Pediatric Primary Care Case Studies, 1st Ed.

Chapter 9. The Constipated 8-Year-Old

Tamra D. Kehoe

Undoubtedly, the primary care provider will encounter patients with concerns related to constipation. Childhood constipation accounts for approximately 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology consultations (Baker et al., 2006). Parents often worry that their child’s stools are too large, too infrequent, or too hard, or are painful to pass. Children presenting with encopresis may have fecal soiling without painful defecation, which is often perceived to be chronic diarrhea.

Families are often frustrated by multiple trials of ineffective strategies or believe their children are lazy or choose to have fecal accidents. The management of constipation and fecal soiling can be challenging for the child, family, and healthcare provider. To successfully treat these children, a well-organized plan utilizing medication as well as behavioral modification is paramount.

Educational Objectives

1.  Discuss the etiology of encopresis including predisposing mechanical and psychosocial factors.

2.  Apply the guidelines for management of encopresis to a school-age child.

3.  Identify barriers to successful treatment.

  Case Presentation and Discussion

Zachary Morris is an 8-year-old male who is brought to your office by his parents with concerns of fecal accidents that have been occurring since 6 years of age. Mrs. Morris reports Zach’s school has recommended a medical evaluation because Zach is now being teased by peers for his malodorous smell and because he often wears a pull-up diaper which is occasionally visible. Zachary has loose to peanut butter consistency stools in his underwear or pull-up approximately four to five times daily; he denies any sensation of these stools. He is frequently malodorous and will sit in his soiled underwear until mandated by his parents to clean up. They believe he is quite lazy and elects to stool in his pants rather than excuse himself to the bathroom. Soiling occurs more frequently when he is on the computer, watching TV, or engaged in active play.

Mom expresses great frustration. Soiling was initially infrequent but has escalated to a daily problem. Because of odor and frequent leakage, the family tends to withdraw from outings and social events.

What questions will you ask about strategies the parents have tried? image

Zachary’s parents have utilized various strategies to correct his soiling including sticker charts and reward systems for putting stool in the potty, mandatory toilet sits every 2 hours, time-outs, and punishments. Medical treatment from their pediatrician has included polyethylene glycol 3350 powder (PEG 3350), 1 cap (17 g) orally every day for 2 weeks. This treatment resulted in more accidents, so his parents discontinued the stool softener after 1 week.

At this point, the problem sounds like encopresis so you consider what you know about this condition.

Pathophysiology of Constipation

Encopresis or fecal soiling refers to the repetitive voluntary or involuntary passage of stool in inappropriate places by children 4 years or older, at which time a child may reasonably be expected to have completed toilet training and exercise bowel control. Encopresis is usually associated with chronic constipation and functional fecal retention; however, it may occur in the absence of fecal retention, in which case, it is termed nonretentive encopresis. If a child is under 4 years old, it is termed fecal incontinence. Criteria for the diagnosis of functional constipation in children can be found in Table 9-1.

Encopresis can be termed retentive or nonretentive. Retentive encopresis is associated with constipation. The major difference between retentive and non-retentive encopresis is intent. In nonretentive soiling, the child is voluntarily stooling in inappropriate places, and it is usually associated with some degree of psychological disturbance.

Pathophysiology

Functional constipation, meaning constipation without evidence of a pathological condition, is most commonly caused by painful bowel movements with resultant voluntary withholding of feces. This withholding is done to avoid uncomfortable or painful defecation. In the majority of cases, encopresis is thought to occur as a consequence of chronic functional constipation with resulting overflow incontinence (Di Lorenzo & Benninga, 2004). The overflow stool can be pasty to watery, and is often confused with diarrhea.

There are time periods when a child is more vulnerable to developing acute constipation. In infancy, the change from breastmilk to formula or the addition of solids can cause constipation. Toddlers may exhibit magical thinking that results in fearful reactions or have conflict over toileting. School-age children may be too busy to stop play or there may be lack of privacy at school. Events common to all age groups that can lead to painful defecation include changes in diet, routines, stressful events, and/or illness (Baker et al., 2006).

Table 9–1 Rome III Criteria for the Diagnosis of Functional Constipation in Children

Infants and Toddlers

Children with Developmental Age 4 to 18 Years

 

At least two of the following present for at least 1 month:

• Two or fewer defecations per week

• At least one episode of incontinence after the acquisition of toileting skills

• History of excessive stool retention

• History of painful or hard bowel movements

• Presence of a large fecal mass in the rectum

• History of large diameter stool that may obstruct the toilet

At least two of the following present for at least 2 months:

• Two or fewer defecations per week

• At least one episode of fecal incontinence per week

• History of retentive posturing or excessive volitional stool retention

• History of painful or hard bowel movements

• Presence of a large fecal mass in the rectum

• History of large diameter stool that may obstruct the toilet

Source: Data from: Hyman, P. E., Milla, P. J., Benninga, M. A., et al. (2006). Childhood functional gastrointestinal disorders: Neonate/toddler. Gastroenterology, 130, 1519; and Rasquin, A., Di Lorenzo, C., Fobes, D., et al. (2006). Childhood functional disorders: Child/adolescent. Gastroenterology, 130, 1527.

Withholding feces can lead to prolonged fecal contact in the colon with reabsorption of fluids and an increase in the size and hardness of stool (Baker et al., 2006). The passage of these large, hard stools can be quite painful and difficult. The child may then consciously delay the passage of stool with subsequent defecation urges. These withholding behaviors can be subtle with children, especially toddlers, and can be mistaken for attempts to pass stool. Maintaining a rigid posture with clenched fists, hiding in a corner or other room, or excessive grunting and straining are often signs of voluntary fecal withholding. For other children, parents will recognize withholding behaviors as children rise up to their toes and rock back and forth. Many parents call this the “poopy dance.”

As the rectum is continually stretched with retained stool, defecation urges subside. Soft or watery stool eventually leaks around the retained fecal mass, resulting in fecal soiling.

Epidemiology

Although few prospective studies have been conducted to examine the prevalence of encopresis in childhood, an estimated 1–2% of children younger than 10 years have encopresis. The range of age at presentation is typically 4–12 years, with a peak at 7–9 years. Approximately 80% of affected children are boys (Borowitz, 2008).

Approximately 80–95% of children with encopresis have a history of constipation or painful bowel movements. The remaining 5–20% are said to have nonretentive encopresis; however, many of these children have a remote history of constipation or painful defecation or demonstrate incomplete evacuation during defecation (Partin, Hamill, Fischel, & Partin, 1992). Little or no evidence indicates that encopresis is primarily a behavioral disorder, and most available evidence suggests that behavioral difficulties associated with encopresis may be the result of the encopresis and not the cause (Joinson et al., 2007). Also, there is no scientific evidence to suggest that encopresis is an indicator of sexual abuse (Mellon, Whiteside, & Friedrich, 2006). Low self-esteem or parent–child conflict as a result of the disorder is not uncommon (Borowitz, 2008).

What information from the history do you need to make the correct diagnosis? image

History Taking

As with all pediatric complaints, the assessment of a child with encopresis begins with a careful and detailed history.

Questions to be asked during evaluation include:

•  What are the frequency and consistency of the stools?

•  What are the frequency and timing of the fecal soiling?

•  Is there visible blood or mucous in the stool?

•  Are there complaints of pain with defecation?

•  When did potty training occur and was that a smooth or difficult transition?

•  What was the timing for the passage of meconium stool after birth?

•  Does the child exhibit any withholding behaviors?

•  Have there been any delays in motor milestones?

•  Is there a history of urinary dysfunction or recurrent urinary tract infections?

•  Is there a family history of constipation or encopresis?

•  Are restrooms at school or daycare available when needed and acceptable by the child for use?

•  What treatments, medications, and/or strategies have been utilized in the past?

In addition, inquire about dietary history, exercise patterns, and behavioral history—what are normal behaviors for this child. A psychosocial history that includes seeking information about members of the household, alternative caregivers, and interactions with family members and peers should also be obtained.

What other conditions might cause stooling problems? image

A history of stool withholding behavior reduces the likelihood that there is an organic disorder (Baker et al., 2006). Organic causes account for only 5% of cases of constipation and include anatomic, neuromuscular, metabolic, or endocrine causes (Castiglia, 2001). The most common organic etiology for constipation is Hirschsprung disease. The absence of ganglion cells in the muscle of the rectum does not allow relaxation of the rectal walls, thus not allowing feces to enter into the anal canal. These children are typically identified when there is no passage of meconium stool shortly after birth or upon evidence of bowel obstruction in the newborn period. Interestingly, most children with Hirschsprung disease never have soiling (Castiglia).

Anatomic defects of the spine and anus can also lead to constipation and encopresis. The most common of these include meningomyelocele (spina bifida), tethered cord syndrome, and imperforate anus with fistula (Coughlin, 2003).

Metabolic and endocrine abnormalities that promote constipation and subsequent stool holding include hypothyroidism, hypokalemia, and hypercalcemia, as well as lead intoxication, cystic fibrosis, celiac disease, and diabetes mellitus (Coughlin, 2003).

You talk with Zachary and his mother. The following information emerges from your interview:

Zachary was the full-term product of a normal vaginal delivery. He produced meconium stool in the first hours of life. He has been well and healthy. You also elicit a history of difficulty with toilet training. He had toilet resistance and had bowel movements in his pull-up diapers until he was 4½ years old. Zachary has always had large diameter stools that frequently clogged the toilet, and he typically has a bowel movement every 3 days. No blood has been noted on his stools, and there has been no evidence of anal fissures.

Since he started school, his parents have minimal knowledge of his toileting behaviors and assume he is defecating regularly. However, they really don’t know. Zachary can’t remember the last time he had a stool in the toilet. The nearest bathroom to his classroom is down the hall. The teacher does not allow students to freely use the restroom; they must raise their hand to get permission and then carry a large red key that signals bathroom permission. Zachary hates to use the bathroom at school.

Zachary had been continent for urine both day and night since 3 years of age. In the past year, he has been incontinent for daytime urine one to three times per week, with urinary dribbling. He insists he does not feel the urge to urinate until it is too late and he wets himself. Zachary is the youngest of three children; both parents work full time. His middle school brother watches him after school for 2 hours until his parents get home. Zachary is quite active at home, enjoying biking, rollerblading, and basketball. He has avoided team sports because he is worried about public soiling. He enjoys the computer and plays computer games for hours at a time.

What aspects of the physical examination will be important in this case? image

Physical Examination

It is necessary to perform a thorough physical examination as part of the evaluation of the child with encopresis. Examination of the external perineum for skin tags, anal position, and anal tone gives clues to an anatomical or inflammatory condition. Inspection of the lower back for pigmentary irregularities, sacral dimples, tufts of hair, or asymmetry of the spine can give clues to a neurologic abnormality. Digital exam of the anorectal area is recommended. It gives immediate indication of sensation, anal tone, the size of the rectum, and the presence of anal wink. It also determines presence of a fecal mass in the rectum and the amount and consistency of rectal stool.

The abdominal exam requires palpation for assessment of the amount of retained fecal matter. A neurological examination will detect signs of spinal nerve involvement, which can be responsible for abnormal sphincter function from a spinal cord tumor or a tethered cord. Assessment of lower extremity tone, strength, and deep tendon reflexes is warranted as well as evaluating the cremasteric reflex. Detection of a physical abnormality could lead to the identification of an organic disorder (see Table 9-2).

Should you order any laboratory or radiology studies? image

In most patients, the diagnosis is established with the history and complete physical examination, including the rectal exam (Baker et al., 2006). Generally speaking, diagnostics are not warranted, except in those children who fail medical management or who have a red flag identified on history and/or physical examination. A KUB can be helpful for evaluating the amount of stool in the colon when the history is unclear; when palpation of the abdomen may be difficult, as with obese children; or sometimes to convince a family there is backed up stool in the colon (Baker et al., 2006). Most often a KUB is done to assess the effectiveness of a bowel clean-out or provide clarity once medical management has begun.

Laboratory studies are seldom warranted. These are typically ordered when patients have failed medical management and/or families need further evidence because encopresis is typically a functional disorder. If additional testing is needed, the healthcare provider should consider the need for such studies as a complete metabolic panel (screen for calcium, potassium, and electrolytes), sedimentation rate, thyroid studies (free T4, TSH), IgA and tissue transglutaminase IgA to screen for celiac disease, and a lead level. If indicated, screen for cystic fibrosis with a sweat chloride test.

When considering tethered cord because of persistent urinary dysfunction despite an effective bowel clean-out, a screening radiograph of the lower spine looking for spina bifida occulta can be helpful. About 98% of people with tethered cord have spina bifida occulta, but 10–20% of the normal population has spina bifida occulta without adverse sequelae. The most definitive diagnostic test for tethered cord is magnetic resonance imaging (Rosen, Buonomo, Andrade, & Nurko, 2004). Once tethered cord is identified, a neurosurgical referral is necessary. Hirschsprung’s disease can be identified by barium enema and/or rectal biopsy.

Table 9–2 Red Flags Distinguishing Organic Constipation from Functional Constipation

• Failure to thrive

 

• Lack of lumbosacral curve

 

• Pilonidal dimple covered by tuft of hair

 

• Midline pigmentary abnormalities of the lower spine

 

• Flat buttocks

 

• Anteriorly displaced anus

 

• Patulous anus

 

• Absent anal wink

 

• Occult blood

 

• Absent cremasteric reflex

 

• Decreased lower extremity tone and/or strength

 

Source: Baker, S., Liptak, G., Colletti, R., Croffie, J., Di Lorenzo, C., Ector, W., et al. (2006). Clinical practice guideline: Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 43, e1–e13.

 

Upon physical examination, you find Zachary is at the 70th percentile for height and weight with a BMI of 17, which is at the 75th percentile. Vital signs are within normal limits. He is well developed. Head, ears, eyes, nose, and throat are all normal and without palpable lymphadenopathy. His heart has a regular rate and rhythm and no murmur is auscultated. Lungs are clear with good aeration bilaterally. The abdomen is rounded and slightly tense with a hard palpable mass from the suprapubic area to his umbilicus. There are ropey loops of bowel palapated in the left lower quadrant and right lower quadrant, without tenderness. Rectal examination reveals a normotonic, normally placed anus without skin tags or fissures and a positive anal wink. There is pasty thick stool in moderate amounts around the anus. The digital examination reveals a rectum full of hard stool, which is guaiac negative. When the patient is asked to expel the examining finger, there is rectal tightening of the external anal sphincter (EAS) rather than expected relaxation. No dimples or tufts of hair are noted. The spine is straight. Strength and deep tendon reflexes in the lower extremities are normal and symmetric.

Making the Diagnosis

The history and physical examination are consistent with the diagnosis of retentive encopresis. He has a history of not wanting to use the restroom at school resulting in fecal withholding, fecal accidents, wearing pull-up diapers, no sensation of stooling, and sitting in his soiled underwear until his parents tell him to clean up. His physical examination is normal except for palpable stool in his abdomen and rectal tightening response.

Management

How do you plan to treat this child with encopresis? image

Are diagnostics warranted at this point in time? image

No red flags were identified to suggest diagnostics are needed. With frequent soiling and a large amount of palpable stool in the abdomen, treatment can begin.

The management of the encopretic child is within the realm of the primary care provider, as long as treatment is approached in a consistent and physiologically oriented way (Levy, 2001). This approach is cost effective and provides faster results than other treatment modalities based on intensive psychological intervention. Once there is improved function, more normal relationships can flourish. For this reason, it is recommended that, unless there are clearly identified psychosocial dysfunction issues, management should concentrate on effective bowel clean-out with subsequent resolution of the soiling. There is time later to refer for mental health intervention if no progress or slow progress is encountered.

Management is based on four key elements (Levy, 2001):

image  Disimpaction of the rectum and colon: To stop the soiling and allow normal sensation to return.

image  Daily stool softening: To keep the colon clear of stool so it can regain normal tone and the ability to propel stool more effectively.

image  Establishment of effective toilet habits: To achieve the goal of evacuating stool at regular times daily.

image  Parental education: With the goal of demystification, which allows greater understanding and, hopefully, commitment to treatment.

Disimpaction is necessary before any long-term success can be maintained. It may be accomplished with the use of oral medications or rectal medications. The oral route allows greater sense of control and is less invasive, but compliance can be more problematic. The rectal route is quite invasive and sometimes traumatic for the child, but is faster and allows the parent more control. The choice of treatment can be determined after discussing options with the child and parents.

When the oral route is selected, high-dose oral electrolyte solutions are recommended (Baker et al., 2006). Although there are no controlled trials demonstrating the effectiveness of high-dose magnesium hydroxide, magnesium citrate, lactulose, sorbital, senna, or bisacodyl for initial disimpaction, these laxatives have been used successfully in that role (Baker et al., 2006).

When the rectal route is preferred, phosphate enemas, saline enemas, or mineral oil enemas followed by a phosphate enema are effective (Baker et al., 2006).

Disimpaction is typically completed using oral medications. Dosages of various medications used in treatment of constipation/impaction are found in Table 9-3. Most disimpactions can be completed at home. On occasion, children may have to be admitted to the hospital for disimpaction. A nasogastric tube is placed, and PEG 3350 (Miralax) with electrolytes is administered until rectal effluent is clear.

Following discussion with Zachary and his parents, it was decided to use an over-the-counter electrolyte solution, PEG 3350. Because it has no taste or texture and dissolves readily in fluids, it is easy to administer. Magnesium citrate is quite effective and typically promotes a faster clean-out, but it is quite sour tasting and is difficult for many children to accept. PEG 3350 also tends to have less association with abdominal cramping than magnesium citrate.

Zachary’s parents were instructed to mix 17 g of PEG 3350, which is measured easily by the bottle’s cap, with 8 ounces of a beverage of choice, which gives about 2 g PEG 3350 per ounce. Beverages can be cold or hot, clear or milk products, and the beverage with PEG mixture is good in the refrigerator for 48 hours. PEG 3350 is not to be mixed with foods. The recommended clean-out dose of PEG 3350 is 1.5 g/kg/day. Zachary weighs 65 pounds (30 kg), so he needs 44 g of PEG 3350 per day in divided doses, which is approximately 22 ounces per day of the PEG 3350/fluid mixture. He is to drink this dose of PEG 3350 daily until his stool is very runny. The amount of time needed to complete a bowel clean-out is quite variable, but commonly takes 4–5 days.

Initially, stool may be quite loose as the softer leakage is cleaned out first. The hard stool then begins to break down and stool will be quite grainy and thick for a number of days, before it finally starts to thin and become a “thin mud puddle.” An effective clean-out has not occurred until you reach this point. Because Zachary is in school, his parents have been instructed to begin the clean-out over the weekend and anticipate missed days of school. Teachers should be advised of his absence and have work sent home. To promote faster evacuation of stool, a stimulant, bisacodyl, can be added to the daily regimen giving one 5 mg tablet orally once or twice a day. During the clean-out, many children feel nauseated and have stomachaches and/or emesis; however, the clean-out should not be stopped unless symptoms are severe.

Table 9–3 Medication for Use in Treatment of Encopresis/Constipation

image

image

Once a bowel clean-out is completed and Zachary is having watery stools, stimulant medication is discontinued and the PEG 3350 dose is decreased to half the initial clean-out dose. Zachary’s maintenance phase begins with the decreased dose. The maintenance dose of PEG 3350 is about 8 g/kg/day in a single dose or divided. Zachary is instructed to return to the office in 3 weeks and call as needed for assistance.

Maintenance or Daily Stool Softening

Once the impaction has been removed, the treatment focuses on the prevention of another impaction. At this point, soiling should significantly decrease or resolve. It is important to have full evacuation of stool from the colon and that stools be soft and easy to pass, be nonpainful, and be difficult to withhold. This is especially paramount for the toddler with active stool withholding related to pain with defecation. There is no correct dose of daily stool softener, but rather enough daily medicine should be given to produce one to three soft, mushy, milkshake-consistency stools. During the first month of maintenance, a stooling calendar charting all stools and their consistency should be logged.

Dietary changes are commonly advised. Recommendations have focused on increasing fluids and fiber in the diet to promote passage of stool; however, the literature is mixed on this issue. A balanced diet that includes whole grains, fruits, and vegetables is recommended as part of the treatment for constipation in children (Baker et al., 2006; Levy, 2001). Milk and cheese should be eaten sparingly because they can cause constipation. Forceful implementation of a high fiber diet is undesirable and often not worth the power struggle it invites.

Next Visit

Zachary is seen back at the office following a bowel clean-out that took 5 days to reach “dirty water” bowel movements. Bisacodyl is discontinued, and he continues to take 12 ounces of the PEG 3350 mixture daily. He is having two soft, milkshake-consistency stools in the toilet every day and soiling has stopped. Zachary finally smiles as he talks to you. Urinary incontinence has resolved. On exam, his abdomen is soft, nontender, and without palpable fecal mass. Zachary and his parents are pleased.

You then discuss continued maintenance on a daily stool softener for a minimum of 4–6 months and very typically closer to 2 years. Stimulants can be utilized intermittently for short periods as needed to avoid recurrence of impaction. Prolonged use of stimulant laxatives is not recommended. When there has been no soiling for about 6 months, discontinuance of maintenance therapy can be discussed. Relapse is common, and the clean-out regimen can be reinstituted at any time as needed. Zachary is asked to maintain a stooling calendar so that progress can be tracked. Timed toileting routines are discussed along with strategies that promote rectal relaxation with defecation. Zachary is to return to the office in 1 month and call as needed.

Establishing Effective Toilet Habits

The goal of establishing effective toileting habits is to promote stool evacuation from the body at regular times of the day. Because the rectum is stretched from months or years of withholding patterns, many encopretic children may not be able to feel when it is time to go to the bathroom.

Timing of toileting routines should be planned to take advantage of the gastrocolic reflex, a series of propulsive mass peristaltic movements triggered by ingestion of food. Convenient times are in the morning after breakfast and after dinner. Many school-age children benefit from routine timed toilet visits when returning from school. If the stool is kept very soft and the child sits on the toilet 15–20 minutes after meals, a successful bowel movement can occur. It is not necessary to remind the child more than two to three times per day to try to have a bowel movement.

Children with painful defecation, especially those under the age of 5, are often afraid to allow the stool to pass out of their bodies. They will try to hold in the stool to avoid having pain. They can sometimes appear to be straining, but may actually be working hard to keep stool inside. If the legs are bent and the child rests his/her feet on the floor or stepstool, it will be easier to allow the stool to pass out of the body. Other toileting tips that promote rectal relaxation with defecation include:

•  Bending forward so your chest is resting on your thighs.

•  Pushing while sitting on the toilet. Fun activities to promote muscle relaxation are:

image  Blow bubbles in a glass of water through a straw.

image  Blow hard through your mouth.

image  Blow up a balloon or blow bubbles.

image  Roar like a lion.

image  Put your hand on your child’s belly and have them use their stomach muscles to push it away.

Some children have a “eureka” moment as they experience rectal relaxation versus tightening.

Be sure to reward any positive change toward the goal of having bowel movements in the toilet. Sticker charts or reward systems that have failed in the past may now be beneficial as stool is comfortably passed. It is important for parents to talk about bowel movements and monitor output. A stooling calendar for the first month is essential and should include how many stools go in the toilet, how many accidents occur, and the texture of the stool. Adjust stool softeners to maintain one to three milkshake-consistency stools per day.

Parental Education

The successful treatment of encopresis requires a well-organized plan, parental understanding of the underlying effects of chronic stool holding, and patience. Most often encopresis is the culmination of months to years of dysfunctional bowel habits. Treatment is time consuming, and relapse is common (Pyles & Gray, 1997). Parents often feel guilty about their reaction to fecal incontinence and their misunderstanding of the situation. Frustration and anger are common emotions encountered. Close follow-up by telephone and/or by office visits is recommended. Some families may need counseling to help manage their emotions, expectations, and dysfunctional patterns. Table 9-4describes the treatment options for encopresis.

Is the child safe on laxatives long term? image What are potential side effects? image Is it habit forming? image

Numerous pediatric studies confirm that PEG 3350 is a safe and nonhabit-forming stool softener (Gandy, Michaia, Preud’Homme, & Mezoff, 2004; Loening-Baucke, Krishan, & Pashankar, 2004; Pashankar, Lowning-Baucke, & Bishop, 2003; Youssef et al., 2002). It is not absorbed by the body but rather stays in the colon and holds onto the water it is mixed with. Miralax is not a stimulant laxative; it does not cause the colon to contract and does not cause laxative dependence. It simply softens the stools and makes it harder for the child to hold onto the stool.

1 Month Later

Zachary is seen in your office 1 month following the clean-out. His mother presents the stooling calendar. Zach continues to have one to two soft, mushy stools per day in the toilet without soiling. There has been no urinary incontinence. Zachary has routine toilet sits after school and dinner, with a large output of soft stool within 3–4 minutes of sitting. He still needs reminders from his mother to maintain toileting routines. A couple of minor fecal accidents have occurred when Zach has been on the computer for over an hour, so his parents curtailed computer time to 30-minute time periods with resolution. They are instructed to maintain daily stool softening and routine toilet sits. Summer vacation is near, so emphasis on daily routines and the need to sit on the toilet regularly are reiterated. A return visit is scheduled in 3 months.

What would you do if your treatment didn’t work? image

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

image PEG 3350 0.5–1 g/kg/day PO qd/bid

image lactulose 1–3 mL/kg/day PO qd/bid

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

• Behavioral training

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

image Promote use of rectal relaxation techniques.

image Provide positive reinforcement for toilet sitting and stool results.

image Maintain stooling calendar, recording time and amount.

• Parental education

image 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? image

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.

What is the prognosis for encopresis? image

Even with aggressive medical and behavioral interventions, as many as 30% of children remain symptomatic (Rockney, McQuade, Days, Linn, & Alario, 1996). Consultation with a pediatric gastroenterologist is warranted when therapy fails, when an organic disease is of concern, or when management is complex.

Key Points from the Case

1. Assessment and management of pediatric encopresis is a challenging problem faced by the primary care provider.

2. Because approximately 80–95% of children with encopresis have a history of constipation or painful bowel movements, management usually focuses on disimpaction of stool followed by daily stool softeners to ensure passage of stool without pain.

3. In addition to stool softeners as the mainstay of treatment, behavioral strategies to promote effective toileting routines are recommended.

4. Progress towards the goal of resolution of soiling is typically slow and tedious. Frequent follow-up by the primary care provider that focuses on continued education about medication dosages, toileting routines and strategies that promote rectal relaxation, age-appropriate rewards and consequences, and importance of consistency is paramount.

5. If therapy fails, consider the adequacy of the disimpaction efforts, compliance of medical management, length of maintenance therapy, and psychosocial issues that may thwart progress. Refer or consult as needed with a pediatric gastroenterologist and/or mental health provider.

REFERENCES

Baker, S., Liptak, G., Colletti, R., Croffie, J., Di Lorenzo, C., Ector, W., & Nurko, S. (2006). Clinical practice guideline: Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 43, e1–e13.

Borowitz, S. (2008). Encopresis. Retrieved May 2008, from http://www.emedicine.com/ped/TOPIC670.HTM#section~AuthorsandEditors

Castiglia, P. (2001). Constipation in children. Journal of Pediatric Health Care, 15(4), 200–202.

Coughlin, E. (2003). Assessment and management of pediatric constipation in primary care. Pediatric Nursing, 29(4), 296–301.

Di Lorenzo, C., & Benninga, M. (2004). Pathophysiology of pediatric fecal incontinence. Gastroenterology, 126(1 Suppl 1), S33–S40.

Gandy, E., Michaia, S., Preud’Homme, D., & Mezoff, A. (2004). PEG for constipation in children younger than eighteen months old. Journal of Pediatric Gastroenterology and Nutrition, 39(2), 197–199.

Hyman, P. E., Milla, P. J., Benninga, M. A., et al. (2006). Childhood functional gastrointestinal disorders: Neonate/toddler. Gastroenterology, 130, 1519.

Joinson, C., Heron, J., Butler, R., Von Gontard, A., Butler, U., Emond, A., et al. (2007). A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics, 120(2), e308–e316.

Levy, J. (2001). A guide to children’s digestive and nutritional needs. Retrieved May 2008, from http://www.naspghan.org/wmspage.cfm?parm1=104

Loening-Baucke, V., Krishna, R., & Pashankar, D. (2004). PEG 3350 without electrolytes for the treatment of functional constipation in infants and toddlers. Journal of Pediatric Gastroenterology and Nutrition, 39(5), 536–539.

Mellon, M., Whiteside, S., & Friedrich, W. (2006). The relevance of fecal soiling as an indicator of child sexual abuse: A preliminary analysis. Journal of Developmental and Behavioral Pediatrics, 27(1), 25–32.

Partin, J. C., Hamill, S., Fischel, J. E., & Partin, J. S. (1992). Painful defecation and fecal soiling in children. Pediatrics, 89(6 Pt 1), 1007–1009.

Pashankar, D., Lowning-Baucke, V., & Bishop, W. (2003). Safety of PEG 3350 for the treatment of chronic constipation in children with dysfunctional elimination. Archives of Pediatric and Adolescent Medicine, 157, 661–664.

Pyles, C., & Gray, J. (1997). Encopresis: An algorithmic approach. Physician Assistant, 21(7), 56, 58, 60–62, 67–68, 70–74.

Rasquin, A., Di Lorenzo, C., Fobes, D., et al. (2006). Childhood functional disorders: Child/adolescent. Gastroenterology, 130(5):1527–1537.

Rockney, R., McQuade, W., Days, A., Linn, M., & Alario, A. (1996). Encopresis treatment outcome: Long-term follow-up of 45 cases. Journal of Developmental and Behavioral Pediatrics, 17(6), 380–385.

Rosen, C., Buonomo, C., Andrade, R., & Nurko, S. (2004). Incidence of spinal cord lesions in patients with intractable constipation. Journal of Pediatrics, 143, 409–411.

Thompson, J. (2001). The management of chronic constipation in children. Community Practitioner, 74(1), 29–30.

Tobias, N., Mason, D., & Lutkenhoff, M. (2008). Management principles of organic causes of childhood constipation. Journal of Pediatric Health Care, 22(1), 12–23. Retrieved June 2008, from http://www.medscape.com/viewarticle/569470

Youssef, N., Peters, J., Henderson, W., Shultz-Peters, S., Lockhart, D., & Di Lorenzo, C. (2002). Dose response of PEG 3350 for the treatment of childhood fecal impaction. Journal of Pediatrics, 14(3), 410–414.