What is the initial treatment for fecal impaction in a child?

Initial Treatment for Fecal Impaction in Children

For children with fecal impaction, the initial treatment should be manual disimpaction followed by rectal therapies (glycerin suppository or enema) to clear the rectum, then oral polyethylene glycol (PEG) to complete the disimpaction process.

Diagnosis and Assessment

Before initiating treatment, confirm fecal impaction through:

• Digital rectal examination (DRE) to identify a large mass of dry, hard stool in the rectum
• Assessment for overflow diarrhea (watery stool leaking around impaction)
• Evaluation for abdominal distension and discomfort

Treatment Algorithm

Step 1: Manual Disimpaction (if rectum is full)

• For distal fecal impaction confirmed by DRE
• Pre-medicate with analgesic and/or anxiolytic as needed
• Perform gentle digital fragmentation of the stool mass

Step 2: Rectal Therapies

• First-line rectal therapy options:
  • Glycerin suppository (lubricates and softens stool)
    • Children 6-12 years: ½ suppository
    • Children >12 years: 1 suppository
  • Mineral oil retention enema (helps lubricate and soften stool)
  • Hypertonic sodium phosphate enema (distends and stimulates rectal motility)
    • Use with caution in young children

Step 3: Oral Disimpaction

• Polyethylene glycol (PEG) at 1-1.5 g/kg/day for 3-6 days 1
  • PEG has been shown to be as effective as enemas for treating rectal fecal impaction
  • May cause more fecal incontinence during treatment than enemas

Step 4: Maintenance Therapy

• Continue osmotic laxatives (PEG, lactulose) or stimulant laxatives (senna, bisacodyl)
• Goal: 1 non-forced bowel movement every 1-2 days 2
• Increase fluid intake and dietary fiber if appropriate

Special Considerations

Age-Specific Recommendations

• Children under 6 years: Avoid bisacodyl suppositories 3
• Children 6-12 years: Use half-dose of bisacodyl suppository 3
• Children >12 years: Adult dosing appropriate for most medications

Cautions

• Enemas are contraindicated in patients with:
  • Neutropenia or thrombocytopenia
  • Paralytic ileus or intestinal obstruction
  • Recent colorectal or gynecological surgery
  • Recent anal or rectal trauma
  • Severe colitis or infection 2

Prevention of Recurrence

After successful disimpaction:

• Implement a bowel regimen with regular toileting schedule
• Consider maintenance therapy with osmotic laxatives
• Increase dietary fiber and fluid intake
• Regular follow-up to monitor progress
• Education for parents and child about recognizing withholding behaviors 4

When to Refer

Consider referral to a specialist if:

• Red flags suggesting organic disease (onset before one month of age, delayed meconium passage, failure to thrive, explosive stools)
• Constipation persists despite adequate therapy 4
• Recurrent impactions despite preventive measures

Fecal impaction in children is typically a complication of chronic constipation that requires prompt treatment to prevent complications such as bowel obstruction or stercoral ulceration 5. A systematic approach with disimpaction followed by maintenance therapy is essential for successful management.