Encopresis

What is encopresis?

Encopresis is a problem that children age four or older can develop due to chronic (long-term) constipation. With constipation, children have fewer bowel movements than normal, and the bowel movements they do have can be hard, dry, and difficult to pass. Once a child becomes constipated, a vicious cycle can develop. The child may avoid using the bathroom to avoid discomfort. Stool can become impacted (packed into the rectum and large intestine) and unable to move forward. The rectum and intestine become enlarged due to the hard, impacted stool. Eventually, the rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) loses its strength. Liquid stool can start to leak around the hard, dry, impacted stool, soiling a child's clothing.

Which children develop encopresis?

Any child with chronic constipation may develop encopresis. Some of the situations that lead to constipation include the following:

• Eating a high-fat, high-sugar, "junk-food" diet

• Drinking mainly soft drinks and sugared drinks, and not drinking enough water and fruit juices

• Lack of exercise

• Reluctance to use public bathrooms

• Stress in the family, with friends, or at school

• Being too busy playing to take time to use the bathroom

• Change in bathroom routine, such as when a child starts a new school year and bathroom breaks are less frequent than they were over the summer

For unknown reasons, boys develop encopresis six times more than girls do. Even though family stress can be linked to constipation, there does not seem to be any association between developing encopresis and how many children are in a family, a child's birth order (i.e. first, middle, last), a child's age, or the family's income.

Why is encopresis of concern?

Encopresis can cause both physical and emotional problems.

Impacted (backed up) stool in the intestine can cause abdominal pain, as well as loss of appetite. Some children develop bladder infections.

Other health problems may cause chronic constipation, including diabetes, hypothyroidism, Hirschsprung's Disease, and inflammatory bowel disease.

Children with encopresis can certainly feel emotionally upset by the "accidents" they have when they soil their clothes. They usually do not have control of this leakage of stool. Their self-esteem and interactions with other people can be affected. Children are often ashamed or embarrassed. They may avoid going to school, playing with friends, or spending the night away from home. Parents may feel guilt, shame, anger, or distaste by the problem. The child will often be aware of a parent's feelings and become even more emotionally affected.

What are the symptoms of encopresis?

The following are the most common symptoms of encopresis. However, each child may experience symptoms differently. Symptoms may include:

• Loose, watery stools

• Involuntary stooling, or needing to have a bowel movement with little or no warning, which may soil underwear when a child cannot get to the bathroom in time

• Scratching or rubbing of the anal area due to irritation by watery stools

• Withdrawal from friends, school, and/or family

• Hiding their underwear

Symptoms of encopresis may resemble other conditions or medical problems. Please consult your child's physician for a diagnosis.

How is encopresis diagnosed?

A physician or health care provider will examine your child, and obtain a medical history. Imaging tests may also be done to evaluate the intestine and rule out other health problems. These tests may include:

• Abdominal X-ray. A diagnostic test to evaluate the amount of stool in the large intestine.

• Barium enema. A test that checks the intestine for obstruction (blockage), strictures (narrow areas), and other abnormalities. A fluid that shows up well on X-ray, called barium, is given as an enema, and then the intestine is looked at with an X-ray.

What is the treatment for encopresis?

Specific treatment for encopresis will be determined by your child's physician based on the following:

• The extent of the problem

• Your child's age, overall health, and medical history

• The opinion of the physicians involved in the child's care

• Your opinion or preference

Treatment for encopresis may include:

• Removing the impacted stool

• Keeping bowel movements soft so the stool will pass easily

• Retraining the intestine and rectum to gain control over bowel movements

An enema may be prescribed by your child's physician to help remove the impacted stool. An enema is a liquid that is placed in your child's rectum and helps loosen the hard, dry stool. (DO NOT give your child an enema without the approval of a physician or health care provider.)

Your child's physician will often prescribe medications to help keep your child's bowel movements soft for several months. This will help prevent stool impaction from occurring again. Please do not give your child stool softeners without the approval of a physician.

• Diet changes. Often, making changes in your child's diet will help constipation. Consider the following suggestions:

  • Increase the amount of fiber in your child's diet by:

    • Adding more fruits and vegetables

    • Adding more whole grain cereals and breads (check the nutritional labels on food packages for foods that have more fiber)

  What are good fiber sources?

  FOODS	MODERATE FIBER	HIGH FIBER
  BREAD	Whole wheat bread, granola bread, wheat bran muffins, Nutri-Grain waffles, popcorn
  CEREAL	Bran Flakes, Raisin Bran, Shredded Wheat, Frosted Mini Wheats, oatmeal, Mueslix, granola, oat bran	All-Bran, Bran Buds, Corn Bran, Fiber One, 100% Bran
  VEGETABLES	Beets, broccoli, brussel sprouts, cabbage, carrots, corn, green beans, green peas, acorn and butternut squash, spinach, potato with skin, avocado
  FRUITS	Apples with peel, dates, papayas, mangos, nectarines, oranges, pears, kiwis, strawberries, applesauce, raspberries, blackberries, raisins	Cooked prunes, dried figs
  MEAT SUBSTITUTES	Peanut butter , nuts	Baked beans, black-eyed peas, garbanzo beans, lima beans, pinto beans, kidney beans, chili with beans, trail mix

  High-fiber meal vs. a typical meal

  Typical Meal	High-fiber Meal
  Breakfast Cornflakes 1/2 cup Donut 1 Milk 1/2 cup Orange juice 1/2 cup Total grams of fiber = 0.5 grams	Breakfast Raisin bran 1/2 cup Bran muffin Milk 1/2 cup Orange juice 1/2 cup Total grams of fiber = 5 grams
  Lunch Beef patty 3 ounces Hamburger bun French fries Green beans 1/2 cup Canned pears 1/2 cup Milk 1 cup Total grams of fiber = 5 grams	Lunch Beef patty 3 ounces Whole wheat bun Baked potato with skin Baked beans 1/2 cup Pear with skin Milk 1 cup Total grams of fiber = 15 grams
  Dinner Grilled chicken 3 ounces Lettuce salad White rice 1/2 cup Watermelon 1/2 cup Milk 1/2 cup Total grams of fiber = 1.5 grams	Dinner Grilled chicken 3 ounces Broccoli 1/2 cup Brown rice 1/2 cup Strawberries 1/2 cup Milk 1/2 cup Total grams of fiber = 6 grams

  • Offer your child fruit juice instead of soft drinks.

  • Encourage your child to drink more fluids, especially water.

  • Limit fast foods and junk foods that are usually high in fats and sugars, and offer more well-balanced meals and snacks.

  • Limit drinks with caffeine, such as cola drinks and tea.

  • Limit whole milk to 16 ounces a day for the child 2 years of age and older, but do not eliminate milk altogether. Children need the calcium in milk to help their bones grow strong.

  • Plan to serve your child's meals on a regular schedule. Often, eating a meal will stimulate a bowel movement within 30 minutes to an hour. Serve breakfast early so your child does not have to rush off to school and miss the opportunity to have a bowel movement.

• Increase exercise. Increasing the amount of exercise your child gets can also help with constipation. Exercise aids digestion by helping the normal movements the intestines make to push food forward as it is digested. People who do not move around much are often constipated. Encourage your child to go outside and play rather than watch TV or engage in other indoor activities.

• Proper bowel habits. Have your child sit on the toilet at least twice a day for at least 10 minutes, preferably shortly after a meal. Make this time pleasant; do not scold or criticize the child if they are unable to have a bowel movement. Giving stickers or other small rewards, and making posters that chart your child's progress can help motivate and encourage him/her. If these methods do not help, or if your physician notices other problems, he/she may recommend laxatives, stool softeners, or an enema. These products should ONLY be used with the recommendation of your child's physician. DO NOT use them without consulting your child's physician first. Until the intestine and rectum regain their muscle tone, children may still have "accidents" and soil their underwear on occasion. Pre-school children may be able to wear a disposable training pant until they regain bowel control. Taking a change of underwear and/or pants to school can help minimize your child's embarrassment and improve his/her self-esteem as bowel control improves.