How do you Treat Encopresis in a 6-Year Old

Question 1

A 6-year-old is being teased at school because he has stool in his underwear daily. He was toilet trained at 2 without difficulty. Over the last two years, he had developed chronic constipation. The fecal soiling developed over the last three months. He complains that he does not know when he needs to defecate. He is otherwise normal; school is going well, and his home life is stable. His examination is significant for stool in the rectal vault. Initial management of this problem should include which of the following?

Barium enema and rectal biopsy

Family counseling

Time-out when he stools in his underwear

Clear fecal impaction and short-term stool softener use

Daily enemas for four weeks

The answer is d, Clear fecal impaction and short-term stool softener use.[1-3]

Encopresis is defined as the passage of feces in inappropriate locations after bowel control would be expected (usually older than 4 years). Encopresis is seen both with chronic constipation and overflow incontinence (retentive encopresis), and without constipation (nonretentive encopresis). Retentive encopresis is more common, and is the source of this child’s problem. There is leakage of liquid stool around a large fecal impaction, resulting in fecal soiling. Treatment involved clearing the fecal mass, maintaining soft stools for a short period of time with mineral oil or stool softeners (3 to 6 months), and behavioral modification. Most children will grow out of this condition. Time-out would be ineffective, because these children usually have dysfunctional anal sphincters and little control over the problem. Daily enemas could potentially be harmful. A rectal biopsy would help diagnose Hirschsprung disease, but the story here is not consistent with that diagnosis.

Question 2

A mother calls you on the telephone and says that her 4-year-old son bit the hand of her 2-year-old son 2 days previously. The area around the injury has become red, indurated, and swollen, and he has a temperature of 39.4°C (103°F). Which of the following is the most appropriate response?

Arrange for a plastic surgery consultation at the next available appointment

Admit the child to the hospital immediately for surgical debridement and antibiotic treatment

Prescribe penicillin over the telephone and have the mother apply warm soaks for 15 min four times a day

Suggest purchase of bacitracin ointment to apply to the lesion three times a day

See the patient in the emergency room to suture the laceration

The answer is b, Admit the child to the hospital immediately for surgical debridement and antibiotic treatment[4,5]

Human bites can pose a significant problem. They can become infected with oropharyngeal bacteria, including Staphylococcus aureus, viridans streptococci, Bacteroides spp., and anaerobes. A patient with an infected human bite of the hand requires hospitalization for appropriate drainage procedures, Gram stain and culture of the exudate, vigorous cleaning, debridement, and appropriate antibiotics. The wound should be left open and allowed to heal by secondary intention (healing by granulation tissue rather than closure with sutures).

Question 3

A 2-year-old child presents to the office with a paternal complaint of “bowlegs.” The girl has always had bowlegs, and her previous pediatrician told the family she would grow out of it. Now, however, it seems to be worsening. Her weight is >95% for age, and she has significant bowing out of her legs and internal tibial torsion; otherwise, her examination is normal. Which of the following is the most likely diagnosis?

Osgood-Schlatter disease

Physiologic genu varum

Slipped capital femoral epiphysis

Legg-Calvé-Perthes disease

Blount disease

The answer is e, Blount disease[6-8]

Genu varum (bowlegs) is a common finding in infants and toddlers under the age of 2. Improvement occurs spontaneously with time, and most children have straight legs by the time they are 2. A few children with bowlegs, however, continue to progress and worsen, and in some cases the bowing is unilateral. This is termed Blount disease and is characterized by an abnormality in the medial aspect of the proximal tibial epiphysis. Radiographically there is a prominent step abnormality with beaking at the proximal tibial epiphysis. Aggressive treatment is essential, as the disease can be rapidly progressive and lead to permanent growth disturbances. Bracing can be effective up to the age of 3; later correction may require surgery. Blount disease can occur in several forms: infantile (ages 1 to 3), juvenile (ages 4 to 10) and adolescent (age 11 and up). Clinically, the findings are the same; in the adolescent group, radiograph findings are less prominent. Legg-Calvé-Perthes disease is avascular necrosis of the femoral head, caused by an interruption of the blood supply by a currently unknown cause. Onset is usually between 2 and 12 years of age and classically presents with a painless limp, although mild pain of the thigh is common. Repeated microfracture of the tibial tubercle at the insertion of the patellar tendon is called Osgood-Schlatter disease. This is an overuse injury, and presents with swelling and knee pain localized to the tubercle. Improvement occurs with rest. Slipped capital femoral epiphysis (SCFE) typically occurs in overweight adolescents, and presents with a limp. Radiographically, the capital femoral epiphysis is separated from the neck of the femur and remains in the acetabulum as the rest of the femur moves anteriorly.

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