pediatrics
Stool Incontinence in Children
Treatment of Stool Incontinence in Children
Education and demystification (for caregivers and child) Relief of stool impaction Maintenance (eg, behavioral and dietary interventions, laxative therapy) Slow withdrawal of laxatives with continued behavioral and dietary intervention (See also the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition's2014 recommendations for the evaluation and treatment of functional constipation in infants and children.) Any underlying disorders are treated. If there is no specific underlying pathology, symptoms are addressed ( Treatment references ). Initial treatment involves educating the caregivers and child about the physiology of encopresis, removing blame from the child, and diffusing the emotional reactions of those involved. Next the goal is to relieve any stool impaction. Stool impactioncan be relieved by a variety of regimens and agents (see table); choice depends on the age of the child and other factors.Polyethylene glycol(PEG) with electrolytes, sometimes plus a stimulant laxative (eg,bisacodylorsenna), or a sequence of sodium phosphate enemas plus a 2-week regimen of oral agents (eg,bisacodyltablets) and suppositories are often used. Sodium phosphate enemas are contraindicated in children younger than 2 years of age. After evacuation, a follow-up visit should be held to assess whether the evacuation has been successful, make sure soiling has resolved, and establish a maintenance plan. This plan includes encouragement of maintenance of regular bowel movements (usually via ongoing osmotic/lubricant laxative management) and behavioral interventions to encourage stool evacuation. There are many options for maintenance laxative therapy (see table), but PEG without electrolytes is used most often, typically 1 to 2 doses of 17 g/day titrated to effect (eg, one to two semisoft stools a day). At times a stimulant laxative may also be continued on the weekends to encourage extra evacuation of stool. Behavioral strategiesinclude structured toilet-sitting times (eg, having children sit on the toilet for 5 to 10 minutes after each meal to take advantage of the gastrocolic reflex). If children have accidents during certain times of the day, they also should sit on the toilet immediately prior to those times. Small rewards are often useful incentives. For example, giving children stickers to place on a chart each time they sit on the toilet (even if there is no stool production) can increase adherence to a plan. Often a stepwise program is used in which children receive small tokens (eg, stickers) for sitting on the toilet and larger rewards for consistent adherence. Rewards may need to be changed over time to maintain children’s interest in the plan. A referral to a behavioral therapist or child psychologist experienced in treating children with encopresis may be needed when caregiver-initiated methods are unsuccessful. These specialists strongly recommend caregivers who are frustrated with incontinence and fecal soiling behaviors avoid punishing the child or showing disappointment with the child for lack of progress or for any subsequent regression after progress. Behavioral therapists and child psychologists also caution caregivers against overly positive praise; rather, they emphasize proportionate praise and neutral feedback depending on the child's level of achievement. In themaintenance phase,regular toilet-sitting sessions still are needed to encourage evacuation of stool before the sensation is felt. This strategy decreases the likelihood of stool retention and allows the rectum to return to its normal size, improving muscle reactivity and nerve sensation. During the maintenance phase, caregiver and child education about toilet sitting is instrumental to the success of the regimen. Regular follow-up visits are necessary for ongoing guidance and support. Bowel retraining is a long process that may take months to years and includes slow withdrawal of laxatives once symptoms resolve and continued encouragement of toilet sitting. Relapses often occur during withdrawal of the maintenance regimen, so it is important to provide ongoing support and guidance during this phase. Encopresis can recur in times of stress or transition, so family members must be prepared for this possibility. Success rates are affected by physical and psychosocial factors, but 1-year cure rates are up to 50%, and 5- and 10-year cure rates are about 50% and 80% ( Treatment references ). The mainstay of treatment is family education, bowel cleanout and maintenance, and ongoing support. 1. Loening-Baucke V, Swidsinski A: Treatment of functional constipation and fecal incontinence. InPediatric Incontinence, Evaluation and Clinical Management,edited by Franco I, Austin P, Bauer S, von Gontard A, Homsy I. Chichester, John Wiley & Sons Ltd., 2015, pp. 163–170. 2.Tabbers MM, DiLorenzo C, Berger MY, et al: Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN.J Pediatr Gastroenterol Nutr58(2):258–274, 2014. doi: 10.1097/MPG.0000000000000266 