Diagnosis and Treatment of Encopresis in Children

Parents often think that stooling accidents (fecal soiling) are done on purpose, but more often, they are caused by encopresis.

These types of accidents occur when children leak stool, usually involuntarily, into their underwear, after they have been potty trained. Although soiling can be secondary to an anatomic problem, such as an anal malformation, meningomyelocele, muscle diseases, or after anal surgery, it is most commonly due to encopresis.

Encopresis

Encopresis is a complication of chronic constipation, and it is fecal soiling with the loss of semi-formed or usually liquid stools, which may be foul-smelling, into a child's underwear. Once a child becomes constipated and has hard and painful stools, he may begin to hold in his bowel movements to prevent it from hurting again.

This creates a cycle that makes constipation continue and become worse, eventually leading to a large fecal impaction and rectal distention (which can make the rectum less sensitive and unable to hold even small amounts of stool). Stool behind the impaction begins to leak around it, and eventually leaks out of the rectum, without the child noticing it or being able to hold it in.

Your child may also have very large, infrequent, hard bowel movements that are painful or may even plug up the toilet. After a very large bowel movement, soiling may improve, until enough time passes and the impaction builds up again. Children with encopresis may also have small, hard, ball-like bowel movements, which might lead parents away from thinking about constipation if they are occurring every day.

Although encopresis occurs equally in boys and girls in younger children, by school age, it is much more common in boys.

Treatments

The treatments for encopresis must include treatment for underlying constipation. This will likely include a 'clean out' regimen of enemas, suppositories or high-dose Miralax or mineral oil to remove the backed up or impacted stool. Before giving a child any over-the-counter laxative or home remedy, always discuss with a pediatrician first.

Other treatments are aimed at improving your child's diet.

The classic diet that might constipate a child might include a lot of junk food and might be low-fiber, high-fat, with few fluids. Keeping that in mind, some steps to improve your child's diet include:

• Increasing Fluids: Increase the amount of water that your child drinks each day.

Increasing Fiber: Increase the amounts of high fiber foods that your child eats, such as fruits and vegetables. Raw, unpeeled fruits and vegetables (especially beans, sweet potatoes, peas, turnip greens, raw tomatoes, and corn) have the most fiber. Popcorn also has lots of fiber in it. According to the Academy of Nutrition and Dietetics, average adults should eat about 14g of fiber for every 1,000 calories they eat. For younger kids, the American Academy of Pediatrics recommends adding 5 to your children's age for the daily total recommended. For example, if your child is 5, they would need 10 grams of fiber in a single day. Learn to check the nutritional label for high fiber foods and snacks with at least 3-4g of fiber per serving. Vegetable soups are especially high in fiber and also add more fluid to your child's diet.

• Increasing Bran in Your Child's Diet: Offer bran cereals, bran muffins, shredded wheat, graham crackers, or whole wheat bread.
• Decreasing Constipating Foods: Constipating foods include whole milk, yogurt, cheese, rice, applesauce, white bread, cooked carrots, and bananas. For some kids, switching to soy or rice milk has been shown to soften stools. If your child is unable to drink milk, then offer a daily multivitamin or other sources of calcium.

Until your child's constipation has improved with a non-constipating diet, your child will most likely also be on stool softeners. Most of these medicines are available in the pharmacy over the counter and do not require a prescription, but should not be given to a child unless a pediatrician advises. They include high-dose Miralax, Ex-Lax Milk of Magnesia, and mineral oil. Unlike laxatives in adults, they are generally not considered to be habit-forming. You should use them every day, with the goal of your child is having a soft BM each day. If your child starts to have diarrhea, then you are giving too much and you should cut back on the dose.

Bathroom Schedules

Another important treatment for encopresis and constipation is behavior management so that your child learns to have a bowel movement each day. You should encourage your child to have regular bowel patterns. The University of Utah recommends having your child sit on the toilet for after meals, when bowel movements are more likely to occur.

The use of simple rewards or a daily calendar with stars or stickers for days that your child takes his medicine and has a bowel movement may be helpful. Your child doesn't necessarily need to have a bowel movement each of these times, and you shouldn't punish him if he doesn't. It is more important that he gets in a regular habit of trying to have a bowel movement.

And remember that the leakage of stool is involuntary. Your child is not doing it on purpose and he shouldn't be punished or shamed when it does happen. The distention and stretching of his rectum from the impacted stool can take a lot of time to get back to normal, and until it does, he may not be able to sense or voluntarily hold in all of his bowel movements, and so leakage may continue even with proper treatment.

Encopresis can sometimes be difficult to treat, and your pediatrician may consider referring you to a pediatric gastroenterologist for further management if he is not improving on his current medication regimen.