From the Guidelines
Emergency management for a large fecalith in a 2-year-old requires prompt medical attention, with the primary goal of disimpaction, typically starting with oral polyethylene glycol (PEG 3350, such as MiraLAX) at a dose of 1-1.5 g/kg/day for 3-6 days, as recommended by the most recent guidelines 1. The management approach should prioritize the child's stability, with assessment of vital signs and hydration status. Key considerations include:
- Ensuring adequate pain management with acetaminophen (15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) 1
- Using enemas, such as saline enemas (5-10 mL/kg) or mineral oil enemas (2-4 mL/kg), if oral therapy is ineffective or the situation is severe 1
- Considering manual disimpaction under sedation in a hospital setting for very large or impacted fecaliths that don't respond to these measures 1
- Implementing maintenance therapy with stool softeners, increased fluid intake, dietary fiber, and regular toileting habits to prevent recurrence, as emphasized in the guidelines 2, 1 Prompt intervention is crucial to prevent complications, including bowel obstruction, perforation, or significant pain and distress for the child. The most recent and highest quality study, published in 2016 1, provides the basis for these recommendations, prioritizing the child's morbidity, mortality, and quality of life as the primary outcomes.
From the Research
Emergency Management for Large Fecalith in a 2-Year-Old
- The management of a large fecalith in a 2-year-old requires careful consideration of the potential complications, such as intestinal obstruction and rectal ischemia, as highlighted in a case report of a giant fecalith in an institutionalized paraplegic patient 3.
- Polyethylene glycol (PEG) with or without electrolytes has been shown to be effective in the treatment of functional constipation and fecal impaction in pediatric patients, with a high safety and tolerability profile 4, 5.
- A study evaluating the use of PEG in the treatment of severe constipation and fecal impaction in adults found that it was highly effective and well-tolerated, with an excellent response rate of 89.3% 6.
- In pediatric patients, the presence of a fecalith has been associated with earlier and higher rates of appendiceal perforation, highlighting the importance of expedient treatment 7.
- The choice between PEG with or without electrolytes should be based on the individual patient's needs, as both formulations have similar effectiveness and safety profiles, although PEG without electrolytes may produce more electrolyte abnormalities 5.