Introduction:
Parents
are cautioned that attention focusing only on one or two factors such
as diet, laxatives, suppositories, enemas, and behavioral approaches
are inadequate to treat children with severe or chronic constipation or
children with encopresis (soiling). Seeing a physician in concert with
a knowledgeable behavioral psychologist and undertaking a comprehensive
treatment approach is strongly recommended to avoid chronic conditions
that may be difficult or impossible to reverse if they persist for too
long. Alternatively, you may try our telehealth approach with our Clean
Kid Manual and consultation options. A knowledge of the topics below will
be helpful in any program that you may undertake.
The
best single, comprehensive, and manageable resource (47 pages) I know
of for information on disorders of the gastrointestinal tract is a Harvard
Health Letter Special Report entitled The Sensitive Gut published in 1996
and last revised in 2002. I paid $16 for my copy. You can order it from
Harvard Health Publications, PO Box 421073, Palm Coast, FL 32142-1073.
They did not list a phone number. There is a website at www.health.harvard.edu/reports.
Another valuable source for information is the International Foundation
of Functional Gastrointestinal Disorders at www.iffgd.org.
The IFFGD is
a nonprofit education and research organization founded in 1991. IFFGD
addresses the issues surrounding life with gastrointestinal (GI) functional
and motility disorders and increases the awareness about these disorders
among the general public, researchers, and the clinical care community.
Their website refers to information and fact sheets, which can be purchased
for learning about a variety of problems and interventions unique to the
GI tract or certain portions or conditions thereof.
Diets
(Fiber):
Dietary fiber
tends to increase the bulk of the stool, softens it, and likely enhances
motility reducing transit time. The current recommendation for adults
is 20-35 gm per day, far above that consumed by most Americans. The requirements
for children, ages 3-18, are less than for adults. The American Dietetic
Association reports a formula for determining recommended fiber intake--a
child's age plus five equals the grams of dietary fiber he or she should
eat daily. Fiber supplements can be helpful. They are very gentle laxatives
in their action in enhancing stool evacuation some 12-72 hours down the
line for the normal bowel. Standard oral laxatives such as Senokot are
irritants and speed up transit time into the 12-24 hour range. Insoluble
fiber does not dissolve or gel in water and is poorly fermented. Insoluble
fiber adds bulk to the stool directly. Soluble fiber dissolves in water,
becomes a soft gel, and is readily fermented. This would include the pectin
in fruit, which retain water adding to bulk and softening. Colon bacteria
action on soluble fiber creates gas and helps to increase fecal mass.
Insoluble fiber would include wheat bran, corn bran, whole grains, dried
beans and peas, popcorn, seeds and nuts, most fruits and veggies, especially
carrots, white potatoes, artichokes, broccoli, leeks, and parsnips. Soluble
fiber includes psyllium, oat bran, whole oats, rice bran, dried beans,
chick peas, black-eyed peas, lentils and virtually all fruits and vegetables,
but especially citrus, apples, pears, sweet potatoes, carrots, okra, cauliflower,
and corn. Some high fiber substances may contain both soluble and insoluble
fibers.
CAUTION:
Parents and many physicians tend to over-exaggerate the importance of
fiber. There is the very real possibility that it may promote too much
stool which the child is not able to evacuate completely with required
sits. This may be especially true for children who are resistant to sitting
on the toilet stool and have retentive encopresis with an enlarged colon.
The Soiling Solutions protocol assures daily evacuations which makes diet
a much less significant factor. Daily voidings assure that older, more
dried out stool is eliminated leaving fresher stool behind. Drinking sufficient
fluids may be even more relevant.
Stool Softeners :
These
substances mix in with the feces and soften their consistency. One is
mineral oil. Daily use of mineral oil is generally discouraged because
it reduces absorption of fat-soluble vitamins and can induce lung damage
if accidentally inhaled. Another problem is that it remains as a liquid
and the child will tend to have more of a problem with leakage and difficulty
telling if he/she is about to pass gas or have an accident. An emulsified
form of mineral oil such as Kondremul is more easily tolerated and mixes
in much better with the stool as a softener, but the same cautions remain
for vitamin deficiency or inhalation by an upset child. Docusate Sodium
(Colace, Dialose, Surfak, others) is generally safe for long-term use.
I recommend the latter for kids in my Clean Kid manual, the problem with
it is that it has a horrible taste and if you get it in solid form some
kids have trouble swallowing it as they might for any pill. If the child
cannot tolerate the taste of Docusate I would suggest using Kondremul,
one of the fiber diets above, or a dietary supplement like Metamucil.
Docusate and Kondremul together is not recommended. The substances above
are all available "off the shelf".
Aside:
Always consult
with a physician when utilizing even "off the shelf" dosed medications.
Read and check about cautions and possible adverse interactions with any
medication.
Osmotic or Hypermolar Agents
(e.g., MOM, Miralax):
These
are salts or carbohydrates taken orally that promote secretion of bodily
fluids across the gastrointestinal membrane into the colon and also act
as softening agents. They include Milk of Magnesia (MOM), citrate of magnesium,
Epsom salts, lactulose, and sorbitol. The Harvard Health Letter special
report on the sensitive gut notes that the latter is less expensive than
lactulose and equally effective. Encouraging
a child to drink lots of water or sports drinks is advisable with these
agents to prevent dehydration or altered electrolyte levels. Recently,
a prescription osmotic with considerable promise has become available
called Miralax (Polyethylene Glycol), which you can read about on its
own website (Miralax.com). Miralax has quickly become dominant in prescribing
by physicians as part of the current practice of a top down treatment
for encopresis. It can be difficult to adjust the dosage for a stool that
is not overly soft. A liquified stool creates problems with leakage and
may hinder achieving control unless a reliable schedule of voiding is
accomplished.
Laxatives:
Top
down use of stimulant (irritative) laxatives bathing the entire GI tract
can lead to dependency, lesser effectiveness with daily use, and they
can cause changes in the bowel over extended periods of time. Using them
daily over months can decrease peristalsis and make the colon flabby and
inert, in need of a chemical fix. They include Dulcolax (bisacodyl), Peri-Colace
(casanthrol), castor oil, Ex-Lax (senna), and Senokot (senna). We will
see in the next section that starting the GI engine from the top is much
more unpredicable in terms of timing and effects than starting up the
voiding reflex from the "bottom." Cultural sensitivities and
the common practice of oral medications for most ills make the use of
oral laxatives so much more acceptable. Some leading pediatric gastroenterologists
pointedly refer to it as the "gentle" approach. That could,
I suppose, render the next section as the "brutal" approach?
Indeed, back in the late 1970's and early 1980's a couple of very significant
pediatric medical publications refered to "anal assault" and
"anal stamp" for the more targeted and timely procedure for
the bottoms up route, which has led to a medical bias throughout much
of the world.
Enemas
and Suppositories:
Enemas
are liquids introduced rectally to stimulate a voiding reflex. Suppositories
are solids introduced by the same route to promote voiding. The term "liquid
suppository" is an oxymoron, but it is used by marketing-types because
a suppository may be viewed as more benign or acceptable by the public.
The rectal route is the least favorite choice of parents and children.
It is viewed as a last resort because of the emotional and physical conflicts
that almost inevitably result. Encopretic children almost by definition
don't want to use this passage for anything going out much less anything
going in! Curiously, this very attitude probably leads to the necessity
of having to use enemas more than is really necessary for clean outs because
these children are very susceptible to holding stool and getting backed
up over and over. An enema is simply the procedure of adding fluid
to the rectum and sigmoid colon, which promotes bowel contractions. It
is a very powerful and immediate unconditioned stimulus leading to an
unconditioned response of bowel evacuation. Most of us have learned more
subtle conditioned stimuli cues for voiding on cue (for example, the gastrocolic
reflex after breakfast), all of which the encopretic child fights and
suppresses as hard as he/she can!!! I suspect that for these children
oral laxatives lead to very tiring battles and confusion within their
bodies in attempting to resist voiding contraction cues for days at a
time!!! The success of the Soiling Solutions protocol relies on
the much more predictable action of the rectal route for promoting rapid
conditioning of successful pooping on the toilet with the immediate relief
experienced by the child, when properly timed in a comprehensive program
to transition the child to pooping to his own natural stimulus cues.
Adding
non-absorbable salts to an enema creates an osmotic differential, which
promote more water absorption adding to bowel pressure and contractions.
Just as with orally administered osmotic agents, over frequent use may
result in dehydration or altered electrolyte imbalances. The drinking
of fluids such as low calorie sports drinks, juices, and water is recommended
to accompany their use. Oil containing enemas are used to help soften
hardened feces, but they are strictly for short-term use. Other
enemas are effective with lower volumes or smaller bottles containing
liquid glycerin or a bisacodyl solution. The smaller size make them less
threatening to children. Enemas may become absolutely necessary for a
proper "clean out" of the child.
Glycerin
suppositories are very gentle in action as they merely lubricate, add
bulk, and promote fluid retention. Indeed,
many parents may feel that they are ineffective, and this may be all too
true for stool-retentive children by the very nature of their problem!
Glycerin or glycol is a three-carbon trihydroxy alcohol which is hygrosopic
(retains water) and it is very slippery. Men shave with glycerin in their
shaving creams every day for its moisture attraction/retention, softening,
and lubricating properties. These
often come as thin "sticks" and are easy to insert. I regard
them as a "gentle" or less demanding "prompt" than
an enema. Another suppository contains bisacodyl in something of a bullet-shaped
form. This latter suppository directly irritates the rectal-colon wall
to promote a more rapid evacuation and may replace the enema in some instances
within the Soiling Solutions protocol. It may also be less intimidating
to a child than the standard Fleet enema bottle. Suppositories should
not be inserted into the fecal mass itself, but off to the side for contact
with the rectal wall.
The
Clean Kid Manual very specifically addresses fears and concerns about
using the rectal route. The manual helps to assure much earlier bowel
competence and voiding success under the child's control through proper
timing and sequencing of prompts and cues to void. Both enhanced physical
responding and sensory awareness are keys to success. Success and competence
has its own rewards and quickly replaces months and years of failure.
Someday physicians, psychologists, and parents will adopt the Soiling
Solutions protocol over continuing to practice failure (or blaming you
parents)! |
