Encopresis is defined as the repeated inappropriate passage or leaking of feces in a child over four years of age that is not caused by a physical illness or disability.
Over 80% of cases of encopresis begin with the child's experience of a painful bowel movement or passing a very large bowel movement. Over time, the child comes to associate using the toilet with pain and begins to hold in, or retain, his or her bowel movements to avoid the pain. The child may occasionally try to pass some of the hardened stool and develop a crack in the skin surrounding the anus known as an anal fissure. Anal fissures cause additional pain and usually reinforce the child's habit of retaining feces. As the mass of stool grows, the colon stretches to many times its normal diameter—a condition known as megacolon. The child also loses the natural urge to have a bowel movement because the muscles in the wall of the colon cannot contract and push the stool out.
Encopresis is thought to affect between 1%–2% of children in the United States below the age of ten. Boys are six times as likely to develop encopresis. It is not known to be related to race or social class, the size of the family, the child's birth order, or the age of the parents.
There is no universal agreement among doctors as to the best method of treatment for encopresis, including dietary recommendations. It is a disorder resulting from the interaction of bodily, psychological, and social factors in the child's life. As a result, there have been no large-scale controlled studies of different treatment methods.
Dietary treatment of encopresis is intended to help the child develop regular bowel habits after disimpaction and to minimize the risk of recurrent constipation. Dietary modifications usually include:
Following disimpaction, the child is given maintenance medications intended to produce soft stools once or twice daily to prevent constipation from recurring. They also help the child break the mental and emotional connection between defecation and pain. The child may be given glycerine or bisacodyl suppositories once or twice a day, or mineral oil, senna syrup (Senokot), milk of magnesia, lactulose, or sorbitol twice a day by mouth. Maintenance treatment typically takes several months.
Glucomannan, a complex sugar derived from the roots of the Japanese konjac plant, is an effective fiber supplement for children that appears to be well tolerated and has fewer side effects than many laxatives. Glucomannan is a water-soluble fiber that forms a gellike mass in the digestive tract and helps to push fecal matter through the lower bowel more rapidly.
Psychological treatment is part of maintenance therapy for encopresis because of the emotional stress the condition causes the child and other family members. In many cases the child has become depressed or developed other behavioral problems as a result of punishment, teasing, or social rejection related to episodes of soiling. Psychological treatment begins with education; the doctor explains to the parents as well as the child how encopresis develops, what causes it, and why medications are used to treat it.
If the child's encopresis is involuntary, behavioral therapy is often used. This approach employs such techniques as star charts and daily diaries to teach the child to recognize the body's internal cues. Some doctors also recommend biofeedback for maintenance therapy in encopresis.
If the child's episodes of soiling are intentional rather than involuntary, he or she is usually referred to a child psychiatrist for specialized evaluation and treatment.
The function of dietary treatment for encopresis is as a form of maintenance therapy. The goal is to prevent stool from building up in the child's colon, allow the colon to return to its normal shape and muscular function, and to help the child have bowel movements in the toilet at appropriate times.
The benefit of dietary treatment for encopresis is prevention of future episodes of constipation while providing adequate nutrition for the child. Medications are used to clear impacted fecal material from the colon and relieve discomfort associated with defecation.
Parents should follow the doctor's advice about using laxatives and enemas during maintenance treatment for encopresis, as some of these products have side effects or interact with other medications that the child may be taking.
There are no reported adverse effects of dietary treatment for encopresis.
Enemas and laxatives often produce side effects, including abdominal cramping, intestinal gas, nausea, and vomiting. The child's doctor may be able to change the dosage or type of product for a child on maintenance treatment. Lactulose should not be given to patients with diabetes because it contains a form of sugar, while sorbitol may reduce the effectiveness of other medications. Mineral oil sometimes causes seepage into underwear and itching in the anal area. Senna and citrate of magnesia may lead to electrolyte imbalance if used in high doses over a long period of time.
Disagreements regarding treatment for encopresis focus on three subjects: whether enemas are preferable to laxatives taken by mouth or whether enemas are emotionally traumatic to the child; whether or not adding fiber to the child's diet is useful; and whether placing the child on the toilet at set times helps in establishing bowel control or whether it creates emotional conflict between parent and child. Opinion is divided about the effectiveness of placing the child on the toilet at fixed times during the day; some doctors think that taking the child to the toilet after a meal helps to teach good bowel habits, while others think it is not a good idea if the child does not feel an urge to defecate.
There is no evidence that long-term use of laxatives creates dependency on them or causes colon cancer.
See also Constipation .
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American Academy of Child and Adolescent Psychiatry (AACAP), 3615 Wisconsin Ave. NW, Washington, DC, 20016, (202) 966-7300, http://www.aacap.org .
American Academy of Pediatrics (AAP), 141 Northwest Point Blvd., Elk Grove Village, IL, 60007, (847) 434-4000, (800) 433-9016, Fax: (847) 434-8000, http://www.aap.org .
American Gastroenterological Association, 4930 Del Ray Ave., Bethesda, MD, 20814, (301) 654-2055, Fax: (301) 654-5920, firstname.lastname@example.org, http://www.gastro.org .
International Foundation for Functional Gastrointestinal Disorders, PO Box 170864, Milwaukee, WI, 53217, (414) 964-1799, (888) 964-2001, Fax: (414) 964-7176, email@example.com, http://www.iffgd.org .
National Digestive Diseases Information Clearinghouse, 2 Information Way, Bethesda, MD, 20892–3570, (800) 891–5389, TTY: (866) 569–1162, Fax: (703) 738–4929, firstname.lastname@example.org, http://www.digestive.niddk.nih.gov .
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, PO Box 6, Flourtown, PA, 19031, (215) 233-0808, Fax: (215) 233-3918, email@example.com, http://www.naspghan.org .
Rebecca J. Frey, PhD