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August 2019

How to determine the correct maintenance dose following a cleanout?

The third step in my Six Step Treatment Program for treating functional constipation is to slowly decrease and then end stool withholding. It requires that you find the maintenance laxative(s) and dosage(s) that keep stools soft enough over a period of months to prevent a reoccurence of dry hard stools. (See Chapter 11). There is no standard laxative maintenance dose for children. The dose must be determined for each child individually starting on the day immediately following the last day of the cleanout. On the last day of a successful cleanout a child's stool should be close to a clear liquid. As stated in an earlier post, a cleanout is usually accomplished be giving higher than usual doses of a water retention laxative such as Miralax.

The procedure for determining the correct maintenance dose is to gradually begin decreasing the cleanout dose until the consistency of the child's stool is like pudding (not formed) or applesauce but not watery or liquid. For example, if the cleanout required 5 teaspoons of Miralax a day, you begin the process of determining the correct maintenance dose by lowering the cleanout dose by 1 teaspoon a day for three days to determine the effect of 4 tsp on stool consistency. If it is still too loose/watery you again lower the dose by 1 teaspoon and wait another three days to determine the effect of 3 tsp on stool consistency and so on until the desired consistency has been achieved.

Some children are especially sensitive to small increases or decreases of water retention laxatives. Therefore, you may have  to "fine tune" the dose by 1/2 a teaspoon up or down in order to achieve the desired pudding or applesauce consistency. For example, a dose of 3  teaspoons may be too high whereas 2 1/2  teaspoons may be just right. (Think "Goldilocks and the Three Bears"!)

(You may have correctly noticed that the pudding consistency I talk about is not one of the 7 stool types on the Bristol Stool Chart in the Appendix of my book. I think of pudding as between a Type 4 and a Type 5 on the Chart or Type 4.5.)


Cleanouts: What Laxative, What Dose, For How Long?

What is a "cleanout"?  A cleanout refers to the process of rapidly removing constipated stool which has backed up in the rectum and, possibly, higher up in the large intestine. This allows new stool to be eliminated when ready.  It is the second of the Six Steps in my book for treating encopresis or functional constipation in children.

Cleanouts are usually done with high doses of a PEG water retention laxative such as Miralax or Restoralax, sometimes in combination with a stimulant laxative.  (If a child's feces are very dry and impacted, a lubricant laxative such as mineral oil may also be necessary.) (See Chapter 11 in my book.) There is no standard cleanout dose for all children just as there is no single standard maintenance dose following the cleanout.  Often, the recommended starting dose of a PEG laxative for a cleanout is "1/2 or more caps". The dose initially recommended by your healthcare provider may be too low and therefore need to be increased.  

The correct cleanout dose produces very loose stool for 1-2 days, followed by a day of mostly liquid or no stool at all, at which time the cleanout is done.

If in doubt about whether a cleanout has been successful, remember that the purpose of a cleanout is to enable your child to move a much larger quantity of poop during the 3-4 days of a cleanout than he/she did in the 3-4 days prior to the cleanout.

PLEASE NOTE: Since your child's poop will be much looser than usual during a cleanout it will be much more difficult for him/her to control. Therefore, for school aged children, I always recommend that cleanouts be done over a weekend or at some other time when your child is not in school.