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==Medical Therapy==
==Medical Therapy==
There is a 3-pronged approach to the treatment of encopresis associated with constipation:
Soiling should always be treated as secondary to constipation (even if in doubt of another cause): 70-75% success
# Cleaning out
# Using stool softening agents
# Scheduled sitting times, typically after meals


The initial clean-out is achieved with enemas, laxatives, or both. Following that, enemas and laxatives are used daily to keep the stools soft and allow the stretched bowel to return to its normal size.  
#Education and Reassurance: Relieves anger and anxiety from parents and child.
 
#* Soiling is not intentional. The child doesn't notice until soiling has occurred.
Next, the child must be taught to use the toilet regularly to retrain his/her body. It is recommended that a child be required to sit on the toilet at a regular time each day and 'try' to go for 10-15 minutes, usually soon (or immediately) after eating.  Children are more likely to be able to expel a bowel movement right after eating. It is thought that creating a regular schedule of bathroom time will allow the child to achieve a proper elimination pattern.
#* Child is not psychologically abnormal. Behavioral problems will resolve once soiling has been treated successfully.
 
#* It can be treated successfully.
Dietary changes are an important management element. Recommended changes to the diet in the case of constipation-caused encopresis include:
#* Explain mechanisms of overflow-[[Fecal incontinence|incontinence]] with pictures. It is important for parents to understand the mechanisms of soiling well, as they might otherwise not comply with treatment, leading to treatment-failure.
# Reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas;
#* Involve children if old enough. Parents of children who have been toilet-trained for a few years have little idea about their child’s bowel habits, although they often assume great authority on the issue.
# Increase in high-fibre foods such as bran, whole wheat products, and fruits and vegetables; and
# Disimpaction: Removal of the hard impacted stools in the [[rectum]] with a strong [[laxative]] (start when child is off school or nursery.) - e.g.:
# Higher intake of liquids, such as juices, although an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices.
#*[[Bisacodyl]] orally 5 mg in mornings for 3 days (10 mg if over 5 years of age).
 
#* Enemas or suppositories are invasive and are usually not needed. Success of treatment depends on its consequent and prolonged application, not on its invasiveness.  
Unless there are immediate, satisfactory results from the above, some practitioners recommend keeping the child on a program of daily laxative use with a laxative recently made available to the public as a generic medicine. Use of laxatives, however, often results in unexpected and/or uncontrollable bowel movements for the child, wherein the child cannot "avoid" soiling. Other practitioners recommend that the child be kept on a regular program of simple, water-based enemas, which can be scheduled for appropriate times when the child is comfortably at home or in other private quarters. One benefit of the enema therapy is that it keeps the child from any attempts at "parent control" by preventing the child from withholding stool. An enema usually results in a fairly timely expulsion at a time and place more convenient to family members.
# Prevention of Re-accumulation: with a stool softener (start simultaneously with disimpaction) for 6-12 months for the child to regain confidence and for the [[colon]] to return to it's original tone and shape. It is important to do this consequently, in sufficiently high doses, and for a sufficient length of time. Taper off treatment gradually after. - e.g.:
#* Liquid Paraffin (mineral oil) (10 - 60 mls at night) titrated to effect (directly from fridge, with yogurt or ice-cream) (Contraindications: Children <1 year and children with neurological abnormalities or learning difficulties should not take liquid Paraffin, because of risk of [[pulmonary aspiration]])
#*[[Lactulose]] may be used in infants <1 year of age. It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern.
#* [[Dietary fiber]] (e.g. fruits) + plenty of fluids are important, but on its own these measures will not be sufficient enough once stool withholding and soiling have established.
#* No [[enema]]s or [[suppositories]]. These are for disimpaction only. If hard stools have formed again, it means that re-accumulation has occurred and higher doses for its prevention are needed.
# Establishing regular bowel pattern: start after successful disimpaction.
#* Encourage the child to sit on toilet regularly, at the same time of day, at least once a day, for at least 5 min. Ideally done after breakfast ([[gastrocolic reflex]]).
#* Continue on daily basis irrespective on whether or not the child has passed stools.  
#* A footstool or other support to ensure a child's hips can be fully flexed, and then a child can sit comfortably on the toilet.


==References==
==References==
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Latest revision as of 21:34, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Soiling should always be treated as secondary to constipation (even if in doubt of another cause): 70-75% success

  1. Education and Reassurance: Relieves anger and anxiety from parents and child.
    • Soiling is not intentional. The child doesn't notice until soiling has occurred.
    • Child is not psychologically abnormal. Behavioral problems will resolve once soiling has been treated successfully.
    • It can be treated successfully.
    • Explain mechanisms of overflow-incontinence with pictures. It is important for parents to understand the mechanisms of soiling well, as they might otherwise not comply with treatment, leading to treatment-failure.
    • Involve children if old enough. Parents of children who have been toilet-trained for a few years have little idea about their child’s bowel habits, although they often assume great authority on the issue.
  2. Disimpaction: Removal of the hard impacted stools in the rectum with a strong laxative (start when child is off school or nursery.) - e.g.:
    • Bisacodyl orally 5 mg in mornings for 3 days (10 mg if over 5 years of age).
    • Enemas or suppositories are invasive and are usually not needed. Success of treatment depends on its consequent and prolonged application, not on its invasiveness.
  3. Prevention of Re-accumulation: with a stool softener (start simultaneously with disimpaction) for 6-12 months for the child to regain confidence and for the colon to return to it's original tone and shape. It is important to do this consequently, in sufficiently high doses, and for a sufficient length of time. Taper off treatment gradually after. - e.g.:
    • Liquid Paraffin (mineral oil) (10 - 60 mls at night) titrated to effect (directly from fridge, with yogurt or ice-cream) (Contraindications: Children <1 year and children with neurological abnormalities or learning difficulties should not take liquid Paraffin, because of risk of pulmonary aspiration)
    • Lactulose may be used in infants <1 year of age. It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern.
    • Dietary fiber (e.g. fruits) + plenty of fluids are important, but on its own these measures will not be sufficient enough once stool withholding and soiling have established.
    • No enemas or suppositories. These are for disimpaction only. If hard stools have formed again, it means that re-accumulation has occurred and higher doses for its prevention are needed.
  4. Establishing regular bowel pattern: start after successful disimpaction.
    • Encourage the child to sit on toilet regularly, at the same time of day, at least once a day, for at least 5 min. Ideally done after breakfast (gastrocolic reflex).
    • Continue on daily basis irrespective on whether or not the child has passed stools.
    • A footstool or other support to ensure a child's hips can be fully flexed, and then a child can sit comfortably on the toilet.

References

Template:WikiDoc Sources