Pediatrics Articles

Even for experienced parents, raising a child can be a challenging thing. From feeding and clothing them to making sure they get all their vaccinations, the health of a child becomes a central pillar of parents’ lives. And of course, taking care of their health and wellbeing also includes ensuring their emotional development. There are times, however, when the spheres of physical and emotional health intersect in potentially unexpected ways. This intersection can be seen clearly in the condition known as encopresis.

Encopresis: What is it?

Encopresis is a disorder that involves the usually involuntary passage of stool for someone who is otherwise toilet trained. Also sometimes referred to as fecal incontinence, encopresis is a disorder that almost always affects children four years or older; it very often involves children soiling their undergarments. To be considered encopresis, other organic medical conditions must be ruled out that might lead to fecal incontinence.

Causes of Encopresis

Encopresis is most often caused by factors that lead to excessive constipation in the child. In the course of the normal digestive process, waste materials moving through the colon form solid stool as water is absorbed; when sufficient water has been absorbed, the stool is then passed through the rectum. But in cases where the stool lingers too long in the colon, so much water is absorbed that the stool becomes hard and difficult to pass. Eventually, if the stool is not passed, it will stay in the colon while other, looser stools pass around the hardened stool and are leaked involuntarily.

One of the most common reasons this happens for most children is related to psychological and emotional factors. Sometimes a child develops a fear of defecation or otherwise feels compelled to avoid passing stool in an ordinary bowel movement. Withholding stool in this way can start to become reflexive, and it then leads to constipation as discussed above. When the stool is so hard and painful to pass, the child is even less likely to give in to the urge to defecate; this can become a vicious cycle for the child where the buildup of stool makes the need to expel ever more necessary and ever more painful.

This cycle of withholding a bowel movement and subsequent constipation can eventually lead to the rectal anal inhibitory response (RAIR); this condition, also known as anismus, is characterized by an involuntary relaxation of the anal sphincter muscle. In other words, the retention of stool can become so intense that the child can no longer distinguish the normal sensations associated with defecating nor can control the muscles used in defecation. It is at this point that encopresis becomes a reality for the child.

The emotional and psychological components of encopresis cannot be overstated, and the onset very often has roots in the process of toilet training or the years following as the child attempts to normalize the experience of using a toilet. It is during these formative years (typically 4 years or older) when negative messaging from parents about feces can cause a child to associate defecation with something to be ashamed of. This can also happen as a child is entering preschool and must navigate the social pressures of shared bathrooms for the first time. Whatever the trigger, it is during these times that the child may develop the emotions that eventually lead to a compulsive need to avoid defecation.

Encopresis: What to look for

Doctors estimate that 1-2% of children under age 10 are affected by encopresis and that potentially up to 80% of those children are boys. Those children who have struggled with constipation in the past are more likely to develop encopresis, particularly because the unpleasantness of having to pass hard, dry stool may trigger an urge to avoid defecation in the future.

Children affected by encopresis may at first have minor soiling in their underwear, and this is a symptom of loose stool leaking out around harder stool they have been holding in. Because the buildup of stool may cause the colon or rectum to stretch, they may also eventually involuntarily pass large stools either in their underwear or on the floor. They are more likely to pass stools during the day when they are active rather than at night.

Treatment for Encopresis

In most cases, encopresis comes about because of chronic constipation, and for these cases, there are three elements of treatment:

  • Clearing the bowels: the need for clearing is different for different children, but sometimes they have withheld defecation for so long that the stool has become impacted, a condition where hardened stool is stuck in the colon. This can be done with an enema or laxatives, depending on the severity of the situation.
  • Prevent constipation: in order to ensure a healthy pattern of regular bowel movements with comfortably-passed stool, stool softeners are used. Doctors typically recommend a six-month course to give the stretched colon and rectum ample time to return to normal.
  • Teaching new habits: to reinforce the normality of defecation, the child should be given regular “toilet sitting” times each day. This can usually be achieved by having the child sit on the toilet for 10-15 minutes after every meal (a time when they are more likely to have a bowel movement).

How to prevent Encopresis?

Initial constipation that leads to encopresis can be caused by a variety of factors, including dietary factors. One of the key elements of a child’s diet to consider is fiber content since a lack of fiber can lead to constipation. So in order to help the child have regular bowel movements and avoid constipation, make sure he or she is drinking enough water and eating foods rich in fiber such as fruits, vegetables, and whole grains. Additionally, you may want to limit foods that can tend to lead to constipation: dairy products, white bread, and white rice.

The other part of preventing encopresis involves psychological and emotional support. As noted earlier, toilet training can be anxiety-producing for young children, and that anxiety can continue as a child gets older and begins to be in situations where shared bathrooms are a factor. Talking regularly with the child and making bathroom topics non-taboo can go a long way to taking away shame or anxiety related to defecation; teach them to trust their body’s urges to “go” and to not be afraid to ask for permission to use the bathroom at school or another situation away from home.

When to seek medical care for Encopresis

The toilet training process can be a very different experience for different children, and a child can be ready for at different ages. For this reason, difficulties with toilet training should be considered normal for the first several years of life. Doctors won’t even diagnose encopresis until a child is 4 years old or older and has had fecal leakage or involuntary passage at least once a month for three months.

Constipation, of course, can be a concerning problem for children of any age, and you should seek out medical advice if your child suddenly has changed their bowel movements. If the child is over the age of 4, however, and he or she has started having problems with leakage, it may very well be encopresis. If you recognize these symptoms, you should seek help from a doctor. Even if you’re not sure your child is affected by encopresis, you might want to talk to a qualified pediatric gastroenterologist. GI Associates has a dedicated pediatric staff, specifically trained to deal with the GI conditions in children.

If you would like to talk to someone about your child’s symptoms, contact GI Associates to make an appointment. The friendly and professional staff are available to provide the best care possible for your child.

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