What You Need to Know About Medical Treatment for Pediatric Chronic Constipation and Fecal Incontinence

The first step in any bowel management program includes a thorough assessment of the patient’s diet. Children benefit from increased water and fiber intake, and a registered dietician can be invaluable in identifying deficiencies in nutrient intake and making recommendations for dietary modifications. For some children, changes in nutritional intake, such as removing lactose from the diet, can completely resolve constipation symptoms if initiated early in the onset of symptoms. Also, routinely screening children with significant constipation symptoms after the age of potty training for celiac disease, food allergies and hypothyroidism is recommended.

Children with loose stools have an overactive colon (hypermotility). Causes of hypermotility may include inflammatory bowel disease, infectious diarrheas and irritable bowel syndrome. 

For these children, a constipating diet consisting of water-soluble fiber and/or medications to slow down the colon are used.

If the patient has a shortened colon related to a prior surgery (such as in patients with an anorectal malformation, Hirschsprung's disease or ulcerative colitis), a daily small volume enema may also be required to help with soiling. To determine the right combination, treatment is initiated with enemas (only for those patients who are soiling), a very strict diet, medication and a water-soluble fiber. Most children respond to this aggressive management within one to two weeks. 

Children should remain on a strict diet until they are able to remain clean for up to three days in a row. This diet includes three scheduled meals and no snacks. They can then choose one new food every two to three days, and the effect of this new food on the child’s colonic activity is observed. If the child soils after eating a newly introduced food, that food must be eliminated. 

Over several months, maintaining a diet that includes as many foods as possible should be the goal. If the child remains clean with this diet, their medication can gradually be reduced to the lowest effective dose to keep the child from soiling.

Some children with hypermotility may develop a severe and painful buttock rash. To help treat the rash, the buttock should be covered with zinc oxide-based barriers, skin emollients and/or liquid skin protectants with each diaper change.

Children who are constipated vs. children who have loose stools will need different diets. Below you can find examples of constipating foods and laxative food:

Constipating Foods

Refined Foods:

• White bread
• White rice
• Pasta
• Sweets (Chocolate)

Fruits:

• Banana
• Apple without skin
• Apple sauce

Foods High in Fat:

• French fries
• Fast food
• Fried foods

Meats:

• Red meat
• Boiled, broiled, baked chicken or fish

Dairy:

• Cheese
• Milk

Laxative Foods

Whole Grain Foods:

• Whole wheat bread
• Whole grain pasta
• Brown rice
• Bran cereal

Fruits and Vegetables:

• Apples with skin
• Berries, dried figs
• Carrots, peas, broccoli
• Pears, peaches, prunes
• Fruit juices

Beans:

• Black beans
• Kidney beans
• Pinto beans

Dairy:

• Yogurt

Introducing fiber into a child’s diet and administering laxatives are the initial methods used to treat constipation.

Fiber

Both water-soluble and insoluble fibers are mainstays in fiber treatment. When mixed with a liquid, soluble fibers dissolve to form a gel-like substance, as opposed to insoluble fibers which pass through the gastrointestinal tract relatively unaltered. Both can provide bulk to stools, but water-soluble fiber is usually recommended (psyllium, pectin, methylcellulose or guar gum) to maximize the bulking effect and maintain a good balance between stool frequency and consistency. This bulking of the stool is important because it allows the child to be more aware of the stool in the rectum which can help signal when it is time to have a bowel movement. 

There are many kinds of fiber that are available over the counter, but it is important to get the sugar-free versions of these as foods and supplements high in sugar can make stools looser and cause a reverse effect. 

Soluble fiber options:

• Pectin (Sure-Jell)
  
  • Dosage and use: 1 Tablespoon = 2 grams of fiber
  • Where to find it: Found in the grocery store in the jelly/canning section or online at www.pacificpectin.com. Get the sugar-free version.
• Citrucel
  
  • Dosage and use:
    
    • Powder: 1 Tablespoon = 2 grams of fiber
    • Capsule: 2 capsules = 1 gram of fiber
  • Where to find it: Found in the pharmacy section of the store or online at www.citrucel.com. You can use the generic or brand name. Get the sugar-free version.
• Metamucil (psyllium husk)
  
  • Dosage and use:
    
    • Powder: 1 Tablespoon = 2 grams of fiber
    • Capsule: 5 capsules = 2 grams of fiber
    • Wafer: 1 packet (2 wafers) = 3 grams of fiber
  • Where to find it: Found in the pharmacy section of the store or online at www.metamucil.com. Get the sugar-free version.

• Nutrisource (guar gum)
  
  • Dosage and use: 1 Tablespoon (scoop) = 3 grams of fiber
    * Can be sprinkled on food or mixed in drinks.
  • Where to find it: Found in the pharmacy section of the store, online or through homecare companies.

Stimulant Laxatives

When dietary changes fail to work, laxatives may be used to increase the colon’s motility. Laxatives are used to relieve symptoms by helping the colon to empty.

High-dose stimulant laxatives and bulking agents such as pectin or water-soluble fiber are given once the patient has been disimpacted (the removal of stool from the colon). The disimpaction process is a very important step prior to laxative use. The process involves either the administration of enemas or using an oral bowel prep. This is done with the patient drinking the prep or via a nasogastric tube. If these options are unsuccessful, then manual disimpaction under anesthesia should be considered. 

Laxative use should be monitored and managed closely by your child’s physician. Every child’s individual case will call for certain dosages and unique treatment protocols. 

Patients with true (anatomic) fecal incontinence who are experiencing constipation should be treated with enemas (not laxatives). Caregivers are taught to empty and clean the colon once a day with a retrograde (bottom up) or anterograde (top down) enema, so the child stays completely clean for 24 hours until the next enema. An X-ray performed shortly after the enema can confirm if the colon has been emptied. If the colon has not emptied, then the patient will need a larger volume or a more concentrated enema.

Once administered, patients should hold the enema for 10 minutes, and then sit on the toilet for 30-45 minutes. The ideal enema is one that allows the child to effectively empty their colon and who then has no accidents between enemas. 

A large volume enema therapy includes a saline solution (0.9% saline can be made by adding two teaspoons of salt to 1000 mL of water) and often requires the addition of stimulants. Most enema cocktails start with 400 or 500 mL of saline. In children older than age five, plain water is also fine, but is slightly less effective in emptying of stool. If normal saline alone is ineffective, glycerin (10-30mL) or other unscented soap (Castile or a baby soap or shampoo) (10-30mL) is added. 

Rectal Enemas

• Begin daily enema, full volume flush, daily
• Example: 400 cc saline plus 20 cc glycerin

Appendicostomy (Native Appendix) (Malone Procedure)

• Begin Antegrade Enema post-operative day 1:
  
  • Post-operative day 1: Full Volume flush, daily
• Follow up: Indwelling tube stays in place 4-6 weeks

Neo-appendicostomy

• Begin Antegrade Enema when starting solid food
  
  • Day 1 (of solid foods): ½ volume (pre-op enema solution) x 1
  • Day 2 (of solid foods): ½ volume (pre-op enema solution) twice a day 
• Discharge enema:  ½ volume (pre-op enema solution) twice a day x 4 weeks
• Follow up: Indwelling tube stays in place for 4-6 weeks 

Children with severe constipation or fecal incontinence will be seen on an outpatient basis for an intensive week of bowel management therapy that is tailored to their individual needs. 

Treatment at a bowel management clinic includes:

• Abdominal X-rays to determine the diameter and length of colon as well as how much stool is impacted in the colon. A treatment plan is designed based on a patient’s history and imaging results.
• Administering medications (such as laxatives): 
  
  • [Medical program] or water-soluble enemas 
  • [Mechanical program] when needed to soften stool and empty the colon 
• Implementing dietary changes and customized nutrition plans that are high in fiber.
• Education for families and caregivers on why children experience soiling.
• Establishing a bathroom schedule and routine to help train children to recognize their body cues to avoid soiling and accidents.
• Access to other specialists including a nutritionist, social worker, psychologist and child life therapist.

Once a child has their constipation under control their condition is usually managed with either high-dose stimulant laxatives or a daily large volume enema. Patients with a foreshortened colon and a tendency towards diarrhea are treated with small volume enemas, a constipating diet and bulking agents.

After a bowel management program has been completed, children should be followed closely over the next few months. These first few months are crucial in preventing a relapse. When a child has been successful on enemas for three to six months, the enemas can be switched to laxatives, but only if the child has the potential for bowel control. Children who are unsuccessful with laxatives can try them again in about six to 12 months while continuing an enema treatment. 

Another option is to undergo an antegrade continence enema (ACE) procedure or Malone procedure, a surgical option that provides a route to flush the colon from top to down mechanically.