Starting doses of laxatives for functional constipation in children

Osmotic and lubricant laxatives
Laxative	Dose	Onset (hours)
PEG 3350 powder (MiraLax, GlycoLax)*		24 to 96
Children (weight-based dosing)	0.4 to 0.8 g/kg per day^¶^Δ; maximum 17 g per day for starting dose Administer by mixing in water, juice, or soda (not milk) using 8 oz of fluid for each 17 g dose of powder
Children (age-based dosing)
Younger than 18 months	0.5 to 1 teaspoon once per day
18 months to 3 years	2 to 3 teaspoons once per day
Older than 3 years	2 to 4 teaspoons once per day^Δ
Adults	17 g of powder (1 heaping tablespoon) per day in 8 oz of beverage^Δ
Lactulose (70% solution)		24 to 48
Children	1 mL/kg once or twice per day (maximum 60 mL per day)
Adults	15 to 30 mL once or twice daily (maximum 60 mL per day)
Sorbitol (syrup, 70% solution)		24 to 48
1 to 11 years	1 mL/kg once or twice per day (maximum 30 mL per day)
12 years to adults	15 to 30 mL once or twice per day
Mineral oil	Caution – Should not be used in individuals at risk for aspiration, including infants; neurologically impaired children; or patients with nausea, vomiting, or marked gastroesophageal reflux	6 to 8
Children >1 year to adults	1 to 2 mL/kg per day, once or divided (maximum 45 mL per day)
Magnesium hydroxide (milk of magnesia)		0.5 to 6
1 to 11 years	1 to 3 mL/kg per day of 400 mg/5 mL solution (maximum 30 mL per day in single or divided doses)
12 years to adults	30 to 60 mL per day of 400 mg/5 mL solution (in single or divided doses) 15 to 30 mL per day of 800 mg/5 mL solution (in single or divided doses)
Stimulant laxatives
Laxative	Dose	Onset (hours)
Senna (syrup 8.8 mg sennosides/5 mL or tablets 8.6 mg sennosides/tab)^◊		6 to 12
2 to 6 years^§	2.5 to 3.75 mL once or twice per day
6 to 12 years	5 to 7.5 mL (or 1 to 2 tabs) once or twice per day
12 years and older	5 to 15 mL (or 1 to 3 tabs) once or twice per day
Bisacodyl
Oral (5 mg tablets)	Must be able to swallow tablet whole; tablet cannot be crushed	6 to 10
Children 3 to <10 years	5 mg (1 tablet) once daily
Children ≥10 to <12 years	5 to 10 mg (1 to 2 tablets) once daily
Children ≥12 years and adolescents	5 to 15 mg (1 to 3 tablets) once daily
Rectal (10 mg suppositories)		0.25 to 1
Children 2 to <10 years	5 mg (1/2 suppository^¥) once per day
Children ≥10 years and adolescents	5 to 10 mg (1/2 to 1 suppository) once per day
Glycerin (glycerol) suppositories^‡		0.25 to 0.5
Children 2 to 5 years	1 pediatric suppository once per day
Children 6 years to adult	1 adult suppository once per day

This table outlines initial doses for each laxative medication; the dose should then be increased or decreased as needed to produce regular soft stools. Refer to the UpToDate topic on chronic constipation in children for guidelines about dose titration. All of the doses are for oral administration except bisacodyl and glycerin suppositories.

PEG: polyethylene glycol; OTC: over-the-counter (ie, available without prescription).

* PEG 3350 is also known as PEG without electrolytes and macrogol. We suggest mixing PEG powder in palatable beverages such as fruit juices, sports drinks, or milk, which may mask gritty texture. Trade names shown are for OTC products available in the United States and some other countries.

¶ For fecal disimpaction with PEG 3350 in outpatients, doses of 1 to 1.5 g/kg per day may be used for up to 6 consecutive days. For inpatients, a PEG-electrolyte solution may be used (eg, 25 mL/kg per hour up to a maximum of 400 mL per hour).

Δ After dose titration, maintenance doses of PEG 3350 may be as high as 1.5 g/kg per day (maximum approximately 34 g per day) for some patients^[1].

◊ Several types of senna products are available on the market, and multiple formulations exist that are not equivalent; pay close attention to the product description and concentration when ordering or administering. Products composed of sennosides are considered OTC medications; senna pod concentrate and senna leaf extract are considered dietary supplements and are not interchangeable on a mL-to-mL (or mg-to-mg) basis with other senna products that contain sennosides.

§ Senna has also been used successfully for short-term treatment of constipation in infants and young children. A reasonable dose for those age <2 years is 1 to 2.5 mL once daily for up to 3 months. However, use with caution in this age group because senna may cause perianal skin breakdown and blistering if the stool is left in contact with the skin for a prolonged time and/or if high doses are given.

¥ Suppositories should be cut in half lengthwise (rather than crosswise) to ensure even distribution of the drug between the 2 suppository halves.

‡ Glycerin suppositories should not be used frequently, because infants may become behaviorally conditioned to depend upon rectal stimulation to initiate stooling. In addition, glycerin may irritate the anus or rectal mucosa, causing symptoms to become chronic.

Reference:

Pashankar DS, Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. J Pediatr 2001; 139:428.

Adapted from: Tabbers MM, Dilorenzo C, Berger MY, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014; 58:258.

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Starting doses of laxatives for functional constipation in children