The best single, comprehensive, and manageable resource (47 pages) I know of for information on disorders of the
gastrointestinal tract is a Harvard Health Letter Special Report entitled The Sensitive Gut published in 1996 and last
revised in 2002. I paid $16 for my copy. You can order it from Harvard Health Publications, PO Box 421073, Palm
Coast, FL 32142-1073. They did not list a phone number. There is a website at www.health.harvard.edu/reports.
Another valuable source for information is the International Foundation of Functional Gastrointestinal Disorders at
www.iffgd.org. The IFFGD is a nonprofit education and research organization founded in 1991. IFFGD addresses
the issues surrounding life with gastrointestinal (GI) functional and motility disorders and increases the awareness
about these disorders among the general public, researchers, and the clinical care community. Their website refers
to information and fact sheets, which can be purchased for learning about a variety of problems and interventions
unique to the GI tract or certain portions or conditions thereof.

Diets (Fiber):

Dietary fiber tends to increase the bulk of the stool, softens it, and likely enhances motility reducing transit time.
The current recommendation for adults is 20-35 gm per day, far above that consumed by most Americans. The
requirements for children, ages 3-18, are less than for adults. The American Dietetic Association reports a formula
for determining recommended fiber intake--a child's age plus five equals the grams of dietary fiber he or she should
eat daily. Fiber supplements can be helpful. They are very gentle laxatives in their action in enhancing stool
evacuation some 12-72 hours down the line for the normal bowel. Standard oral laxatives such as Senokot are
irritants and speed up transit time into the 12-24 hour range. Insoluble fiber does not dissolve or gel in water and
is poorly fermented. Insoluble fiber adds bulk to the stool directly. Soluble fiber dissolves in water, becomes a soft
gel, and is readily fermented. This would include the pectin in fruit, which retain water adding to bulk and softening.
Colon bacteria action on soluble fiber creates gas and helps to increase fecal mass. Insoluble fiber would include
wheat bran, corn bran, whole grains, dried beans and peas, popcorn, seeds and nuts, most fruits and veggies,
especially carrots, white potatoes, artichokes, broccoli, leeks, and parsnips. Soluble fiber includes psyllium, oat
bran, whole oats, rice bran, dried beans, chick peas, black-eyed peas, lentils and virtually all fruits and vegetables,
but especially citrus, apples, pears, sweet potatoes, carrots, okra, cauliflower, and corn. Some high fiber substance
s may contain both soluble and insoluble fibers.

CAUTION: Parents and many physicians tend to over-exaggerate the importance of fiber. There is the very real
possibility that it may promote too much stool which the child is not able to evacuate completely with required sits.
This may be especially true for children who are resistant to sitting on the toilet stool and have retentive encopresis
with an enlarged colon. The Soiling Solutions protocol assures daily evacuations which makes diet a much less
significant factor. Daily voidings assure that older, more dried out stool is eliminated leaving fresher stool behind.
Drinking sufficient fluids may be even more relevant.

Stool Softeners :

These substances mix in with the feces and soften their consistency. One is mineral oil. Daily use of mineral oil is
generally discouraged because it reduces absorption of fat-soluble vitamins and can induce lung damage if
accidentally inhaled. Another problem is that it remains as a liquid and the child will tend to have more of a
problem with leakage and difficulty telling if he/she is about to pass gas or have an accident. An emulsified form
of mineral oil such as Kondremul is more easily tolerated and mixes in much better with the stool as a softener,
but the same cautions remain for vitamin deficiency or inhalation by an upset child. Docusate Sodium (Colace,
Dialose, Surfak, others) is generally safe for long-term use. I recommend the latter for kids in my "Clean Kid
Manual", the problem with it is that it has a horrible taste and if you get it in solid form some kids have trouble
swallowing it as they might for any pill. If the child cannot tolerate the taste of Docusate I would suggest using
Kondremul, one of the fiber diets above, or a dietary supplement like Metamucil. Docusate and Kondremul
together is not recommended. The substances above are all available "off the shelf". 

Aside: Always consult with a physician when utilizing even "off the shelf" dosed medications. Read and check about
cautions and possible adverse interactions with any medication.

Osmotic or Hypermolar Agents (e.g., MOM, Miralax):

These are salts or carbohydrates taken orally that promote secretion of bodily fluids across the gastrointestinal
membrane into the colon and also act as softening agents. They include Milk of Magnesia (MOM), citrate of
magnesium, Epsom salts, lactulose, and sorbitol. The Harvard Health Letter special report on the sensitive gut
notes that the latter is less expensive than lactulose and equally effective. Encouraging a child to drink lots of
water or sports drinks is advisable with these agents to prevent dehydration or altered electrolyte levels. Recently,
a prescription osmotic with considerable promise has become available called Miralax (Polyethylene Glycol), which
you can read about on its own website (Miralax.com). Miralax has quickly become dominant in prescribing by
physicians as part of the current practice of a top down treatment for encopresis. It can be difficult to adjust the
dosage for a stool that is not overly soft. A liquified stool creates problems with leakage and may hinder achieving
control unless a reliable schedule of voiding is accomplished.

Laxatives:

Top down use of stimulant (irritative) laxatives bathing the entire GI tract can lead to dependency, lesser
effectiveness with daily use, and they can cause changes in the bowel over extended periods of time. Using them
daily over months can decrease peristalsis and make the colon flabby and inert, in need of a chemical fix. They
include Dulcolax (bisacodyl), Peri-Colace (casanthrol), castor oil, Ex-Lax (senna), and Senokot (senna). We will
see in the next section that starting the GI engine from the top is much more unpredicable in terms of timing and
effects than starting up the voiding reflex from the "bottom." Cultural sensitivities and the common practice of oral
medications for most ills make the use of oral laxatives so much more acceptable. Some leading pediatric
gastroenterologists pointedly refer to it as the "gentle" approach. That could, I suppose, render the next section
as the "brutal" approach? Indeed, back in the late 1970's and early 1980's a couple of very significant pediatric
medical publications refered to "anal assault" and "anal stamp" for the more targeted and timely procedure for
the bottoms up route, which has led to a medical bias throughout much of the world.

Enemas and Suppositories:

Enemas are liquids introduced rectally to stimulate a voiding reflex. Suppositories are solids introduced by the
same route to promote voiding. The term "liquid suppository" is an oxymoron, but it is used by marketing-types
because a suppository may be viewed as more benign or acceptable by the public. The rectal route is the least
favorite choice of parents and children. It is viewed as a last resort because of the emotional and physical conflicts
that almost inevitably result. Encopretic children almost by definition don't want to use this passage for anything
going out much less anything going in! Curiously, this very attitude probably leads to the necessity of having to use
enemas more than is really necessary for clean outs because these children are very susceptible to holding stool
and getting backed up over and over.  An enema is simply the procedure of adding fluid to the rectum and sigmoid
colon, which promotes bowel contractions. It is a very powerful and immediate unconditioned stimulus leading to an
unconditioned response of bowel evacuation. Most of us have learned more subtle conditioned stimuli cues for
voiding on cue (for example, the gastrocolic reflex after breakfast), all of which the encopretic child fights and
suppresses as hard as he/she can!!! I suspect that for these children oral laxatives lead to very tiring battles
and confusion within their bodies in attempting to resist voiding contraction cues for days at a time!!!  The success
of the Soiling Solutions protocol relies on the much more predictable action of the rectal route for promoting rapid
conditioning of successful pooping on the toilet with the immediate relief experienced by the child, when properly
timed in a comprehensive program to transition the child to pooping to his own natural stimulus cues.

Adding non-absorbable salts to an enema creates an osmotic differential, which promote more water absorption
adding to bowel pressure and contractions.  Just as with orally administered osmotic agents, over frequent use
may result in dehydration or altered electrolyte imbalances. The drinking of fluids such as low calorie sports drinks,
juices, and water is recommended to accompany their use.  Oil containing enemas are used to help soften
hardened feces, but they are strictly for short-term use.  Other enemas are effective with lower volumes or smaller
bottles containing liquid glycerin or a bisacodyl solution. The smaller size make them less threatening to children.
Enemas may become absolutely necessary for a proper "clean out" of the child. 

Glycerin suppositories are very gentle in action as they merely lubricate, add bulk, and promote fluid retention.
Indeed, many parents may feel that they are ineffective, and this may be all too true for stool-retentive children by
the very nature of their problem! Glycerin or glycol is a three-carbon trihydroxy alcohol which is hygrosopic (retains
water) and it is very slippery. Men shave with glycerin in their shaving creams every day for its moisture attraction/
retention, softening, and lubricating properties. These often come as thin "sticks" and are easy to insert. I regard
them as a "gentle" or less demanding "prompt" than an enema. Another suppository contains bisacodyl in
something of a bullet-shaped form. This latter suppository directly irritates the rectal-colon wall to promote a more
rapid evacuation and may replace the enema in some instances within the Soiling Solutions protocol. It may also be
less intimidating to a child than the standard Fleet enema bottle. Suppositories should not be inserted into the fecal
mass itself, but off to the side for contact with the rectal wall.

The Clean Kid Manual very specifically addresses fears and concerns about using the rectal route. The manual
helps to assure much earlier bowel competence and voiding success under the child's control through proper
timing and sequencing of prompts and cues to void. Both enhanced physical responding and sensory awareness
are keys to success. Success and competence has its own rewards and quickly replaces months and years of failure.
Someday physicians, psychologists, and parents will adopt the Soiling Solutions protocol over continuing to practice
failure (or blaming you parents)!