| A. Small fecal impaction (oral medications) | B. Large fecal impaction (oral and rectal medication) |
Day 1 | - Educate family and caregiver about fecal impaction and overflow incontinence and the need for long-term laxative therapy
- Start PEG (eg, Miralax, Glycolax, Pegalax), 1 g/kg once daily, given in the morning¶
| - Educate family as in column A
- Start PEG 1 to 1.5 g/kg daily, divided into 2 doses¶
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Day 2 to 3 | | |
Day 4 to 6 | - If child is beginning to pass 1 to 2 soft to loose stools daily, continue above dose of PEG
- If child is not passing soft to loose stools, increase dose of PEG to 1.5 g/kg, divided into two doses; soiling should gradually decrease and stop
- Establish regular toileting patterns by having the child sit on the toilet for 5 to 10 minutes, 2 to 3 times daily after meals
| - If child has not passed a large amount of stool, give sodium phosphate enemaΔ (eg, Fleet enema), 33 to 66 mL, depending on the size of the child
- Continue twice-daily dosing of PEG for up to 6 days total, until the child has passed a large amount of stool
- Once the child is having soft stools at least once daily, reduce PEG to 1 g/kg, given once daily in the morning
- Establish regular toileting patterns (as described in column A)
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Day 7 to 30 | - Be sure parent calls if not making progress, so further adjustments in PEG dose can be made
- Occasionally, it is necessary to increase PEG to twice-daily dosing
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1 month | - Return office visit to evaluate progress and to reinforce need for regular laxative therapy
- Provide handout or references for fiber-rich diet and have family work to increase fiber content of diet for long-term maintenance
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1 to 6 months | - Return office visit every 1 to 2 months to reinforce therapy and adjust dose of laxative if necessary
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6 to 12 months (or longer) | - Once the child is maintaining normal bowel movements without soiling for several months, consider gradually tapering laxative over 2 months
- Be sure patient is on a fiber-rich diet
- Some children require ongoing laxative treatment for 1 or more years
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Beyond 12 months | - Follow as long as it takes for resolution; it can be months to several years before encopresis resolves completely
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