Constipation in Children Drug Summary

Drug	Dosage	Remarks
Bulk-forming Laxative
Ispaghula1 (Ispaghula husk, Plantago ovata seed shells)	6-12 years old: 2.5 g PO 8-24 hourly >12 years old: 5-15 g PO 24 hourly in divided doses or 6-12 years old: 2.5-5 mL PO 12 hourly	Adverse Reactions GI effects (flatulence and feeling of fullness in the first few days) Special Instructions Should be taken/mixed with water and drunk immediately Contraindicated in patients with poorly-controlled diabetes, narrowing of the GI tract, and ileus Not recommended in children <6 years old
Enemas
Glycerol (Glycerin)1	1.9 g suppository per rectum single dose	Adverse Reactions GI effects (rectal burning, irritation, discomfort, cramping pain, and feeling of inadequate evacuation) Special Instructions Contraindicated in patients with acute or undiagnosed abdominal pain and symptoms of appendicitis Use with caution if there is presence of sudden changes in bowel habits for >2 weeks, abdominal pain, nausea/vomiting Should not be used >1 week at a time
Sodium chloride1	15% enema: 10-20 mL per rectum	Adverse Reactions GI effects (nausea/vomiting, abdominal pain)
Sodium phosphate1	>2 years old: 66.6 mL per rectum >12 years old: 133 mL per rectum Oral solution: 5-9 years old: 5-7.5 mL PO single dose 10-11 years old: 10-15 mL PO single dose >12 years old: 15-45 mL PO single dose	Adverse Reactions GI effects (nausea/vomiting, bloating, abdominal cramps, diarrhea) Special Instructions Oral solution is not recommended in children <5 years old Avoid use of oral solution for >1 week Contraindicated in patients with congenital megacolon, imperforate anus, CHF, renal failure, bowel/GI obstructions, ascites, active inflammatory bowel disease or when there is a presence of nausea/vomiting or abdominal pain
Osmotic Laxatives
Lactitol monohydrate	1-6 years old: 5 g PO 24 hourly or 0.5-1 g/kg/day PO divided 8-12 hourly ≥6 years old: 5-10 g PO 24 hourly or 10-30 g/day PO divided 8-12 hourly 12-18 years old: 20-60 g/day PO divided 8-12 hourly	Adverse Reactions GI effects (abdominal distension, abdominal cramps, flatulence, diarrhea) Special Instructions Advise to take with meal for patients who have complaint of nausea Use with caution in patients with ileostomy, galactosemia, intestinal obstruction, low galactose diet, lactose intolerance, diabetes Contraindicated in patients with appendicitis, galactosemia, intestinal obstruction, or in cases of unexplained abdominal pain/bleeding Periodic monitoring of serum electrolytes, blood glucose and lactate, blood electrolyte levels on long-term treatment
Lactulose	0.7-2 g/kg/day PO divided 12-24 hourly or Starting dose (for 3 days): Infant: 5 mL PO 24 hourly 1-6 years old: 5-10 mL PO 24 hourly 7-14 years old: 15-20 mL PO 24 hourly >15 years old: 15-45 mL PO 24 hourly Maintenance dose: Infant: 5 mL PO 24 hourly 1-6 years old: 5-10 mL PO 24 hourly 7-14 years old: 10-15 mL PO 24 hourly >15 years old: 15-30 mL PO 24 hourly	Adverse Reactions GI effects (flatulence, abdominal pain) In high doses: Nausea/vomiting, diarrhea, electrolyte imbalance Special Instructions May be taken with food to decrease GI distress and preferably taken during breakfast Contraindicated in patients with galactosemia, and bowel obstruction Use with caution in lactose-intolerant patients
Macrogol 4000	≥8 years old: 10-20 g PO 24 hourly Max duration: 3 months	Adverse Reactions GI effects (nausea, abdominal distention and/or pain, diarrhea); Other effect (very rarely hypersensitivity) Special Instructions Dissolve in water before administration Contraindicated in patients with intestinal obstruction or perforation, ileus, Crohn’s disease, ulcerative colitis, fructose intolerance and toxic megacolon Prolonged use is discouraged
Magnesium hydroxide	2-5 years old: 0.4-1.2 g PO 24 hourly or in divided doses 6-11 years old: 1.2-2.4 g PO 24 hourly or in divided doses >12 years old: 2.4-4.8 g PO 24 hourly or in divided doses	Adverse Reactions GI effects (bloating, diarrhea, increased thirst, nausea/vomiting, abdominal pain) Special Instructions Contraindicated in patients with sudden change in bowel habits >2 weeks, bleeding per rectum, impaired renal function Use with caution in patients with Mg-restricted diet, kidney diseases, no passage of stool after 6 hours after administration
PEG 3350 (Polyethylene glycol 3350)1	240-480 mL/day PO x ≤1 week or Maintenance dose: 0.2-0.8 g/kg/day PO in 1-2 divided doses Fecal disimpaction: 1-1.5 g/kg/day PO (max 6 days)	Adverse Reactions GI effects (nausea/vomiting, bloating, rectal irritation) Special Instructions Do not take any laxatives for >1 week Contraindicated in patients with GI obstruction, bowel perforation, toxic colitis
Sorbitol1	5 g PO at bedtime and 2.5 g PO before breakfast	Adverse Reactions GI effects (flatulence, abdominal cramps) Special Instructions Should be taken on an empty stomach or before meals Use with caution in patients who are unable to metabolize Sorbitol Contraindicated in patients with abdominal pain and nausea/vomiting
Softeners, Emollients
Docusate sodium (Sodium docusate)	<12 years old: 50-150 mg/day PO or in divided doses ≥12 years old: 50-360 mg/day PO in divided doses Max dose: 500 mg/day PO or Age-directed (fixed) dosing: ≥6 months-<2 years old: 12.5 mg PO 8 hourly ≥2 years old: 50-150 mg/day PO divided 6-24 hourly 283 mg/5 mL enema: 2-<12 years old: 1 enema per rectum 24 hourly ≥12 years old: 1 enema per rectum 8-24 hourly	Adverse Reactions GI effects (abdominal pain, nausea/vomiting, diarrhea); Dermatologic effect (skin rash) Special Instructions May be taken with a glass of milk or juice Contraindicated in patients with intestinal obstruction Prolonged use is discouraged Use with caution if there is presence of sudden changes in bowel habits for >2 weeks, abdominal pain, nausea/vomiting Discontinue if rectal bleeding occurs or failure to have a bowel movement within 3 days
Liquid paraffin2	3-12 years old: 0.5-1 mL/kg PO 24 hourly in the evening after dinner 12-18 years old: 10-30 mL PO 24 hourly	Adverse Reactions GI effects (anal leakage and irritation from prolonged use, excessive purgation, watery diarrhea); Respiratory effect (lipoid pneumonia); Other effect (granulomatous reaction) Special Instructions Should be taken on an empty stomach Contraindicated if nausea/vomiting or abdominal pain is present Use with caution if planning long-term use Not recommended in children <3 years old
Stimulant Laxatives (Contact Laxatives)
Bisacodyl	4-10 years old: 5 mg PO at night >10 years old: 5-10 mg PO at night or <10 years old: 5 mg suppository per rectum in the morning >10 years old: 10 mg suppository per rectum in the morning	Adverse Reactions GI effects (rarely, abdominal cramps and pain, nausea/vomiting, diarrhea, bloody stool); Other effect (rarely dehydration) Special Instructions Tab should be taken on an empty stomach for rapid effect and not taken within 1 hour of antacids or dairy products Contraindicated in patients with acute surgical abdominal conditions, intestinal obstruction, ileus and severe dehydration Prolonged use is discouraged Use with caution in patients intolerant to galactose or fructose
Castor oil	4.4 mL/5 mL liquid oil: <2 years old: 2.5-5 mL single dose 2-12 years old: 15 mL single dose	Special Instructions Do not use for >1 week Use with caution in patients with mechanical intestinal obstruction, with symptoms (eg nausea/vomiting, abdominal pain, etc) suggestive of appendicitis
Sennosides3	7.5 mg tab: 6-11 years old: 7.5-15 mg PO 24 hourly >12 years old: 15-37.5 mg PO 24 hourly 8.6 mg tab: 6-11 years old: 1-2 tabs PO 12-24 hourly >12 years old: 1-3 tabs PO 12-24 hourly 8.8 mg/5 mL syrup: 2-6 years old: 2.5-3.75 mL PO 12-24 hourly 6-11 years old: 5-7.5 mL PO 12-24 hourly 12-18 years old: 5-15 mL PO 12-24 hourly 15 mg granules: >10 years old: 1-2 teaspoonful PO an hour after dinner	Adverse Reactions GI effects (mild abdominal discomfort, with prolonged use may cause diarrhea with severe dehydration and non-functioning colon); Other effect (urine discoloration) Special Instructions Contraindicated in patients with undiagnosed abdominal symptoms and intestinal obstruction, acute inflammatory intestinal disease and fluid or electrolyte imbalance Use with caution in inflammatory bowel disease and if planning prolonged use Tablet is not recommended in children <2 years old and granules in children <10 years old
Sodium picosulfate	<4 years old: 250 mcg/kg body wt PO 24 hourly at bedtime Max dose: 5 mg PO 4-10 years old: 2.5-5 mg PO 24 hourly at bedtime >10 years old: 5-10 mg PO 24 hourly at bedtime	Adverse Reactions GI effects (diarrhea, abdominal pain, cramps, and discomfort); Other effect (hypersensitivity reaction eg skin reaction and angioedema) Special Instructions Should be taken on an empty stomach and not taken within 1 hour of antacids or dairy products Contraindicated in patients with severe dehydration, intestinal obstruction, ileus, acute surgical abdomen Prolonged use is not recommended Use with caution in patients with hypokalemia and imbalance of fluid and electrolytes May cause rebound constipation

¹Various combination products are available. Please see the latest MIMS for specific formulations and prescribing information.
²Combination product with Glycerol and Phenolphthalein is available. Please see the latest MIMS for specific formulations and prescribing information.
³Combination products with Ispaghula are available. Please see the latest MIMS for specific formulations and prescribing information

Drug	Dosage	Remarks
Linaclotide	6-17 years old: 72 mcg PO 24 hourly	Adverse Reactions GI effects (diarrhea, abdominal pain and distension, flatulence) Special Instructions Take at least 30 minutes prior to first meal of the day Avoid in patients with known or suspected mechanical GI obstruction Discontinue treatment if severe diarrhea occurs

Drug	Dosage	Remarks
Bifidobacterium spp/Galacto-oligosaccharide1	≥2 years old: 1 sachet PO 24 hourly	Special Instructions Consume with a meal May sprinkle in water, non-fizzy and non-alcoholic drinks, or food (below 45°C) Take at least 3 hours before or after taking antibiotic Use with caution in patients with lactose intolerance
Lactobacillus spp/Bifidobacterium spp/Streptococcus thermophilus1	1 sachet or 1-2 tabs PO 24 hourly	Special Instructions Contents of the sachet may be added to food/water/milk/juice

¹Various combination products are available. Please see the latest MIMS for specific formulations and prescribing information.

All dosage recommendations are for children with normal renal and hepatic function unless otherwise stated. 
Not all products are available or approved for above use in all countries. 
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs. 
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.