Management of Fecal Impaction in a 2-Year-Old After Failed Fleet Enema
After a failed Fleet enema in a 2-year-old with rectal fecal impaction, proceed with manual disimpaction (digital fragmentation and extraction) followed by oral polyethylene glycol (PEG) for complete evacuation and prevention of recurrence. 1
Immediate Management: Disimpaction
Manual Disimpaction
- Digital fragmentation and extraction of the impacted stool is the primary intervention for distal rectal impaction when enemas have failed. 1
- This approach is recommended by ESMO guidelines for managing fecal impaction in the absence of suspected perforation or bleeding 1
- The procedure involves manually breaking up and removing the hard stool mass from the rectum 1
Post-Disimpaction Treatment
- After initial manual disimpaction, administer oral polyethylene glycol (PEG) to complete the evacuation process. 1, 2
- PEG works as an osmotic laxative and is FDA-approved for relieving constipation, generally producing bowel movements within 1-3 days 2
- For fecal impaction specifically, high-dose PEG should be used for the first few days to ensure complete clearance 3
- PEG is effective and well-tolerated in children over 6 months of age 4, 3
Alternative Disimpaction Approaches
If Manual Disimpaction is Not Feasible
- Consider repeated phosphate enemas as an alternative to manual disimpaction, though use extreme caution in young children. 3
- However, Fleet (sodium phosphate) enemas carry significant risks in pediatric patients, including severe metabolic derangements, hyperphosphatemia, hypocalcemia, and even death, particularly in children with gastrointestinal or renal abnormalities 5
- Glycerin suppositories combined with mineral oil retention enemas may be safer alternatives for rectal intervention 6
Proximal Impaction Considerations
- If the impaction is proximal (sigmoid colon) rather than distal (rectum), digital rectal exam will be non-diagnostic 1
- For proximal impaction without complete bowel obstruction, PEG lavage solutions containing electrolytes can help soften or wash out stool 1
Critical Safety Considerations
Before Any Intervention
- Rule out bowel obstruction or perforation before proceeding with disimpaction or additional laxatives. 1, 6
- Assess for signs of obstruction including severe abdominal distension, bilious vomiting, or peritoneal signs 1
- Check for complications of fecal impaction such as urinary retention, rectal bleeding, or stercoral ulceration 1
Age-Specific Cautions
- At 2 years old, this child is particularly vulnerable to complications from aggressive interventions 5
- Ensure adequate hydration status before and during treatment 4
- Monitor for electrolyte disturbances, especially if multiple enemas were attempted 5
Maintenance Therapy to Prevent Recurrence
Long-Term Management
- After successful disimpaction, implement a maintenance bowel regimen immediately, as relapse is common and may require months to years of treatment. 1, 4
- Continue PEG at maintenance doses (lower than disimpaction doses) 4, 3
- Alternative maintenance options include mineral oil, lactulose, milk of magnesia, or sorbitol 4
Behavioral and Dietary Interventions
- Ensure proper toileting habits with adequate privacy and appropriate toilet positioning for the child's age 6
- Increase dietary fiber and fluid intake once acute impaction is resolved 6, 4
- Encourage regular physical activity appropriate for age 6
- Education of family regarding normal bowel function and prevention strategies is essential 4, 7
Common Pitfalls to Avoid
- Do not discharge the child after enema alone without ensuring complete disimpaction and prescribing maintenance laxatives - studies show 28% of children were discharged without constipation medication after ED enemas, contributing to poor outcomes 8
- Do not rely on dietary changes or increased fluids alone for established fecal impaction - these are not treatments for existing impaction, only prevention strategies 3
- Do not use bulk laxatives like psyllium - they are ineffective for constipation management in this context 1
- Avoid repeated Fleet enemas due to toxicity risks in young children 5