When disimpaction is achieved, the child begins the maintenance phase of treatment. This phase promotes regular stool production and prevents reimpaction. It involves attention to diet, medications to promote stool regularity, and behavioral training. Increasing dietary fiber and fluid are recommended. For children with chronic constipation, the recommended daily dose of fiber is calculated as 10 grams plus the child’s age in years (e.g., a 10-year-old should take 20 grams of fiber per day). At least 2 oz of nondairy fluid intake per gram of fiber intake is recommended. Sorbitol-based juices, including prune, pear, and apple juice, increase the water content of bowel movements. Lubricants or osmotic laxatives are used to promote regular soft bowel movements. Maintenance medications, including side effects, are listed in Table 14-3. Polyethylene glycol powder is well tolerated because the taste and texture are palatable. Some children may require the use of a lubricant in addition to an osmotic laxative; children with severe constipation may require a stimulant laxative.
Treatment failure occurs in approximately one in five children secondary to problems with adherence or poor recognition of inadequate treatment resulting in reimpaction.
Chronic constipation and soiling interfere with social functioning and self-esteem. Discomfort and fear of accidents may distract children from their schoolwork and other important tasks. Children also may develop unusual eating habits in response to chronic constipation and their beliefs about this condition. Case reports of child abuse related to soiling have been published.
The primary care physician can recommend adequate fiber intake in all children and encourage families to help their children institute regular toileting habits at an early age as preventive measures. Earlier diagnosis of chronic constipation can prevent much secondary disability and shorten the length of treatment required.
Juices containing sorbitol Pear, prune, apple
Lactulose or sorbitol: 1–3 mL/kg/day ÷ doses bid See below
Corn syrup (light or dark): 1–3 mL/kg/day  doses bid Per Rectum Not considered risk for Clostridium botulinum spores
Mineral oil: 1–3 mL/kg day as one dose or  bid Aspiration—lipoid pneumonia
Chill or give with juice
Leakage: dose too high or impaction
Osmotics Retain water in stool, aiding bulk and softness
Lactulose: 10 g/15 mL, 1–3 cc/kg/day  doses bid Synthetic disaccharide: abdominal cramping, flatus
Magnesium hydroxide (milk of magnesia): Risk of hypermagnesemia, hypophosphatemia, secondary 400 mg/5 mL, 1–3 mL/kg/day  bid hypocalcemia with overdose or renal insufficiency 800 mg/5 mL, 0.5 mL/kg  bid
MiraLAX (polyethylene glycol powder): Titrate dose at 3-day intervals to achieve mushy stool consistency 17 g/240 cc water or juice stock, 1.0 g/kg/day  doses bid May make stock solutions to administer over 1–2 days (approximately 15 cc/kg/day)
Sorbitol: 1–3 mL/kg/day  doses bid Less costly than lactulose
Stimulants† Improve effectiveness of colonic and rectal muscle contractions
Senna: syrup—8.8 g sennoside/5 mL Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy; abdominal cramping 2–6 yr: 2.5–7.5 cc/day  doses bid 6–12 yr: 5–15 cc/day  doses bid Improvement of melanosis coli after medication stopped (Tablets and granules available)