Suggested Pre-Referral Evaluation and Management Guidelines
Rectal exam to ensure normal muscle tone, no narrowing, etc.
If no clinical concerns of Hirschprung¿s and palpable stool is felt in the abdomen/rectum, use either of the following options:
Miralax: 1.5gm/kg/day x 3 days as a clean-out, then decrease to 1gm/kg/day on following days. Mix 17gm in 8oz water or juice and give whatever dose it takes to have soft, applesauce-consistency stools on a daily basis. (Adjust dose in small amounts every 3-4 days until desired consistency is reached.)
Milk of Magnesia, regular concentrate 400mg/5ml. For children <2 years, 0.5ml/kg/dose, 2-5 years 5-15ml/day, 6-11 years 15-30 ml/day, >12 years 30-60ml/day. If using the concentrated (strawberry) flavor, divide the dose in half. Note: This medicine is much more palatable if refrigerated.
Regular toilet-sitting program: recommend sitting for 5 minutes after each meal (3 times/day).
Sticker or reward chart to encourage toilet-sitting and successful stools in the toilet.
High-fiber diet recommendation: age in years +5 = grams/fiber per day with double that amount in ounces of water daily (i.e. 10gms fiber with 20 oz water/day, minimum). Maximum 20-25 grams/fiber/day.
Miralax should be used in addition to regular toilet sitting program for 6 months for the intestines to shrink back to a normal size and for the child to make regular toilet sitting a habit. If after 6 months there are no problems with constipation, slowly decrease dose.
Refer to GI after 6-8 weeks of Miralax/toilet-sitting if still having problems, if encopresis continues, or if there is difficulty in regulating the dose of Miralax, and for any other concerns once on Miralax.
Suggested Additional Test/Management Prior to Specialty Visit
3 months, sooner for Nurse Practitioners (typically 1-2 months)
How to Get Results to Consultant
UMHS Patients: See MiChart
External Patients: Fax records to 734-763-7359 prior to appointment.
A referral from the primary care physician is required prior to the appointment. Consult for a second opinion requires approval by a staff Pediatric Gastroenterologist. The covering staff physician may be reached by M-line.
It is helpful for us to have records of any prior laboratory studies, x-rays, prior endoscopy reports, other test results, or hospitalizations. Having the child's growth record (obtained from their primary care clinician) is very helpful.
Clinic Contact Information
Physicians: 734-763-9650 or M-Line 734-936-3856