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Assessing Motivation: A key component of any treatment program is
assessing the motivation of both parents and child in addressing the problem.
The clinician may ask parents and the child “how important is it to you to
stop the soiling and have clean underwear?” Children with encopresis may be
so habituated to soiling that they require active encouragement to participate
in a bowel training program. If either the child or parent is resistant,
facilitated referral to a structured program or counseling should be
considered.
Treatment: Bowel Cleansing
Bowel clean out is the first essential component of intervention. Using
an effective laxative such as polyethylene glycol (Miralax) on a daily
basis may be sufficient to clean out the bowel. Additional laxatives may
need to be added to achieve this goal. Osmotic laxatives such as
lactulose (1 ml/kg up to a max of 15-30 ml per day), or magnesium
hydroxide (milk of magnesia) (1 to 2 mL/kg once daily); or stimulant
laxatives such as senna (age 4-6 years- ½ tsp once or twice daily; age 6-
12 years- 1 tsp once or twice daily) may be useful adjuncts to Miralax.
Dosages of laxatives may need to be adjusted if the child’s stools become
too loose
Some children who are impacted with stool do not respond initially to
just oral laxatives and may require a more aggressive clean out before
oral laxatives can be effective. One approach is to initiate 3 day cycles
of a Dulcolax tablet on day #1, a Dulcolax suppository on day #2 and a
Fleets pediatric or adult enema on day #3. The 3 day cycle can be
repeated 3-4 times taking 9-12 days to complete. Abdominal films
before and after clean out may be helpful to ascertain effectiveness of
the clean out regimen. On some occasions, children may require an
inpatient 24 hour regimen of GoLytely per NG tube to achieve an
effective clean out
Treatment: Bowel training
The goal should be for the child to have daily bowel movements that are
not huge or extremely hard and are easily passed. The stool is kept soft
with the use of long term stool softeners. Miralax is a good choice to
achieve this goal and will be needed to be continued for several months
(or longer) to effectively allow the bowel to resume normal function.
The child is encouraged to sit on the toilet for 10 minutes twice a day.
Efforts should be made to make this a positive time while reminding the