Constipation — Treatment Per Rectum, PO/NG Clean Out and RN Administration Guidance — Clinical Pathway: Emergency Department and Inpatient

Constipation Clinical Pathway — Emergency Department and Inpatient

Treatment Per Rectum, PO/NG Clean Out and RN Administration Guidance

Age Treatment Medication Dose Comments
< 1 yr 1st and 2nd line Glycerin 1 suppository if no stool in previous 24 hrs
≥ 1 yr to < 2 yrs 1st and 2nd line Sodium chloride (0.9%) enema 10 mL/kg, max 120 mL
≥ 2 yrs 1st Line Sodium phosphate
(Fleet)		 2-12 yr: pediatric preparation 66 mL
≥ 12 yr: adult preparation 133 mL
  • Consider mineral oil enema before sodium phosphate enema to soften stool
  • Do not repeat sodium phosphate enema without bowel movement in between doses due to increased risk of toxicity and death
  • Do not use sodium phosphate enema if severe renal impairment
Mineral oil enema 2-12 yr: 60 mL
≥ 12 yr: 133 mL
2nd line treatment for inpatient setting GoLYTELY enema 20 mL/kg, Max 500 mL

PO/NG Cleanout

If possible, consider giving stimulant laxative ~4 hrs prior to polyethylene glycol administration.

Bisacodyl only for children who can swallow pills; delayed-release tablets cannot be crushed.

Weight Bisacodyl Senna
20 kg 5 mg 17.2 mg or 10 mL
21-30 g 10 mg 25.8 mg or 15 mL
> 31 kg 15 mg 51.6 mg or 30 mL

Oral/NG Cleanout Options

Convert to NG if PO not tolerated.

  Dose Rate Comment
Miralax ≥ 6 mos: 4g/kg
  • Administer over 3-4 hrs
  • Until rectal effluent clear
  • Give only once
  • Follow with GoLYTELY as needed
GoLYTELY
  • 10-20 kg
    • Up to 100 mL/kg/dose
    • Total dose to be determined on an individual basis
  • > 20 kg
    • 125 mL/kg/dose or up to 4 L
  • 25-40 mL/kg/hr
  • Given over 4-10 hrs
  • Until rectal effluent is clear
  • May repeat multiple times
  • If repeated
    • Check BMP for electrolyte abnormalities
    • Assess for dehydration
    • Supplement with IVF as needed

RN Considerations for Constipation Medications

Administration of Rectal Medications Procedure

Enemas
  • Give mineral oil enema 10 mins prior to sodium phosphate (Fleet) enema to help soften stool
  • Lubricate nozzle, insert and squeeze cheeks
  • If hit stool, remove and clean nozzle, wait 10 mins and reinsert, in attempt to shift around stool
GoLYTELY
  • Contact provider if child does not meet minimum intake within first 1-2 hrs
  • NG GoLytely may be required
  • Vomiting with PO or NG GoLYTELY
    • Notify provider
    • Give a break
    • Restart at lower rate
    • If tolerating lower rate, may slowly increase rate to goal
    • If persistent emesis develops, discuss possibility of obstruction with provider