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When the Going Gets Tough Pediatric and Encopresis

Lisa Philichi, MN, RN, CPNP

Constipation and encopresis are two common conditions seen in the pediatric gastroenterology setting. Organic causes cannot be excluded although they are rarely diagnosed in infants and children with defecation disorders. To successfully treat these disorders, a combination of family education, disimpaction and maintenance medications, a well-balanced diet, and behavior management is essential.

om, a 7-year-old boy, presents with daily fecal age, and less invasive tests and psychological evaluations soiling in his underwear for 3 years. He has are being done before referral (Fishman, Rappaport, passed hard stools since 1 year of age when he Schonwald, & Nurko, 2003). Management can be chal- transitioned to whole milk. Tom was toilet lenging and time consuming for the provider. Ttrained for urine at 3 years of age, but he was never com- pletely trained for stool. His parents recall that he would Definitions often hold on to a table and stiffen his body to avoid using the toilet. He rarely sits on it independently to defecate. Tom Constipation is a symptom and not a disease. It is defined as passes a bowel movement once every 2 weeks and they are a decrease in bowel movement frequency or trouble defecat- large in diameter, often plugging the toilet. His parents are ing for more than 2 weeks associated with distress to the child frustrated and believe Tom is lazy. “If he would just use the (Benninga, Voskuijl, & Taminiau, 2004). Parents are often toilet on his own he would get better.” They do not under- concerned when the consistency or frequency of their child’s stand why he does not know when he soiled or why he does stool changes; however, only 50% of parents know their child not smell it. His siblings call him “poopy pants.” Tom com- is constipated and few equate soiling with constipation plains of that is relieved with defecation. He (Loening-Baucke, 1996). Encopresis is derived from the admits to withholding stool because he is afraid it will hurt Greek word kopros, which means “stool.” It is the repeated to defecate and wants to avoid passing stool in his under- loss of feces in inappropriate places, or predominantly loose wear. Treatments previously tried include rewards, punish- stool in the underwear, by a child older than 4 years develop- ment, and over-the-counter laxatives. mentally (Benninga et al., 2004). Primary encopresis is The above is a typical presentation in the pediatric gas- defined as soiling in a child who never mastered toilet train- troenterology clinic. Constipation is the second most ing, whereas secondary encopresis is incontinence in a child referred condition and accounts for as much as 25% of who is completely toilet trained. Encopresis occurs in 2.8% pediatric gastroenterology consultations. In the general of 4-year-olds, 1.9% of 6-year-olds, and 1.6% of 10- to pediatric outpatient setting, 3% of visits are related to per- 11-year-olds. Boys are more likely than girls to have this con- ceived defecation problems (Levine, 1975; Molnar, Taitz, dition. The onset of symptoms to the time of diagnosis is usu- Urwin, & Wales, 1983). Pediatricians are now referring ally 1–5 years or longer. Encopresis is a result of long-stand- children with encopresis (repeated soiling) at a younger ing constipation and is involuntary (Loening-Bauke, 1996). Very few children have fecal soiling without a history of con- stipation (Mason, Tobias, Lutkenhoff, Stoops, & Ferguson, Received October 19, 2007; accepted January 18, 2008. 2004). About the author: Lisa Philichi, MN, RN, CPNP, is Pediatric Gastroen- terology Nurse Practitioner, Gastroenterology Clinic, Mary Bridge Chil- dren’s Hospital and Health Center, Tacoma, Washington. Pathophysiology Correspondence to: Lisa Philichi, MN, RN, CPNP, Gastroenterology Clinic, Mary Bridge Children’s Hospital and Health Center, 311 South L St, Fluid and electrolyte absorption as well as stool passage and MS: 311-W3-GI, Tacoma, WA 98405 (e-mail: [email protected]). storage are the two functions of the large intestine. The

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majority of fluid is absorbed in the ascending and transverse process, in children with primary encopresis. These children colon (Lewis & Rudolph, 1997). Peristalsis moves stool are usually described as challenging to train (Fishman, through the colon and into the rectum. In healthy children, Rappaport, Cousineau, & Nurko, 2002). total colonic time is 45.7 hours, and half of this time occurs Other causes of functional constipation include a change in in the rectosigmoid colon (Gutiérrez, Marco, Nogales, & diet, such as transitioning to solids, illness, stress, beginning Tebar, 2002). school, vacation, or not willing to stop playing to defecate. Stool enters the rectum and reflex contraction of the rec- Attention disorders make it difficult for the child to focus and tum occurs. The internal anal sphincter relaxes, allowing respond promptly to the urge to defecate. Medications such as stool to enter the anal canal. Anoderm stretch receptors anticonvulsants, psychotherapeutic agents, narcotic contain- sense the stool and the decision whether to defecate or delay ing analgesics, and cough suppressants contribute to constipa- passage is made (Youssef & Di Lorenzo, 2001). If the child tion. Most infants and children with functional constipation does not want to defecate, he or she voluntarily squeezes the need minimal workup (Loening-Baucke, 1996). external anal sphincter and gluteal and pelvic floor muscles. The fecal mass then moves out of the rectal ampulla and Nonfunctional/Organic Causes back into the rectosigmoid colon where the stool becomes larger and harder. The rectum accommodates the stool and Organic causes occur in less than 5%--10% of children with the urge to defecate goes away. Bowel movement frequency constipation, but should be considered in the differential is decreased. Fecal soiling, or leakage of liquid feces around diagnosis of every child who presents with difficulty defe- the retained fecal mass, occurs and is the mechanism of cating or fecal soiling (Youssef & Di Lorenzo, 2001). There encopresis (Bulloch & Tenenbein, 2002). is a greater likelihood of organic origin if there is a history Urinary symptoms can result from the dilated rectum of fever, , anorexia, , , pushing on the bladder and causing spasms (Schonwald & weight loss, or poor weight gain (Baker et al., 2006). Rappaport, 2004). Urinary tract infections are a result of Hirschsprung’s disease, or congenital aganglionic mega- fecal flora ascending the urethra and are more common in colon, is an absence of ganglion cells in the rectum and may girls with encopresis. Enuresis and urinary tract infections extend proximally at varying lengths resulting in a portion are reported in 30% of constipated children (Benninga of the bowel that is tonically contracted (Bulloch & Tenen- et al., 2004). bein, 2002). This is a rare disease, but it must be ruled out in all infants and children with constipation. Less than 1% Functional/Nonorganic Causes of children with constipation are diagnosed with Hirschsprung’s disease after the first year of life (Youssef & Painful defection is the most frequently reported event caus- Di Lorenzo, 2001). A higher incidence of this disease is ing constipation (Borowitz et al., 2003). Sixty-three percent reported in children with Down’s syndrome. of children with encopresis have a history of passing painful The hallmark sign of Hirschsprung’s disease is failure to bowel movements before 36 months of age (Partin, Hamill, pass meconium within 24 hours after birth. A small rectum Fischel, & Partin, 1992). Unfortunately, painful defecation empty of stool is also a sign of this disease (Loening-Baucke, leads to withholding, which creates a cycle of further pain 1996). The typical presentation in infants is constipation, when defecating. Withholding behavior is typically observed abdominal distension, and vomiting or . Bloody as stiffening of the legs in infants, whereas toddlers often diarrhea with fever of sudden onset and abdominal disten- become pale, stiffen or squat, hold on to a piece of furniture, tion may be a sign of life-threatening enterocolitis, a compli- or hide behind a couch or in a corner. Withholding behaviors cation of Hirschsprung’s disease. This is more likely in the can become automatic over time. Parents frequently mistake second and third months of life and is associated with 20% withholding as straining or an attempt to defecate. The result mortality (Baker et al., 2006). Fecal soiling occurs only when of this behavior is stool retention and soiling (Youssef & Di the aganglionic segment is extremely short and is often not Lorenzo 2001). is reported as diarrhea by diagnosed until childhood. After surgical resection of the some parents. Withholding behaviors lessen the likelihood of aganglionic bowel, up to 50% of children have constipation an organic cause (Baker et al., 2006) or fecal soiling due to persistent colonic and anorectal motor A functional disorder in infancy, referred to as infant dysfunction (Di Lorenzo & Benninga, 2004). dyschezia, occurs because of the inability to coordinate Anorectal anomalies or malformations such as anal increased intra-abdominal pressure with relaxation of the stenosis are congenital and range from minor defects pelvic floor. The infant will strain and scream with defeca- requiring uncomplicated surgery to complex lesions requir- tion of soft liquid stools. This can happen for 20-minute ing a high degree of skill and expertise to correct. These intervals several times a day. As there is improved muscle conditions result from the lower rectum, urogenital tract, coordination, this condition resolves (Youssef & Di or the anus developing incorrectly in utero. Children with Lorenzo, 2001). surgically corrected anorectal malformations may have The highest incidence of constipation occurs during toi- fecal soiling and constipation despite repair (Di Lorenzo & let training and is the second most often reported event lead- Benninga, 2004). ing to constipation (Borowitz et al., 2003). In the United Abnormal innervation, limited defecation effort due to States, most children are toilet trained by age 3. Children poor muscle tone, and dyssynergia (anal sphincter contracts who are not toilet trained until older than 4 years are out- instead of relaxing during defecation) are all neurogenic dis- side the norm developmentally (Schonwald & Rappaport, orders that cause constipation (Bulloch & Tenenbein, 2004). There is a greater likelihood of being punished dur- 2002). These include spinal disorders such as meningomye- ing toilet training, or experiencing an interruption in the locele and spinal trauma. In children with cerebral palsy or

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generalized hypotonia, fecal soiling is common (Loening- Baucke, 2002). Other organic causes include hypothyroidism and meta- bolic conditions that lead to water depletion (i.e., renal aci- dosis, diabetes insipidus, and hypercalcemia). Pellet-like stools are seen with these disorders. Rectal prolapse and constipation are associated with cystic fibrosis and celiac disease (Loening-Baucke, 1996).

Evaluation A thorough history and physical examination are usually adequate to determine if functional constipation is present or further evaluation is necessary (Baker et al., 2006). When obtaining a history, the following key points should be included: age of onset; precipitating event; bowel consis- tency, size, amount, and pattern; incontinence; pain or bleeding with defecation; withholding behaviors; dietary habits; delayed passage of meconium; urinary incontinence; weight loss; vomiting; medications; school and public toilet use; abuse or other trauma; and rectal prolapse. The presence of stool and gas in the colon can be eval- FIGURE 1. Abdominal radiograph. Extensive impacted fecal mat- uated during the abdominal examination. The sacral spine ter throughout the colon and rectal impaction with moderate dilatation of should be assessed for dimpling, which may indicate spinal the colon and rectum is shown. abnormality (Youssef & Di Lorenzo, 2001). Inspection of the perianal area for fecal soiling, fissures, position of the anus, dermatitis, and hemorrhoids is an important part of demonstrate where it is being accumulated (Youssef & the assessment. It is recommended that at least one rectal Di Lorenzo, 2001). A delay in colonic transit time may be examination be done to evaluate the amount, consistency, secondary to significant chronic fecal retention in the rec- and location of stool in the rectum; size of the rectum; tum (Benninga et al., 2004). anal tone; voluntary contraction and relaxation of the Anal rectal manometry is appropriate for children with external anal sphincter; perianal sensation; and presence early onset constipation, no history of fecal soiling, or exam- of an anal wink (Benninga et al., 2004). More than 84% ination revealing no stool mass and an empty rectal ampulla. predictive value of nonorganic constipation is reported if If the child has Hirschsprung’s disease, the internal anal a stool impaction is present in the rectum (Mason et al., sphincter will not relax in response to rectal distention. If the 2004). Feces should be tested for occult blood in all sphincter does relax, then the child most likely has a func- infants with constipation and in children who also present tional defecation disorder (Youssef & Di Lorenzo, 2001). with abdominal pain, failure to thrive, intermittent diar- rhea, or a family history of colon cancer or colonic polyps Treatment (Baker et al., 2006). Laboratory workup is usually minimal and is determined on the basis of the history and Education physical findings. The family needs to understand causes of constipation and A plain abdominal film is a useful tool diagnostically and encopresis to be compliant with the treatment plan. A study for family education because the presence and amount of of 503 children with encopresis over 20 years reveals that retained stool can be visualized (Figure 1). It is especially parents often continue to blame behavioral aspects on fecal helpful when the child is obese or refuses a rectal examina- soiling. These include laziness, carelessness, and emotional tion or there are other psychological components such as problems. Some parents believe an organic problem is the sexual abuse (Baker et al., 2006). Not recognizing the cause of encopresis (Fishman et al., 2003). Parents may need degree of stool retention can lead to ineffective treatment regular reassurance that there is no organic cause, especially (Loening-Baucke, 2002). when there is little improvement in their child’s condition. An unprepared barium is a screening test for They may also believe that toxins can be absorbed into the Hirschsprung’s disease. Verification of a transition zone, body from too much stool in the colon leading to serious where the dilated, normally innervated proximal colon problems. No scientific evidence exists to support this belief meets the narrowed aganglionic distal colorectal segment, is (Müller-Lissner, Kamm, Scarpignato, & Wald, 2005). suggestive of this disorder. Confirmation requires a suction In the primary care setting, constipation and encopresis rectal biopsy to determine the absence of ganglion cells in may be viewed as constitutional conditions or something the the submucosal plexus. Sometimes the suction biopsy is not child will grow out of. This belief can delay treatment and diagnostic and a full-thickness biopsy is required (Baker create frustration for the family. Few children and their par- et al., 2006). ents know others with encopresis (Fishman et al., 2003). It is Swallowed radio-opaque markers can be used to evalu- often the school nurse who first provides treatment resources. ate segmental colonic transit time and can be useful in Denial of fecal soiling is common in children. Shame and revealing the progression of stool through the colon and fear of punishment may contribute to this denial. It can be

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exasperating for parents because often the child is not aware used to treat constipation in children. The correct amount that fecal soiling has occurred and is unable to recognize the of medication is the dose that allows daily soft stools with- smell. It may be that the child loses bowel distension sensa- out adverse effects (Benninga et al., 2004). Generally, a min- tion or is not aware of such cues from a persistently stretched imum of 6 months of medication therapy is necessary, so colon and rectum (Levine, 1975). Smell desensitization may compliance is essential. The medication should be tapered occur from repeated exposure to the fecal soiling. Further- slowly as the child’s constipation resolves. more, it may take 6–9 months for the child to redevelop the urge to defecate (Schonwald & Rappaport, 2004). Behavior Management The purpose of medications, adverse effects, and when to Enhanced toilet training, including education, incentives to decrease or discontinue medications needs to be discussed use the toilet, and defecation instructions, combined with with the family. They should be actively involved in the medication is more effective treatment than medication treatment plan. Stopping medication treatment too soon is therapy alone (Borowitz, Cox, Sutphen, & Kovatchev, most likely a cause of relapse and a detailed plan improves 2002). A consistent routine needs to be followed by the fam- compliance (Loening-Baucke, 2002). ily. Positive reinforcement, unhurried use of the toilet, and bathroom privacy are important parts of therapy. The child Medication Therapy should be instructed to attempt to defecate for 5–10 minutes If a is present, a cleanout, or disimpaction, on the toilet 20–30 minutes after meals. The benefit of this must first be done. The child is more likely to improve if this is to take advantage of the gastrocolic reflex, high-ampli- occurs before daily laxative treatment begins. and tude colonic contractions from the proximal to distal sig- suppositories are useful in removing stool from the rectum moid colon that push stool into the rectum following a meal and lower colon. Table 1 provides an overview of medication or after awakening (Lewis & Rudolph, 1997). Proper posi- therapy. Enemas are poorly absorbed from the colon, caus- tioning helps facilitate defecation; therefore, children whose ing retention of water leading to evacuation of the bowel feet do not touch the floor should place them on a footrest (Bulloch & Tenenbein, 2002). If a cleanout is not completed, to flatten the anorectal angle and aid in stool passage (Ben- treatment with only oral medications may result in increased ninga et al., 2004). Keeping a diary or using a calendar to fecal soiling, due to overflow diarrhea, and increased pain keep track of the child’s bowel pattern may allow the fam- and (Benninga et al., 2004); however, high doses of ily to accurately assess and identify areas of improvement, oral medications have been shown to be an effective method as well as increase adherence to the treatment plan. With the of disimpaction (Baker et al., 2006). Cleanout options child who develops constipation while being toilet trained, should be discussed with the family. Rectal medications can it is suggested that further toilet training be delayed until be challenging for parents to administer and may not result there is a normal stool pattern and no resistance to sitting. in success. If a child has a severe fecal impaction, or if the Psychological referral is recommended for the child who home cleanout is not adequate, a lavage cleanout may be fails medical treatment or if there are emotional problems or necessary. This is usually done in the hospital setting. family issues (Benninga et al., 2004). A mental healthcare Maintenance therapy is essential to ensure daily bowel provider can also reinforce the treatment plan. Family coun- movements that are soft enough to allow complete emptying seling is a method for parents to receive guidance and create of the rectosigmoid colon and to prevent soiling an emotional release process for the child with encopresis (Loening-Bauke, 1996). The rectum needs to be emptied reg- (Reid & Bahar, 2006). ularly so that over time, the rectal caliber regains its natural Biofeedback is done to increase rectal sensation, strengthen size and the child’s defecation pattern returns to normal and enhance external anal sphincter control, and improve (Bulloch & Tenenbein, 2002). Medication selection includes coordination of muscle contraction and relaxation for effec- daily laxatives, lubricants, and stimulants. Laxatives such as tive defecation and continence (Di Lorenzo & Benninga, polyethylene glycol (Miralax) and lactulose (Kristalose) make 2004). The benefit of biofeedback training is limited in the stools softer and facilitate passage (Benninga et al., 2004). treatment of childhood constipation (Benninga et al., 2004). Laxative studies show similar effectiveness, but polyeth- ylene glycol may be better tolerated (Torres & McGregor, Diet 2004). Mineral oil works primarily as a stool lubricant and No proof is available that diet reduces functional constipa- does not deplete tissue stores of fat-soluble vitamins. A risk tion when there is stool withholding and retention (Loening- of aspiration or concern of lipoid pneumonia exists if given Baucke, 2002). The role of dietary fiber is controversial for to children who have difficulty swallowing, and mineral oil the treatment of encopresis, and current findings are not should not be used in children younger than 1 year. Most strong enough to support fiber supplementation in the treat- infants are instead treated with lactulose (Sharif, Crushell, ment of constipation (Baker et al., 2006). If a child is severely O’Driscoll, & Bourke, 2001). Stimulants such as senna constipated, increased fiber may actually worsen symptoms (Senokot) stimulate motility, and sodium and water secre- (Müller-Lissner et al., 2005). Instead, whole grains, fruits, tion from the colon is increased. They are generally used if and vegetables are recommended as part of a balanced diet other medications are ineffective and are considered rescue for the treatment of constipation (Baker et al., 2006). therapy (Baker et al., 2006). The concern of melanosis coli Increased fluid intake does not treat constipation unless development, a brown discoloration of the colon, with use the child is dehydrated (Müller-Lissner et al., 2005). With of stimulants has no functional significance (Müller-Lissner constipated infants, various formulas may be tried. Infants et al., 2005). who drink ProSobee, a soy-based formula, have harder, No information is available regarding maximum dose, firmer stools than other formula-fed and breast-fed infants duration, or long-term adverse effects of any medications (Hyams et al., 1995). When either iron-fortified or

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TABLE 1 Medications Useful for Bowel Evacuation

Adverse Effects/ Drugs Dose Guidelines Side Effects Nursing Implications

Enemas and suppositories: Stimulate bowel activity and emptying of the lower intestine Bisacodyl (Dulcolax) Ͻ 2 years Abdominal pain Long-term use may result in dependency 5 mg/day as a single dose Diarrhea Onset of action is 0.25–1 hr 2–11 years Hypokalemia 5–10 mg/day as a single dose Rectal burning Ն 12 years 10 mg/day as a single dose Glycerin (Fleet Neonates May cause tenesmus or Use caution during insertion to Glycerin) rectal irritation avoid intestinal perforation, 0.5 ml/kg per dose of rectal especially with infants solution as an enema Ͻ Insert suppository in the rectum Children 6 years and retain for 15 min One infant suppository as needed Onset of action for suppository or 2–5 ml of rectal solution as or enema: 15–30 min an enema Ն Moisten suppository with water Children 6 years and adults before insertion to reduce One adult suppository as needed stinging or 5–15 ml of rectal solution as an enema Phosphate (Fleet) Children Ͻ 2 years Abdominal distension Use caution in patients with a colostomy Avoid Vomiting Enema tips are latex free Children 2–5 years Risk of trauma to rectal wall Onset of action is 2–5 min Half contents of one 2.25 oz pediatric enema Children 5–12 years Contents of one 2.25 oz of pediatric enema May repeat Children Ն 12 years and adults Contents of one 4.5 oz of enema as a single dose May repeat Lavage: Cleansing of stool from the colon Polyethylene Disimpaction Electrolyte disturbances May require hospitalization glycol (PEG)-elec- 25 ml/kg/hr (to 1,000 ml/hr) by Nausea Directions differ according to the trolyte solution formulation and indication (CoLyte, GoLYTELY, nasogastric tube until clear Bloating NuLYTELY, TriLyte) Do not eat any solid foods for at Abdominal cramps least 2–3 hr before administra- Anal irritation tion and do not take any other oral medication for 1 hr before use Rapidly drinking each portion is preferred to drinking small amounts continuously The first bowel movement should occur approximately 1 hr after the start of administration Abdominal bloating and distention may occur before bowel starts to move

(Continued)

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TABLE 1 Medications Useful for Bowel Evacuation (Continued)

Adverse Effects/ Drugs Dose Guidelines Side Effects Nursing Implications

Do not add flavorings as addi- tional ingredients before use Chilled solution often is more palatable Discard any unused portion Laxatives: Facilitate passage of stool at the time of defecation

Barley malt extract Infants > 1 month Odorous (Maltsupex) Breast-fed Bloating Can be given in baby’s bottle Liquid: 1–2 teaspoonfuls in 2–4 oz Abdominal pain of water or fruit juice 1–2 Vomiting times/day for 3–4 days Powder: 4 g in 2–4 oz of water or fruit juice daily for 3–4 days Bottle-fed 1 Liquid: /2 to 2 tablespoonfuls/day in formula for 3–4 days, then 1–2 teaspoonfuls/day Powder: 8–16 g/day in formula for 3–4 days, then 4–8 g/day Children 2–6 years Liquid: 7.5 ml, 1–2 times/day for 3–4 days Powder: 8 g bid for 3–4 days Children 6–12 years Liquid: 15–30 ml, 1–2 times/day for 3–4 days Powder: Up to 16 g/day for 3–4 days Children Ն 12 years and adults Liquid: 30 ml bid for 3–4 days, then 15–30 ml at bedtime Powder: Up to 32 g bid for 3–4 days, then 16–32 g at bedtime Lactulose Children Flatulence Administer with juice, water, or milk (Constulose, 7.5 ml/day (5 g/day) after Abdominal cramps Enulose, breakfast Mix crystals in 4 oz of juice or Diarrhea Kristalose) water Adults Nausea Higher doses are used for treat- 15–30 ml/day (10–20 g/day) Vomiting ment of portal systemic Increase to a maximum of encephalopathy 60 ml/day (40 g/day) if needed Magnesium citrate Children Ͻ 6 years Hypermagnesemia Use with caution in patients who have impaired renal function (Citrate of 2–4 ml/kg given in single or Abdominal cramps Magnesia) divided doses or who are receiving a cardiac Diarrhea glycoside or lithium Children 6–12 years Gas formation 100–150 ml Children Ն 12 years and adults Half to full bottle (120–300 ml)

(Continued)

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TABLE 1 Medications Useful for Bowel Evacuation (Continued)

Adverse Effects/ Drugs Dose Guidelines Side Effects Nursing Implications

Magnesium hydroxide Liquid Hypermagnesemia, Infants are sensitive to magne- sium poisoning (Phillips’ Milk of Children < 2 years hypophosphatemia, Magnesia) and secondary Use with caution in patients with 0.5 ml/kg per dose hypocalcemia can renal impairment Children 2–5 years result from overdose Liquid doses may be diluted 5–15 ml/day (2.5–7.5 ml/day of with a small amount of water liquid concentrate) or in divided before administration. All doses doses should be followed by Children 6–12 years sufficient amounts of water 15–30 ml/day (7.5–15 ml/day of Onset of action is 4–8 hr liquid concentrate) or in divided Can cause decreased absorp- doses tion of tetracyclines, digoxin, Children Ն 12 years and adults indomethacin, or iron salts 30–60 ml/day (15–30 ml/day of liquid concentrate) or in divided doses Tablet Children 2–5 years 1–2 tablets before bedtime Children 6–11 years 3–4 tablets before bedtime Children Ն 12 years and adults 6–8 tablets before bedtime Polyethylene glycol Children 10–30 kg Bloating Chilled solution and intermittent stirring for 4–6 min makes (MiraLax, 8.5 g daily Nausea GlycoLax) solution more palatable Cramps Adults Onset of action is 48–96 hr 17 g daily Vomiting Abdominal distension Diarrhea Sorbitol Children 2–11 years 2 ml/kg Less expensive than lactulose Children Ն 12 years and adults Abdominal discomfort 30–150 ml Nausea Vomiting

Lubricants: Help ease the passage of stool and lubricates the intestines Nausea Mineral oil Oral Not recommended in children younger than 1 year and in (Kondremul, Fleet) Children 5–11 years Vomiting children with swallowing prob- Diarrhea 5–15 ml once daily or in divided lems because of the risk of doses Abdominal cramps aspiration Children Ն 12 years and adults Anal itching More palatable when given cold 15–45 ml/day once daily or in Anal seepage Anal leakage/orange stain divided doses indicates dose is too high or a Lipid pneumonitis with need for a cleanout aspiration Onset of action is 6–8 hr Nonemulsified mineral oil may be administered at bedtime on an empty stomach. Emulsified mineral oil should be shaken before using and may be administered with meals. (It is more palatable than nonemul- sified mineral oil.)

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TABLE 1 Medications Useful for Bowel Evacuation (Continued)

Adverse Effects/ Drugs Dose Guidelines Side Effects Nursing Implications

Stimulants: Local irritant on the colon Bisacodyl (Dulcolax) Oral Abdominal pain Administer with water on empty stomach Children Ͻ 3 years Diarrhea Swallow tablet whole Do not use Hypokalemia Do not take within 1 hr of Children 3–12 years Rectal burning ingesting antacids, alkaline 5–10 mg or 0.3 mg/kg/day as a material, milk, or dairy products single dose Long-term use may result in Children Ն 12 years and adults dependency 5–15 mg/day as a single dose Onset of action Maximum dose 30 mg Oral: 6–10 hr Suppository (see enemas and Rectal: 15–60 min suppositories section) Senna (Senexon, Syrup Abdominal cramping Chronic use may cause dependency, melanosis coli Senokot, Fletcher’s Infants 1 month to 2 years Discoloration of urine Castoria) (pink, red, or brown) 1.25–2.5 ml (2.2–4.4 mg of and feces (dark) sennosides) at bedtime Nausea Not to exceed 5 ml (8.8 mg of sennosides per day) Vomiting Children 2–6 years Diarrhea 2.5–3.75 ml (4.4–6.6 mg of sennosides) at bedtime Not to exceed 3.75 ml (6.6 mg of sennosides) bid Children 6–12 years 5–7.5 ml (8.8–13.2 mg of sennosides) at bedtime Not to exceed 7.5 ml (13.2 mg of sennosides) bid Children Ն 12 years and adults 10–15 ml (17.6–26.4 mg of sennosides) at bedtime, not to exceed 15 ml (26.4 mg of sen- nosildes) bid Tablet Children 2–6 years 1/2 tablet (4.3 mg of sennosides) at bedtime Not to exceed 1 tablet (8.6 mg of sennosides) bid Children 6–12 years 1 tablet (8.6 mg of sennosides) at bedtime Not to exceed 2 tablets (17.2 mg of sennosides) bid Children Ն 12 years and adults 2 tablets (17.2 mg of sennosides) at bedtime Not to exceed 4 tablets (34.4 mg of sennosides) bid

Note. From “GI Medications,” In R. J. Young & L. Philichi (Eds.), Clinical Handbook of Pediatric Gastroenterology, by K. Gura, S. Huffman, & L. Philichi, 2008, St. Louis, MO: Quality Medical Publishing. Used with permission of the authors.

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non–iron-fortified formula is given, there is no difference in ogy, Hepatology, and Nutrition. Journal of Pediatric Gas- the consistency of stools (Oski et al., 1980). A time-limited troenterology and Nutrition, 43(3), 405–407, e1–e13. trail of cow’s milk removal from the diet may be considered Benninga, M., Voskuijl, W., & Taminiau, J. (2004). Child- for children unresponsive to standard medical and behav- hood constipation: Is there new light in the tunnel? ioral management (Baker et al., 2006). Journal of Pediatric Gastroenterology and Nutrition, 39(5), 448–464. Recovery Borowitz, S., Cox, D., Kovatchev, B., Ritterband, L., Sheen, J., & Sutphen, J. (2005). Treatment of childhood consti- Predictors of successful treatment have been identified. pation by primary care physicians: Efficacy and predic- Children with secondary encopresis have higher rates of tors of outcome. Pediatrics, 115(4), 873–877. recovery (Loening-Baucke, 2004). Resolution of symptoms Borowitz, S., Cox, D., Sutphen, J., & Kovatchev, B. (2002). is more likely in children with an onset of symptoms after Treatment of childhood encopresis: A randomized trial 4 years of age and those without encopresis (van Ginkel comparing three treatment protocols. Journal of Pedi- et al., 2003). Poor outcome predictors include a family his- atric Gastroenterology and Nutrition, 34(4), 378–384. tory of constipation and early onset of constipation (Sta- Borowitz, S., Cox, D., Tam, A., Ritterband, L., Sutphen, J., iano, Andreotti, Greco, Basile, & Auricchio, 1994). These & Penberthy, J. (2003). Precipitants of constipation dur- predictors support the need for early recognition and treat- ing early childhood. Journal of the American Board of ment of constipation in young children. Vigorous treatment Family Practice, 16(3), 213–218. by the primary care provider at the onset of symptoms may Bulloch, B., & Tenenbein, M. (2002). Constipation: Diag- prevent the development of chronic constipation or fecal nosis and management in the pediatric emergency soiling (Borowitz et al., 2005). Instructing parents during department. Pediatric Emergency Care, 18(4), 254–258. primary care visits on signs of childhood constipation and Di Lorenzo, C., & Benninga, M. (2004). Pathophysiology when it commonly occurs, for example, with diet changes of pediatric fecal incontinence. Gastroenterology, and the start of school, may also be beneficial. As men- 126(1), S33–S40. tioned previously, less than half of parents are aware that Fishman, L., Rappaport, L., Cousineau, D., & Nurko, S. their child is constipated. Furthermore, children do not (2002). Early constipation and toilet training in children always recognize they have a problem. Often school-aged with encopresis. Journal of Pediatric Gastroenterology children present with only generalized abdominal pain when and Nutrition, 34(4), 385–388. diagnosed with constipation (Bulloch & Tenenbein, 2002). Fishman, L., Rappaport, L., Schonwald, A., & Nurko, S. Studies support a 53%–60% recovery rate after 1 year of (2003). Trends in referral to a single encopresis clinic treatment, 51.6% after 5 years, and 80% after 8 years of over 20 years. Pediatrics, 111(5), e604–e607. treatment (Staiano et al., 1994; van Ginkel et al., 2003). Gura, K., Huffman, S., & Philichi, L. (2008). GI medica- Half of children have at least one relapse within 5 years tions. In R. J. Young & L. Philichi (Eds.), Clinical hand- after initial treatment, and relapses are more common in book of pediatric gastroenterology (pp. 266–280). St. boys. Constipation is still present in 30% of children after Louis, MO: Quality Medical Publishing. puberty. The importance of regular follow-up visits for at Gutiérrez, C., Marco, A., Nogales, A., & Tebar, R. (2002). least 1 year after successful treatment is recommended to Total and segmental colonic transit time and anorectal prevent relapse (van Ginkel et al., 2003). If there is repeated manometry in children with chronic idiopathic constipa- treatment failure, regardless of compliance, reconsideration tion. Journal of Pediatric Gastroenterology and Nutri- of the differential diagnosis is indicated (Youssef & Di tion, 35(1), 31–39. Lorenzo, 2001). Hyams, J., Treem, W., Etienne, N., Weinerman, H., MacGilpin, D., Hine, P., et al. (1995). Effect of infant formula on stool characteristics of young infants. Conclusion Pediatrics, 95(1), 50–54. Recognition and treatment of constipation and encopresis Levine, M. (1975). Children with encopresis: A descriptive are often delayed. Family education, particularly dispelling analysis. Pediatrics, 56(3), 412–416. misconceptions, helps the family better understand the Lewis, G., & Rudolph, C. (1997). Practical approach to treatment plan and may increase adherence. Medication defecation disorders in children. Pediatric Annals, 26(4), selection is based on the severity of constipation as well as 260–268. the likelihood of the child taking it consistently. Behavior Loening-Baucke, V. (1996). Encopresis and soiling. management requires appropriate use of the toilet to allow Pediatric Clinics of North America, 43(1), 279–298. complete emptying of feces from the rectum. Because Loening-Baucke, V. (2002). Encopresis. Current Opinion in relapses in the child’s condition are common, ongoing man- Pediatrics, 14(5), 570–575. agement is necessary to provide reassurance to the family Loening-Baucke, V. (2004). Functional fecal retention with and ensure successful treatment. encopresis in childhood. Journal of Pediatric Gastroen- terology and Nutrition, 38(1), 79–84. Mason, D., Tobias, N., Lutkenhoff, M., Stoops, M., & References Ferguson, D. (2004). The APN’s guide to pediatric con- Baker, S., Liptak, G., Colletti, R., Croffie, J., DiLorenzo, C., stipation management. Nurse Practitioner, 29(7), 13–21. Ector, W., et al. (2006). Evaluation and treatment of con- Molnar, D., Taitz, L., Urwin, O., & Wales, J. (1983). stipation in infants and children: Recommendations of Anorectal manometry results in defecation disorders. the North American Society for Pediatric Gastroenterol- Archives of Disease in Childhood, 58, 257–261.

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Müller-Lissner, S., Kamm, M., Scarpignato, C., & Wald, A. Sharif, F., Crushell, E., O’Driscoll, K., & Bourke, B. (2001). (2005). Myths and misconceptions about chronic consti- Liquid paraffin: A reappraisal of its role in the treatment pation. American Journal of Gastroenterology, 100, of constipation. Archives of Disease in Childhood, 85, 232–242. 121–124. Oski, F., Bennett, R., Campbell, J., Charles, W., Cirincione, Staiano, A., Andreotti, M., Greco, L., Basile, P., & Auric- F., Corwin, R., et al. (1980). Iron-fortified formulas and chio, S. (1994). Long-term follow-up of children with gastrointestinal symptoms in infants: A controlled study. chronic idiopathic constipation. Digestive Diseases and Pediatrics, 66(2), 168–170. Sciences, 39(3), 561–564. Partin, J. C., Hamill, S., Fischel, J., & Partin, J. S. (1992). Torres, M., & McGregor, T. (2004). What is the most effec- Painful defecation and fecal soiling in children. Pedi- tive way for relieving constipation in children aged Ͼ1 atrics, 89(6), 1007–1009. year? Journal of Family Practice, 53(9), 744–745. Reid, H., & Bahar, R. (2006). Treatment of encopresis and van Ginkel, R., Reitsma, J., Buller, H., van Wijk, M., chronic constipation in young children: Clinical results Taminiau, J., & Benninga, M. (2003). Childhood consti- from interactive parent–child guidance. Clinical Pedi- pation: Longitudinal follow-up beyond puberty. atrics, 45(2), 157–164. Gastroenterology, 125(2), 357–363. Schonwald, A., & Rappaport, L. (2004). Consultation with Youssef, N., & Di Lorenzo, C. (2001). Childhood constipa- the specialist: Encopresis: Assessment and management. tion evaluation and treatment. Journal of Clinical Pediatrics in Review, 25(8), 278–282. Gastroenterology, 33(3), 199–205.

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