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)! |
