The younger the child is when diagnosis and treatment begin,the higher the success rate. Treatment involves a combination of behavioral training and laxative therapy. Successfultreatment requires 6 to 24 months. The next step is adequatecolonic cleanout or disimpaction. Clean-out methods includeenemas alone or combinations of enema, suppository, and orallaxatives. High-dose oral mineral oil is a slower approach toclean-out. Choice of disimpaction method depends on the ageof the child, family choice, and the clinician’s experience witha particular method. Methods and side effects are summarized in Table 14-2. The child and family should be includedin the process of choosing the clean-out method. Because enemas may be invasive and oral medication may be unpleasant,allowing points of choice and control for the child and praisingall signs of cooperation are important.
Behavioral training is essential to the treatment of chronic constipation and soiling. The child and family are asked tomonitor and document stool output. Routine toilet sitting isinstituted for 5 to 10 minutes three to four times per day. Thechild is asked to demonstrate proper toilet sitting position withthe upper body flexed forward slightly and feet on the floor
Enema—6 mL/kg up to 4.5 oz (135 mL) If enemas are considered, administer first in physician’s office.
Enema—6 mL/kg up to 4.5 oz (135 mL) every 12–24 h × 1–3 Invasive; risk of mechanical trauma Large impaction: mineral oil enema followed 1–3 h later by normal saline or phosphate enema Small impaction: normal saline or phosphate enema
Normal saline Abdominal cramping; may not be as effective as hypertonic phosphate
Hypertonic phosphate Abdominal cramping; risk of hyperphosphatemia, hypokalemia, and hypocalcemia, especially with Hirschsprung or renal insufficiency or if retained. Some experts do not recommend phosphate enema for children <4 yr, others for children <2yr.
Milk of molasses: 1:1 milk:molasses For difficult to clear impaction
Combination: enema, suppository, oral laxative
Day 1: Enema q12–24 h See enemas above
Day 2: Bisacodyl suppository (10 mg) q12–24 h Abdominal cramping, diarrhea, hypokalemia
Day 3: Bisacodyl tablet (5 mg) q12–24 h Abdominal cramping, diarrhea, hypokalemia
Oral/nasogastric tube: Polyethylene glycol electrolyte solution Nausea, cramping, vomiting, bloating, aspiration. Large volume. Usually (GoLYTELY or NuLYTELY)—25 mL/kg/h up to 1000 mL/h × 4 h/day requires nasogastric tube and hospitalization to administer
Oral high-dose mineral oil—15–30 mL per year of age per day up Aspiration—lipoid pneumonia. Give chilled. to 8 oz × 3–4 days
X-Prep (senna): 15 mL q12h × 3 Abdominal cramping. May not see output until dose 2 or 3
Magnesium citrate: 1 oz/yr of age to maximum of 10 oz per day for Hypermagnesemia 2–3 days or foot support. The child should be praised for all components of cooperation with this program, and punishment andembarrassment should be avoided. As symptoms resolve, toiletsitting is decreased to twice daily and finally to once a day.