Rectal Enema for Impacted Stool in a 5-Year-Old
Rectal enemas are an effective and safe first-line treatment for fecal impaction in a 5-year-old child, with phosphate or saline enemas administered once daily for up to 6 days showing an 80% success rate. 1
Initial Disimpaction Strategy
For a 5-year-old with fecal impaction, use either phosphate enemas or saline enemas once daily for up to 6 days as first-line therapy. 1 Both solutions are equally effective with approximately 80% success rates, though enemas may be less acceptable to patients than oral polyethylene glycol (PEG). 1
Enema Solution Options
- Sodium phosphate enemas are effective and widely used in pediatric emergency departments for acute fecal impaction 2, 3
- Saline enemas (10 mL/kg for infants and young children) provide equivalent efficacy to phosphate enemas 4, 1
- Soap suds enemas demonstrate 82% efficacy in producing bowel movements in children with fecal impaction, though they carry a higher rate of abdominal pain (10.6% vs. 4-5% with other solutions) 2, 3
- Glycerine suppositories can be used for less severe impaction 1
- Mineral oil retention enemas may serve as an adjunct therapy 1
Important Safety Considerations
Pre-medicate the child with analgesics and anxiolytics before the enema procedure to minimize distress. 1 The procedure should be performed with the child in a comfortable position with proper buttock support, foot support, and comfortable hip abduction to facilitate relaxed defecation. 1
Avoid sodium phosphate preparations in children with kidney disease, dehydration risk, electrolyte imbalances, or significant comorbidities (liver disease, hypertension, diabetes, heart disease). 4 The Israeli Society of Pediatric Gastroenterology specifically recommends against NaP use in children younger than 12 years with these conditions. 4
When Enemas Fail
If oral and rectal treatments fail after 6 days, manual disimpaction under sedation or anesthesia is indicated. 1 This represents the next step in the treatment algorithm rather than continuing ineffective enema therapy. 1
Critical Post-Disimpaction Management
After successful disimpaction with enemas, immediately begin maintenance PEG therapy for many months (not weeks) to restore normal bowel motility and rectal sensation. 1 This is the most common pitfall where parents discontinue treatment prematurely, leading to recurrence. 1
- Add bisacodyl 10-15 mg daily to three times daily with a goal of one non-forced bowel movement every 1-2 days 1
- Implement scheduled toilet sits 15-30 minutes after meals to leverage the gastrocolic reflex 1
- Continue maintenance therapy for months until normal bowel function is restored 1, 5
Evidence Quality and Clinical Context
The recommendation for enemas is supported by high-quality pediatric emergency department data showing 82% efficacy with minimal adverse events (5% abdominal pain, 4% nausea/vomiting, no serious adverse events). 2 A comparative study of 768 pediatric patients found no significant difference in stool output between sodium phosphate, soap suds, and pink lady enemas, though soap suds had higher rates of abdominal pain. 3
Do not rely on education and behavioral therapy alone if constipation is present—comprehensive approaches that include aggressive constipation management with enemas and maintenance laxatives are superior. 1 Approximately 50% of children will be cured after 1 year and 65-70% after 2 years of comprehensive management. 5
Common Pitfalls to Avoid
- Do not discontinue laxative therapy prematurely before normal bowel motility is restored—this is the single most common cause of treatment failure 1
- Do not use anticholinergic medications as they worsen constipation 1
- Do not perform colectomy for fecal impaction in children, as outcomes are poor; if surgery is ever considered, a reversible defunctioning loop ileostomy is preferable 1
- Rectal examination is now performed less often as it can be distressing and may be deceptive if the child had a recent bowel movement 1