Pediatric Primary Care Case Studies (34 page)

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:

   Blow bubbles in a glass of water through a straw.

   Blow hard through your mouth.

   Blow up a balloon or blow bubbles.

   Roar like a lion.

   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 9-4
describes the treatment options for encopresis.

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

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?