Fecal Impaction

Dear Lisa,

My daughter has recently gotten fecal impaction. We went 3 days with no bowel movement with the last one being one little ball. We tried karo syrup, glycerin suppository, magnesium citrate, and milk of mag with no results. We ended up in the ER with x-rays finding stool in the colon. They gave her an enema at the ER and got good results. She continued to c/o stomach pain throughout the next week and I called and took her to the Dr. numerous times that week. They kept insisting me to continue with the Miralax which she has been on for 1 year. I kept telling them it was doing nothing for her.

One week later with no BM I took her back with severe cramping and did a ct scan finding stool in the ascending and descending colon. They told me to do the Dulcolax. So we did the Dulcolax suppositories and on sun got one result. Mon morning she was able to go on her own and the Dr. also told me to give her another suppository. So I did and got another result on Mon. On Tues she went one time on her own and Dr. said, don't give another laxative. Wed. did not have one at all and Thurs did not have one. Fri had one with the pill form of Dulcolax and Sat(2-17-07)gave Dulcolax again with some results but not as good as they have been.

I went for a second opinion and this Dr. said to cut out the Dulcolax due to side effects are really bothersome to my daughter and said to try Senokot, mineral oil and to continue with my Miralax. So my concern is my daughter is constantly c/o leg aches, bad headaches, and just so fatigued. Is this a sign that the waste left in her is making her colon toxic? The DR. said she still has more in her can tell from pressing on stomach. How long can it stay in there before it starts making things toxic? Will she at some point just start having multiple BM's to get cleaned out all the way? B/c right now she is only having one a day or like now she has skipped 2 days. Should I let her skip or do I need to go back and do the suppository to get immediate results so that she is not getting further backed up? And what I don't understand either is that she stays hungry constantly and although she is having BM she is far from cleaned out with the look of her stomach. IT is so hard and so bulging. How can she possibly still want to continue to eat so much? Do you suggest taken her to a pediatric gastroenterologist also?

Thanks for any advice.

“Fecal Impaction”

Dear “Fecal Impaction”,

A fecal impaction occurs when a constipated child is not able to have a bowel movement. When a child develops constipation she experiences hard painful stools which are difficult to pass. This painful experience causes a child to hold back the stool because they fear it will hurt to have a bowel movement. As a result, a child becomes more constipated and the stool becomes larger and more difficult to pass.

The recommended treatment for fecal impaction is an enema, which is the treatment that your daughter received in the Emergency Room. (1) Once the initial problem is alleviated, and a bowel movement is produced it is imported to figure out the original cause of the constipation and fecal impaction. It is important to determine the cause so that the condition can be treated and the incidence of fecal impaction does not occur again.

Constipation in childhood is usually caused by the child’s diet. Excessive milk ingestion, insufficient amount of fluids and inadequate intake of bulk-forming foods are common causes of constipation in children. (1) Other potential causes include poor bowel habits, laxative misuse or underlying medical conditions. (1)

Medical conditions that may cause constipation include; Hypothyroidism, Celiac Disease, Hirschsprung Disease, muscle disorders, endocrine disorders such as Hypothyroidism or Diabetes mellitus, and medication side effects. (2) Medications that are commonly associated with constipation include; analgesics, anticholinergics, calcium channel blockers and stomach preparations containing Aluminum.

In some cases a child can develop constipation due to an anatomical defect such as rectal stenosis. Rectal stenosis is a condition that occurs when a child’s rectal openining is too tight or too small. Because the opening is so small it is very difficult to pass stools and as a result the child becomes constipated. Rectal stenosis can be confirmed by digital examination by a health care professional. (1)

Pelvic Floor Dyssynergia is another potential cause of constipation in children. This occurs when a child fails to learn to properly coordinate the muscle contractions necessary to pass a stool. When a child experiences Pelvic Floor Dyssynergia, the anal sphincter does not contract properly or in some cases, involuntary spasms occur during a bowel movement. This abnormal contraction prevents the stool from being expelled from the body. Signs of Pelvic Floor Dyssynergia include hard stools, fecal impaction, feelings of anal blockage, severe straining, and the need for digital maneuvers. (3)

Regardless of the cause of the constipation, the first step in treating the condition includes taking measures to promote adequate bowel movements. There needs to be an initial “clean out" period where the fecal material is removed from the colon. (4) This clean out period includes dietary alterations, behavior modification and the administration of laxatives under the supervision of a health care professional. Behavior modifications include having a child sit on the toilet for 10 minutes three times per day.

During this cleaning out process, a child should have a bowel movement on a daily basis until the stool is soft and no longer difficult to pass. If the stools become hard, difficult to pass or cause a lot of straining your doctor should be notified so that an adjustment can be made to the regimen. Since your daughter has an extensive history of constipation that has led to fecal impaction it would be important to not let her go too many days without having a bowel movement. Preferably, she should have a soft bowel movement on a daily basis until her system is cleaned out.

The purpose of laxatives is to soften the stool which allows it to pass more freely. Laxatives are not considered the cure for constipation, but a necessary measure to ensure the proper elimination of stool until the cause of the constipation is determined. It is important to address the underlying cause of your daughter’s symptoms, otherwise the symptoms will most likely return after the laxative is discontinued.

Miralax is one of the laxatives that is commonly used in the pediatric population. From my experience with children treated with Miralax, it works very well at loosening the stool. Typically within a couple of days of administering Miralax the stools should develop a softer consistency. Studies have shown that there is a statistically significant increase in bowel movement frequency observed when patients take Miralax as compared to a placebo. One study demonstrated that on average, patients receiving placebo had 2.7 bowel movements per week, while patients receiving Miralax had 4.5 bowl movements per week. (5)

You mentioned that your daughter was on Miralax for a year and that it was doing nothing for her. I’m not sure if you mean that it never loosened her stools or if the “need” for the Miralax persisted. The purpose of a laxatives is to loosen the stool so they will pass, not cure the cause of the constipation. If the underlying reason for the constipation was never addressed, it would be expected that your daughter’s constipation would return after discontinuing the Miralax. In general, if a child needs a laxative for a over three months, a work up is indicated in order to determine the cause of the constipation.

If your daughter is experiencing abdominal discomfort and pain with her bowel movements, it may helpful to have her to sit in a bath tub filled with warm water. The water should cover her abdomen and she should be allowed to play in the tub while she is monitored by an adult. This can serve as a “natural” enema because during her play in the tub she will relax and water will enter her rectum. This is a non-threatening and non-invasive way of getting water into her rectum, which will soften the stool and help it pass more readily. This approach is much more desirable than giving frequent enemas. Frequent enemas may be psychologically unsuitable and can cause electrolyte imbalances. (4)

Since your daughter has a long standing problem an evaluation by a Pediatric Gastroenterologist is a very reasonable next step. A Pediatric Gastroenterologist can perform a history and Physical examination on your child and order diagnostic testing in order to determine the cause of your daughter’s constipation. A Gastroenterologist can also recommend a treatment plan that addresses her present problem passing stools.

Pertaining to your question about your daughter’s food intake; all children requires a certain amount of calories per day based on their weight. A child needs to ingest the recommended amount of calories in a twenty-four hour period in order to achieve proper growth and development. The same amount of calories is needed whether or not a child has a bowel movement on that particular day. The fact that your daughter is hungry and wants to eat is normal.

It is true that constipation causes some children to experience a decrease in appetite. The abdominal distention and increased intra-abdominal pressure that results from being constipated can exacerbate Gastroesophageal reflux symptoms such as heartburn and regurgitation. These GER symptoms can cause a child to lose their appetite and suffer from insufficient weight grain. Other GER symptoms include vomiting, heartburn, difficulty swallowing, chronic cough, recurrent pneumonia, sore throat, hoarseness, wheezing, bad breath, sinusitis, dental erosions, feeding problems, poor weight gain and weight loss. (6,7,8) In particular children over 2 years old with GERD most often have symptoms related to heartburn as well as abdominal pain, vomiting and cough. (8,9)

The intestines are divided into two sections; the small intestine and the large intestine. The small intestine connects to the stomach and on average measures 21 feet long. It is in the small intestine that most of the absorption of water and nutrients takes place. The large intestine is connected to the small intestine and on average measures 5 feet long. The large intestine is also responsible for the absorption of water and nutrients. Additional purposes of the large intestine include the manufacturing of certain vitamins and the formation of stool. (10) It is the role of the intestines to form and hold stool, therefore presence of stool in the intestines is normal.

The reason why health care professionals are concerned about constipation is not because of toxicity, but because it is a problem that can worsen if not addressed. The longer the stool remains in the intestines, the more water and nutrients are absorbed from the stool into the body. When a lot of water is absorbed from the stool in the large intestines, the stool becomes hard and difficult to pass. This can just worsen the situation. Therefore the goal is to have a constipated child experience a soft bowel movement on a regular basis.

I would not worry that your child will become “toxic” if she doesn’t have a bowel movement. It is more important that the consistency of her stool is soft so she does not experience pain during a bowel movement or hold the stool in. Non-specific symptoms such as leg aches, headaches and fatigue, are common to many conditions and are not necessarily related to constipation. Even thought these specific symptoms may not be caused by constipation, chronic constipation can have a very significant impact on a patient’s overall health. A short term questionnaire given to patients demonstrated that physical functioning, vitality, social functioning, mental health, perception of health and pain scores were worse for patients that suffered from constipation. (11)

I hope your daughter finds relief from her symptoms soon.

If you are interested in reading other Pediatric Advice Stories covering this topic:


Constipation

Constipation Treatment

Stool Withholding

Celiac Disease

Gastroesophageal Reflux

Gastroesophageal Reflux in Infancy

Nutritional Requirements

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994: 1490-1492.
(2)Borum ML. Constipation: evaluation and management. Prim Care. 2001.28:577-590.
(3) Lembo A. Camilleri M, Chronic Constipation. N England J Med. 2003:349:1360-1368.
(4)Chronic Constipation in Children. Consultant for Peditricians. 2003. Apr:152-155.
(5)Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P, Talley NJ. Systemic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005. 100(Suppl 1)S5-S21.
(6) Waring JP, Feiler MJ, Junter JG. Childhood Gastroesophageal reflux symptoms in adult patients. J Pediatr Gastroenterl Nutr. 2002; 35:334-348.
(7) Christensen M, Gold B. Clinical Management of Infants and Children with Gastroesophageal Reflux Disease: Disease Recognition and Therapeutic Options. Presented at: The Exhibitor’s Theatre Session at the 2002 ASHP Midyear Clinical Meeting, the Georgia World Congress Center; Dec 9, 2002:Atlanta.
(8)Hassall E. Decisions in diagnosing and managing chronic Gastroesophageal reflux disease in children. J Pediatr. 2005;146:S3-S12.
(9)Suwandhi E, Ton M, Schwarz M. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006;35(4):259-266.
(10)Tortora G, Anagnostakos N. Principles of Anatomy and Physiology. 4th ed. Sao Paulo, Sidney:Biological Sciences Textbooks, Inc. 1984:610-622.
(11)Irvine EJ, Ferrazzi S, Pare P, Thompson WG, Rance L. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am Journal Gastroenterology. 2002. 97:1986-1993.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Health Advice