If your child who has bowel movements (BMs) in places other than
the toilet, you know how frustrating it can be. Many parents assume
that kids who soil their pants are simply misbehaving or that
they're too lazy to use the bathroom when they have the urge to
go.
The truth is that many kids beyond the age of toilet teaching
(generally older than 4 years) who frequently soil their underwear
have a condition known as
encopresis
. They have a problem with their bowels that dulls the normal urge
to go to the bathroom - and they can't control the accidents
that typically follow.
Although encopresis is estimated to affect 1% to 2% of kids
under the age of 10, problems with encopresis and constipation
account for more than 25% of all visits to pediatric
gastroenterologists (doctors who specialize in disorders of the
stomach and intestines).
Most encopresis cases (90%) are due to functional
constipation
- that is, constipation that has no medical cause. The stool (or
BM) is hard, dry, and difficult to pass when a person is
constipated. Many kids "hold" their BMs to avoid the pain
of constipation, which sets the stage for having a poop
accident.
Well-intentioned advice from family members and friends
isn't always helpful because many people mistakenly believe
that encopresis is a behavioral issue - a simple lack of
self-control. Frustrated parents, grandparents, and caregivers may
advocate various punishments and consequences for the soiling -
which only leaves the child feeling even more alone, angry,
depressed, or humiliated. Up to 20% of kids with encopresis
experience feelings of low self-esteem that require the
intervention of a psychologist or counselor.
Punishing or humiliating a child with encopresis will only make
matters worse. Instead, talk to your doctor, who can help you and
your child through this challenging but treatable problem.
Encopresis and Its Causes
Three to six times more common in boys, encopresis isn't a
disease, but rather a symptom that may have different causes. To
understand encopresis, it's important to understand
constipation.
There's a wide range of normal when it comes to having a BM.
The frequency of BMs varies with a person's age and individual
nature. "Normal" pooping might range from one or two BMs
per day to only three or four per week. Some kids don't poop on
a regular basis, but a child who passes a soft BM without
difficulty every 3 days is not constipated. However, a child who
passes a hard BM (small or large) every other day is. Other kids
may go every day, but they only release little, hard balls and
there's always poop left behind in the
colon
.
So, what causes the hard poop in the first place? Any number of
things, including diet, illness, decreased fluid intake, fear of
the toilet during toilet teaching, or limited access to a toilet or
a toilet that's not private (like at school). Some kids may
develop chronic constipation after stressful life events such as a
divorce or the death of a close relative. Whatever the cause, once
a child begins to hold his or her BMs, the poop begins to
accumulate in the colon and a vicious cycle begins.
The colon's job is to remove water from the poop before
it's passed. The longer the poop is stuck there, the more water
is removed - and the harder it is to push the large, dry poop out.
The large poop also stretches out the colon, weakening the muscles
there and affecting the nerves that tell a child when it's time
to go to the bathroom. Because the flabby colon can't push the
hard poop out, and it's painful to pass, the child continues to
avoid having a BM, often by dancing, crossing the legs, making
faces, or walking on tiptoes.
Eventually, the lower part of the colon becomes so full that
it's difficult for the sphincter (the muscular valve that
controls the passage of feces out of the anus) to hold the poop in.
Partial BMs may pass through, causing the child to soil his or her
pants. Softer poop may also leak out around the large mass of feces
and stain the child's underwear when the sphincter relaxes. The
child can't prevent the soiling - nor does he or she have any
idea it's happening - because the nerves aren't sending the
signals that regulate defecation (or pooping).
At first, parents may think their child has a simple case of
diarrhea
. But after repeated episodes, it becomes clear that there's
another problem - especially because the soiling occurs when the
child isn't sick.
Parents are often frustrated by the fact that their child seems
unfazed by these accidents, which occur mostly during waking hours.
Denial may be one reason for the child's nonchalance - kids
just can't face the shame and guilt associated with the
condition (some even try to hide their soiled underpants from their
parents). Another reason may be more scientific: Because the brain
eventually gets used to the smell of feces, the child may no longer
notice the odor.
When to Call the Doctor
Although rectal surgery or birth defects such as Hirschsprung
disease and
spina bifida
can cause constipation or encopresis without constipation, these
are uncommon.
Call the doctor if your child shows any of the following
symptoms:
- poop or liquid stool in the underwear when your child
isn't ill
- hard poop or pain when having a BM
- toilet-stopping BM
- abdominal pain
- loss of appetite
Treating Encopresis
As the colon is stretched by the buildup of stool, the
nerves' ability to signal to the brain that it's time for a
BM is diminished. If untreated, not only will the soiling get
worse, but kids with encopresis may lose their appetites or
complain of stomach pain.
A large, hard poop may also cause a tear in the skin around the
anus that will leave blood on the stools, the toilet paper, or in
the toilet. Constipation is also associated with
wetting
and
urinary tract infections (UTI)
. If you think your child has encopresis, call your doctor.
Most cases of encopresis can be managed by your doctor, but if
initial efforts fail, you may be referred to a
gastroenterologist.
Treatment is done in three phases:
- The first phase involves emptying the colon of hard, retained
poop. Different doctors might have different ways of helping kids
with encopresis. Depending on the child's age and other
factors, the doctor may recommend medicines, including a stool
softener (such as mineral oil), laxatives, and/or enemas.
(Laxatives and enemas should be given
only
under the supervision of a doctor;
never
give these treatments at home without first checking with your
doctor.) As unpleasant as this first step sounds, it's
necessary to clean out the bowels to successfully treat the
constipation and end your child's soiling.
- After the large intestine has been emptied, the doctor will
help the child begin having regular BMs with the aid of
stool-softening agents, most of which aren't habit-forming.
At this point, it's important to continue using the stool
softener to give the bowels a chance to shrink back to normal
size (the muscles of the intestines have been stretched out, so
they need time to be toned without the poop piling up again).
Parents will also be asked to schedule potty times twice daily
after meals (when the bowels are naturally stimulated), in which
the child sits on the toilet for about 5 to 10 minutes. This will
help the child learn to pay attention to his or her own urges.
It's especially helpful for parents to keep a record of their
child's daily BMs.
- As regular BMs become established, your doctor will reduce
the child's use of stool softeners.
Keep in mind that relapses are normal, so don't get
discouraged if your child occasionally becomes constipated again or
soils his or her pants during treatment, especially when trying to
wean the child off of the medications.
A good way to keep track of your child's progress is by
keeping a daily poop calendar. Make sure to note the frequency,
consistency (i.e., hard, soft, dry), and size (i.e., large, small)
of the BMs.
Patience is the key to treating encopresis. It may take anywhere
from several months to a year for the stretched-out colon to return
to its normal size and for the nerves in the colon to become
effective again.
Diet and Exercise
In the meantime,
diet
and
exercise
are extremely important in keeping stools soft and BMs regular.
Also, make sure your child gets plenty of
fiber-rich foods
such as fresh fruits, dried fruits like prunes and raisins, dried
beans, vegetables, and high-fiber cereal.
Because kids often cringe at the thought of fiber, try these
creative ways to incorporate it into your child's diet:
- Bake cookies or muffins using whole-wheat flour instead of
regular flour. Add raisins, chopped or pureed apples, or prunes
to the mix.
- Add bran to baking items such as cookies and muffins, or to
meatloaf or burgers, or sprinkled on cereal. (The trick is not to
add too much bran or the food will taste like sawdust.)
- Serve apples topped with peanut butter.
- Create tasty treats with peanut butter and whole-wheat
crackers.
- Top ice cream, frozen yogurt, or regular yogurt with
high-fiber cereal for some added crunch.
- Serve bran waffles topped with fruit.
- Make pancakes with whole-grain pancake mix and top with
peaches, apricots, or grapes.
- Top high-fiber cereal with fruit.
- Sneak some raisins or pureed prunes or zucchini into
whole-wheat pancakes.
- Add shredded carrots or pureed zucchini to spaghetti sauce or
macaroni and cheese.
- Add lentils to soup.
- Make bean burritos with whole-grain soft-taco shells.
And don't forget to have your child drink plenty of fluids
each day, including water and 100% fruit juices like pear, peach,
and prune to help draw water into the colon. Try mixing prune juice
with another drink to make it a little tastier. Also be sure to
limit your child's total daily dairy intake (including cheese,
yogurt, and ice cream) to 24 ounces or less.
Successful treatment of encopresis depends on the support the
child receives. Some parents find that positive reinforcement helps
to encourage the child throughout treatment. Provide a small
incentive, such as a star or sticker on the poop calendar, for
having a BM or even just for trying, sitting on the toilet, or
taking medications.
Whatever you do, don't blame or yell - it will only make
your child feel bad and it won't help manage the condition.
Show lots of love and support and, assure your child that he or she
isn't the only one in the world with this problem. With time
and understanding, your child can overcome encopresis.
Reviewed by:
Mary L. Gavin, MD
Date reviewed: May 2008
Originally reviewed by:
Wendy Kutz, MSN, RN
Note: All information is for educational purposes only. For specific medical advice,
diagnoses, and treatment, consult your doctor.
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