laxatives. Several days of this can be helpful with the child with a large fecal mass. Then transition them to a stool softener. Options here include Mag citrate which is dosed at 4cc/kg/dose, given 3 times in a 24 hour period. Another favorite option of our residents in the miralax home clean-out regimen.
Miralax home clean-out. Make sure you tell the parents this is off-label. It is available over the counter. Miralax does not dissolve well in cold liquids, so tell them to mix it at room temperature. Once it is dissolved, you can refrigerate it and it will be OK. Tell the folks to do this on a week-end, since the child will miss school to do this. For a child 4-10 years old, have them take 1 Dulcolax tablet in the afternoon. Then mix 8 caps of miralax in 32 ounces of Gatorade and start drinking it about 2 hours later. Aim for 4 ounces every 30 minutes, it’s OK if the child goes slower. Just get it all in. For a child older than 10 years old, double everything. That is, have them take 2 dulcolax, and mix an entire 14 ounce bottle of miralax in 64 ounces of Gatorade, taking 8 ounces every 30 minutes. Once the child is finished, have them continue to take clear liquids until bedtime. Then the next day the child should be started on maintenance miralax.
This is a chronic problem. The colon took a long time to get so backed up and one clean-out shouldn’t mean you’re done. Keep on the miralax.
Have the child sit on the potty 3 times daily, after meals. If they are small, make sure they have a stool to rest their feet on. They only need to sit for 5-10 minutes. This will take advantage of the gastro-colic reflex and help get them back on track.
Hospital admission for a NG Go-Lytely clean-out is indicated for a child with significant abdominal pain or continued fecal soiling, despite your best efforts.
Now you’re ready to do some spring cleaning.