NICE has published a clinical guideline (CG99) on the diagnosis and management of idiopathic childhood constipation in primary and secondary care.

In terms of the clinical management of disimpaction, NICE make the following recommendations:

 Offer the following oral medication regimen:
– Polyethylene glycol 3350 + electrolytes using an escalating dose regimen as the first-line treatment. Polyethylene glycol 3350 + electrolytes can be mixed with a cold drink
– Add a stimulant laxative if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks
– Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if polyethylene glycol 3350 + electrolytes is not tolerated
– Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain

 Do not use the following unless all oral medications have failed:
– rectal medications
– sodium citrate enemas

 Do not use phosphate enemas unless under specialist supervision in hospital, and if all oral medications and sodium citrate enemas have failed

 Do not perform manual evacuation of the bowel under anaesthesia unless all oral and rectal medications have failed

 Review all children undergoing disimpaction within 1 week

In terms of the clinical management of maintenance therapy, NICE make the following recommendations:

 Start maintenance therapy as soon as the child or young person's bowel is disimpacted

 Reassess the child or young person frequently during maintenance treatment to ensure they do not become reimpacted and assess issues in maintaining treatment such as taking medicine and toileting

 Offer the following regimen for ongoing treatment or maintenance therapy:
– Polyethylene glycol 3350 + electrolytes as the first-line treatment
– Adjust the dose of polyethylene glycol 3350 + electrolytes according to symptoms and response. As a guide for children and young people who have had disimpaction the starting maintenance dose might be half the disimpaction dose
– Add a stimulant laxative if polyethylene glycol 3350 + electrolytes does not work
– Substitute a stimulant laxative if polyethylene glycol 3350 + electrolytes is not tolerated by the child or young person. Add another laxative such as lactulose or docusate if stools are hard
– Continue medication at maintenance dose for several weeks after regular bowel habit is established. Children who are toilet training should remain on laxatives until toilet training is well established. Do not stop medication abruptly: gradually reduce the dose over a period of months in response to stool consistency and frequency. Some children and young people may require laxative therapy for several years. A minority may require ongoing laxative therapy