When Toilet Training Isn’t Working- Encopresis
If your child 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. Children with developmental or behavioral disabilities may also have difficulty learning a consistent bathroom routine.
Encopresis affects about 1% to 2% of kids under age 10. 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 they feel when they go to the bathroom, 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 suggest various punishments and consequences for the soiling — which only leaves the child feeling even more alone, angry, depressed, or humiliated.
Treating Encopresis
As the colon is stretched by the buildup of stool, the nerves' ability to signal the brain that it's time for a BM is harmed. If untreated, the soiling will get worse and kids 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).
Treatment is done in three phases:
The first phase involves emptying the rectum and colon of hard, retained poop. Depending on the child's age and other factors, the medical provider may recommend medicines, including a stool softener. 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 medical provider will help your child begin having regular BMs with the aid of stool-softening agents, most of which aren't habit-forming. 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 also will 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 the urges to go.
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. Your child might get constipated again or soil his or her pants during treatment, especially when being weaned off of the medicines.
A good way to track your child's progress is by keeping a daily poop calendar. Make sure to note the frequency, consistency (hard, soft, dry), and size (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
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 bread and cereal.
Because kids often cringe at the thought of fiber, try these creative ways to add it to 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, especially water. Diluted 100% fruit juice (like pear, peach, or prune) is an option if your child is not drinking enough water. Also, limiting your child's daily dairy intake (including milk, cheese, and yogurt) may help.
Successful treatment of encopresis depends on the support a child gets. Some parents find that positive reinforcement helps to encourage the child throughout treatment. For instance, put a star or sticker on the poop calendar for having a BM (or even just for trying to), sitting on the toilet, or taking medicines.
Whatever you do, don't blame or yell — it will only make your child feel bad and it won't help manage the condition. With lots of love, support, and reassurance that he or she isn't the only one in the world with this problem, your child can overcome encopresis.
Our medical providers at the Rosenberg Center are trained and able to help your family and your child with encopresis. Our Occupational Therapy staff can also help with planning schedules and helping your child learn to eat a variety of foods. Give us a call. We can help! 651-636-4155
October 24, 2016