A 2020 systematic review on treating constipation in pediatric patients mentions docusate 5 mg/kg/day (max 400 mg) as a potential agent for maintenance therapy, but no evidence is presented for its use. In general, most experts prefer non-stimulant laxatives, such as polyethylene glycol (PEG) 3350, lactulose, and milk of magnesia, since they tend to be gentle when used at an appropriate dose. Of note, the review does not provide dosing recommendations for docusate in children <2 years of age. However, it does provide dosing recommendations for other laxatives in this age group, including senna (1-2 years: 2.2-4.4 mg/day in 1-2 divided doses) and magnesium hydroxide (<2 years: 0.5 mL/kg/day). [1]
Another systematic review on treating constipation in children states there is no evidence that docusate is effective in pediatric patients with functional constipation. Docusate is mainly administered rectally, even though oral formulations exist. One randomized, controlled trial found high-dose PEG to be as equally effective as docusate enemas for bowel disimpaction. Similarly, dosing recommendations for docusate in children <2 years of age were not provided. [2]
The efficacy of docusate, as a component of a combined enema solution, was compared to sodium phosphate and soap sud enemas in a 2020 retrospective review (Table 1). Children (N= 768) treated in a pediatric emergency department over a period of 5 years (mean age 6.2 years) were given enema solutions for constipation, including sodium phosphate (n= 396), “pink lady” (a compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate; n= 198), soap suds (n= 160), or other (n= 14). No significant difference in stool output was reported between sodium phosphate, pink lady, and soap suds solutions (p= 0.88). A higher incidence of adverse events, including abdominal pain, was reported with soap suds (10.6%, p= 0.0003). Initial recording of stool output outcomes was subjective (e.g., “minimal,” “good,” or “very good”), potentially preventing an accurate comparison of outcomes. As docusate was combined in a solution with additional agents, its true efficacy as an individual drug cannot be concluded based on these results. No control group was included in this study. The authors mentioned the lack of available literature to guide the selection of enemas for acute pediatric constipation, stating that the current selection is generally based on preference of the ordering physician. [3]
A landmark 1957 study (Table 2) evaluated the use of docusate sodium (dioctyl sodium sulfosuccinate) in 50 children, aged between 5 weeks and 14 years, who had persistent chronic constipation or acute/subacute constipation. Docusate was given as 10 mg/day in infants and 120 mg/day in older children for up to 15 days (or used PRN after 15 days). The docusate was reported to be very effective, with the effects noted as early as 2 days after initiating therapy. This study did not report the baseline characteristics of enrolled patients and did not include a control group. Of note, several children had migraine headaches that the author suspected to be associated with “faulty elimination”; these headaches disappeared when the constipation resolved. While docusate offers a relatively safe way to draw water into the colon and soften stool, its use can be limited by the medicine’s bitter taste. Newer medications, such as PEG, can accomplish the same goal without a bitter taste. [4], [5]