Daily Maintenance Therapy

Tips

• Daily maintenance therapy is a 3 pronged approach involving medications, behavioral modifications, and diet modifications
• If not improving despite following clean out and maintenance recommendations, consider referral to pediatric GI
• If stopping stimulant laxatives that have been given consistently, the dose needs to be slowly weaned off to prevent re-impaction

Medications - Adjust until the patient is having daily oatmeal consistency bowel movements

• Osmotic Laxatives (aka “smushers)
  PEG 3350 (MiraLAX ) 0.2 - 0.8 g/kg/day mixed with clear liquid . 1 capful (17 g) should be mixed in 8 oz clear liquid. Adjust dose to ensure one
  to two soft bowel movements per day

OR

• Lactulose (10 g packets or 10 g/15 mL syrup) 1 - 2 g (1.5 - 3 mL kg/day divided into one to two doses . Up to 60 mL per day for initial dose.
• Stimulant Laxatives (aka “pushers”) Add only if osmotic laxatives are ineffective .

Behavioral Modifications

• Toilet sitting 5 -10 minutes after meals
• Ensure that smaller children have a footstool or other object so that they have a solid base to push off
• Use positive reinforcement , not punishment

Diet Modifications

• Balanced diet: whole grains, and 5 servings of fruits and vegetables per day
• Fluids: Consider prune juice and age-appropriate water intake
  • Ages 1 to 2: Three to four cups of water per day
  • Ages 2 to 4: Four cups of water per day
  • Ages 5 to 10: Six cups of water per day
  • Ages 10+: Eight cups of water per day
• Although the role of cow’s milk after age 1 is controversial , a trial of stopping milk for two to four weeks might be considered in children not
  responding to bowel therapy