Example of treatment plan for a 4-year-old child with fecal incontinence

	A. Small fecal impaction (oral medications)	B. Large fecal impaction (oral and rectal medication)
Day 1	Educate family and caregiver about fecal impaction and overflow incontinence and the need for long-term laxative therapy Start PEG (eg, Miralax, Glycolax, Pegalax), 1 g/kg once daily, given in the morning^¶	Educate family as in column A Start PEG 1 to 1.5 g/kg daily, divided into 2 doses^¶
Day 2 to 3	Continue PEG once daily	Continue PEG twice daily
Day 4 to 6	If child is beginning to pass 1 to 2 soft to loose stools daily, continue above dose of PEG If child is not passing soft to loose stools, increase dose of PEG to 1.5 g/kg, divided into two doses; soiling should gradually decrease and stop Establish regular toileting patterns by having the child sit on the toilet for 5 to 10 minutes, 2 to 3 times daily after meals	If child has not passed a large amount of stool, give sodium phosphate enema^Δ (eg, Fleet enema), 33 to 66 mL, depending on the size of the child Continue twice-daily dosing of PEG for up to 6 days total, until the child has passed a large amount of stool Once the child is having soft stools at least once daily, reduce PEG to 1 g/kg, given once daily in the morning Establish regular toileting patterns (as described in column A)
Day 7 to 30	Be sure parent calls if not making progress, so further adjustments in PEG dose can be made Occasionally, it is necessary to increase PEG to twice-daily dosing
1 month	Return office visit to evaluate progress and to reinforce need for regular laxative therapy Provide handout or references for fiber-rich diet and have family work to increase fiber content of diet for long-term maintenance
1 to 6 months	Return office visit every 1 to 2 months to reinforce therapy and adjust dose of laxative if necessary
6 to 12 months (or longer)	Once the child is maintaining normal bowel movements without soiling for several months, consider gradually tapering laxative over 2 months Be sure patient is on a fiber-rich diet Some children require ongoing laxative treatment for 1 or more years
Beyond 12 months	Follow as long as it takes for resolution; it can be months to several years before encopresis resolves completely

This treatment plan describes the author's approach to treating a typical 4-year old child* with constipation and fecal incontinence. Alternative regimens and considerations are described in the topic text. Trade names shown are for over-the-counter products available in the United States and some other countries.

PEG: polyethylene glycol-3350, also known as PEG without electrolytes and macrogol (eg, Miralax, Pegalax).
* Body weight 15 to 20 kg.
¶ 1 packet or capful PEG = 17 g = 3.5 teaspoons.
Δ Sodium phosphate enemas or other phosphate-containing laxatives are rarely associated with severe electrolyte abnormalities and acute phosphate nephropathy. Avoid using these agents more than once daily or in children who are dehydrated, aged <2 years, or have chronic kidney disease.

Courtesy of Manu Sood, MD, with additional data from Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014; 58:258.

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