Acute constipation usually responds well to dietary measures. Constipation induced by whole cow’s milk will improve if formula is reintroduced for a few months. The addition of fruits such as prunes, apricots, and plums is helpful. Lactose or lactulose can be added to formula. If constipation has led to painful defecation, the pain retention cycle must be broken. The addition of a lubricant (mineral oil) or a stool softener like docusate sodium is sometimes necessary. These should be continued for several months so that the child no longer associates defecation with pain.
Chronic severe constipation
Chronic severe constipation, with or without encopresis, needs a systematic long-term approach.
1. Family education: the physiology of the problem must be explained to both child and parents, who need to acknowledge that the fecal soiling is involuntary. Punitive measures must be stopped.
2. Disimpaction: the bowel must first be cleared of impacted feces. Less severe retention can be treated at home with hypophosphate enemas and bisacodyl suppositories. In severe cases clearing has to be done in hospital by repeated administrations of saline enemas or by nasogastric infusion of a balanced polyethylene glycol-electrolyte solution. G4-Lytely is administered at 14 to 40 mL/kg/h until clear fluid is excreted through the rectum. Children with encopresis can require up to 500 mL/kg over 19 hours.
3. Maintenance therapy: Lubrication, diet, and regular bowel habits are necessary in long-term care.
Regular bowel movements and prevention of stool accumulation are encouraged by the use of mineral oil. The dose is 28 to 140 mL (2 to 10 T) daily, in two divided doses titrated to achieve one or two soft bowel movements each day. Mineral oil at this dose is safe and effective and does not deplete fat-soluble vitamins. Some authors prefer milk of magnesia in a dose of 1 or 2 mL/kg of body weight.
The fiber content of the diet should be increased through intake of fruits, vegetables, bran, and unbuttered popcorn. Children with severe constipation and encopresis have been successfully treated with diet alone.
Regular bowel habits
The child must establish regular bowel habits. The child should sit on the toilet regularly for 10 minutes twice a day, ideally after meals to take advantage of the gastrocolic reflex.
Long-term follow up
Long-term follow up is required. Relapses are quite common and should be treated with senna and increased mineral oil for several weeks. Treatment will have to be continued in most cases for at least 6 months, and often for several years. Regular telephone contact should be maintained. In our practice, we ask children who are old enough to phone the physician once a week to give a progress report and to discuss changes in medications. Later, this interaction is decreased to once a month. Children appreciate being given an active role and more responsibility in the treatment of their condition.
If encopresis is resistant to this approach-which is not common – investigations by a gastroenterologist may be indicated. If there is evidence of non-compliance and major psychologic or psychiatric problems, treatment should be continued in conjunction with a psychologist or pediatric psychiatrist.
Successful treatment with biofeedback has been reported from several centers. This option, however, is not widely available.
If all medical treatment fails, surgical procedures (rarely) must be considered. Anorectal myectomy, sphincteromyectomy, and sphincteroplasty have led to improvement.