Pediatric Primary Care Case Studies (35 page)

The most common reason for continued encopresis despite medical treatment is an inadequate clean-out. If necessary, a KUB can be obtained to assess for retained fecal material. Children who initially present with a many-year history of encopresis without any previous medical management may take a number of weeks on high-dose laxative before a clean-out is completed. Consider adding a stimulant to the daily regimen for a couple of weeks to enhance motility. Certainly the wrong dose of softener, especially too little, or incorrect administration may thwart clean-out efforts. Lack of buy-in by the parents, child, or school may prevent adherence with treatment. Additionally,
if maintenance therapy is aborted too quickly, the child can then revert to holding patterns, which create constipation and continued fecal accidents. Maintenance therapy should be given a minimal trial of 4–6 months and more realistically 1–2 years, especially if the encopresis is centered around potty training issues (Thompson, 2001).

Table 9–4 Treatment for Encopresis

Phase I: Disimpaction (bowel clean-out) 3–5 days until stool output is runny diarrhea
Oral clean-out (preferable)

• PEG 3350 1–3 g/kg/day in divided doses, 2–4/day

Mix 17 g (4 level tsp. of Miralax) in 8 oz of fluid to equal ~2 g/oz; can be mixed in hot or cold fluids and stored in the refrigerator for 48 hours.

OR

• Magnesium citrate: < 6 years: 1–3 mL/kg/day PO; 6–12 years: 100–150 mL/day PO; > 12 years: 150–300 mL/day PO

Serve chilled or mixed with other fluids or syrups to make more palatable.

PLUS (as desired)

• Stimulant such as Dulcolax or Ex Lax qd to bid as tolerated.

Enema clean-out (infrequently)

• Sodium phosphate (Fleet enema): 2–11 years: 6 mL/kg/day PR; may administer up to 135 mL qd/bid in older children; > 11 years: an adult enema or 4.5 oz (135 ml) PR qd/bid prn

Note: 1 pediatric enema = 2.25 oz (67.5 mL)

Phase II: Maintenance, daily stool softening (4–12 months)

The goal is to stop re-accumulation of stool in the emptied out rectum. Adjust daily medicine to achieve one to three soft mushy stools/day.

• Oral laxatives

PEG 3350 0.5–1 g/kg/day PO qd/bid

lactulose 1–3 mL/kg/day PO qd/bid

Magnesium hydroxide 1–3 mL/kg/day PO qd/bid

• Behavioral training

Establish daily toilet schedule 20 minutes after meals two to three times per day for 5–10 minutes.

Promote use of rectal relaxation techniques.

Provide positive reinforcement for toilet sitting and stool results.

Maintain stooling calendar, recording time and amount.

• Parental education

Demystification, which allows greater understanding and, hopefully, commitment to treatment

Phase III: Weaning

• Gradual tapering of laxative

• Continued high-fiber diet, adequate fluid intake, and behavioral modification

How often should you follow up with children and families with an encopresis problem?

Follow-up is very important. It is recommended that the healthcare provider see the patient within 2–4 weeks of the initial clean-out and then monthly until new routines are established and there is good family understanding of the treatment plan and goals. If soiling reoccurs, the child needs to start over again with a new bowel clean-out because the rectum is impacted again.

If a bowel clean-out has been adequate and medical management has been followed, a careful review by the primary care provider of the differential diagnosis of the organic causes of constipation/encopresis should be undertaken. It may be appropriate at this time to consider laboratory or radiologic tests to search for nonfunctional causes of the child’s symptoms.

In cases where psychosocial issues are at the foundation of the soiling problem, a referral to a psychiatrist, psychologist, and/or other mental health provider may be appropriate. Unfortunately, the number of therapists who are experienced in the management of encopretic children is small, and many times the primary care provider is left to assume the main role in directing care.