What are the guidelines for bowel prep in children undergoing colonoscopy?

Bowel Preparation Guidelines for Colonoscopy in Children

For children undergoing colonoscopy, polyethylene glycol (PEG) 3350 is the recommended bowel preparation agent, with dosing and duration tailored to the child's age, with sodium phosphate preparations specifically contraindicated in children under 12 years of age due to safety concerns. 1, 2

Age-Specific Recommendations

Infants

• Clear liquids for 24 hours
• Normal saline enema (10 mL/kg) is usually sufficient for infants with normal or frequent bowel movements 1

Children (Age-Based Approach)

1. PEG 3350 Regimens (Preferred):

   • 4-Day Regimen: 1.5 g/kg/day for 4 days before procedure, with clear liquid diet on the fourth day 1, 3
   • 2-Day Regimen: 2 g/kg/day of PEG 3350 plus 5 mg bisacodyl daily for 2 days before colonoscopy 4
   • 1-Day Regimen: Can be effective for older children and adolescents 5

2. Split-Dose Administration:

   • Strongly recommended for all patients regardless of preparation volume 1, 2
   • First dose evening before procedure, second dose morning of procedure (at least 2 hours before)

Safety Considerations

Contraindications for Sodium Phosphate (NaP)

NaP should NOT be used in:

• Children younger than 12 years of age
• Children with kidney disease
• Children on medications affecting renal function
• Children with significant comorbidities (liver disease, hypertension, hypoparathyroidism, diabetes, heart disease)
• Children at high risk for dehydration or electrolyte imbalance
• Children with ileus or suspected severe colitis 1

Monitoring Requirements

• Maintain adequate hydration during preparation
• Monitor for signs of dehydration
• For sodium picosulfate preparations (approved for children ≥9 years), monitor for electrolyte disturbances 6

Efficacy Markers

• Stool frequency (≥5 stools/day) and liquid stool consistency in the last 2 days of preparation are excellent predictors of adequate colon preparation (91-95% positive predictive value) 7

Dietary Recommendations

• Clear liquid diet on the day before colonoscopy
• Low-residue/low-fiber diet for breakfast and lunch the day before for older children 2
• Continue clear liquids up to 2 hours before the procedure 2

Preparation Selection Algorithm

1. For children 9-12 years:

   • First choice: PEG 3350 at 1.5-2 g/kg/day (4-day or 2-day regimen)
   • Alternative: Sodium picosulfate, magnesium oxide, and anhydrous citric acid (one packet as two doses) has shown 88% efficacy 6

2. For children 13-16 years:

   • First choice: PEG 3350 (1-day or 2-day regimen)
   • Alternative: Sodium picosulfate, magnesium oxide, and anhydrous citric acid (one packet as two doses) has shown 81% efficacy 6

3. For all children with renal, cardiac, or hepatic issues:

   • Use only PEG-based preparations 2

Patient Education

• Provide both verbal and written instructions
• Ensure adequate hydration throughout the preparation process
• For sodium picosulfate preparations, each packet must be dissolved in 5 ounces of cold water 6
• Monitor for adverse effects (nausea, abdominal pain, vomiting)

Common Pitfalls to Avoid

1. Using sodium phosphate preparations in children under 12 years
2. Inadequate hydration during preparation
3. Not completing the full preparation regimen
4. Not monitoring stool consistency and frequency as markers of adequate preparation
5. Using adult dosing protocols without appropriate pediatric adjustments

The key to successful bowel preparation in children is selecting an age-appropriate regimen, ensuring adequate hydration, and monitoring for completion markers such as stool frequency and consistency.