Encopresis (cont.)

Medications

Enemas: Most enema preparations contain large amounts of water in addition to something that is not efficiently absorbed by the intestinal lining. This prevents the water in the enema from being absorbed, so the water remains in the colon. The enema is inserted into the rectum. This softens the stool in the rectum and creates pressure within the rectum. This pressure gives the child a powerful urge to pass a bowel movement, and the stool is usually expelled rapidly. Common examples include phosphate or saline (salt) solutions or milk and molasses. The effectiveness of any particular enema preparation is probably more dependent on the volume (size) of the enema than on its chemical make-up. The phosphate-sodium enema (Fleet Enema) is probably the most widely used type.

Note: Some gastrointestinal specialists discourage the use of enemas and suppositories or any anal intervention because the child associates fear and pain with the anal area. The child may struggle or feel additional trauma when these types of manipulations are performed. Eventually, all impacted stool can be dissolved or disimpacted by using medications taken by mouth.

Osmotic laxatives: These laxatives contain agents that are not efficiently absorbed by the intestinal lining. This results in large amounts of extra water in the intestine, which softens the stool. Since all osmotic laxatives work by increasing the amount of water in the colon, it is important that your child drinks lots of fluid while taking any of these laxatives. Like any medication, these should be given only as recommended by your child’s health care provider. If the laxative does not seem to be working, do not increase the dose without talking to your child’s health care provider. Rarely, these products interfere with other medications that your child takes.

• Magnesium hydroxide (FreeLax, Philip's Milk of Magnesia, Haley's MO) - Besides causing retention of fluid in the intestine, this laxative promotes the release of a hormone that stimulates movement of stool through the intestine. Some children experience abdominal cramping. This laxative is flavorless but has a thick chalky texture that may be more acceptable when mixed with a fluid such as milk or chocolate milk. It should be avoided by children with kidney problems.
  
  
• Lactulose (Chronulac, Constilac, Duphalac, Kristalose, Lactulose) - This laxative is generally very well tolerated and tastes sweet. It may cause gas and abdominal cramping at usual doses.
  
  
• Polyethylene glycol powder (Miralax) -  This may pose less risk of dehydration or electrolyte imbalance than other osmotic laxatives. The powder is mixed in 8 ounces of water, juice, soda, coffee, or tea.  The usual dose is 17 g (fill to measuring line in cap of bottle) of powder per day.  This laxative is tasteless, odorless, and usually quite easy to take.  It may take slightly longer to work than other products.
  
  
• Sorbitol -  This is generally well tolerated and tastes quite sweet.  It often causes gas and abdominal cramping.
  
  
• Magnesium citrate (Evac-Q-mag) - This works by the same mechanism as magnesium hydroxide. The product is clear (not chalky like magnesium hydroxide) and may be chilled to improve palatability.
  
  
• Polyethylene glycol balanced electrolyte solutions (COLYTE, GoLYTELY) - These balanced electrolyte solutions are often used as purgatives in preparation for colonoscopy or abdominal surgery. They require drinking a large volume of fluid, which may be more acceptable if chilled. This laxative may be associated with nausea, bloating, abdominal cramps, and vomiting.

Emollient laxatives: These products decrease the absorption of water from the colon, and thus soften the stool, making it easier to pass.

• Mineral oil (Mineral Oil, Milkinol) - This laxative is largely tasteless and has an oily consistency. It may be more palatable if cold or mixed into a fluid such as orange juice. It may cause seepage of orange oil from anus, which can cause itching and stain the underwear. This laxative should generally not be given with food.

Stimulant laxatives: These agents have direct actions on the lining of the intestinal wall. They increase water and salt secretion into the colon and irritate the intestinal lining to produce contractions.

• Sennosides (Aloe Vera, Ex-Lax, Fletcher’s Castoria, Senokot) - This laxative is derived from a plant, stimulates salt and water secretion into the colon, and promotes movement of stool through the colon. It may cause abdominal cramping at higher doses.
  
  
• Bisacodyl (Dulcolax) - This colorless and odorless compound increases colonic peristalsis and stimulates salt and water secretion. It can be given by mouth or as a suppository and may cause abdominal cramping at higher doses.
  
  
• Dioctyl sodium sulphosuccinate (Colace) - This is a detergent that simulates salt and water secretion into the colon and promotes movement of stool through the colon. It may cause abdominal cramping at higher doses.