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Soiling - Encopresis
What is Encopresis? This is when your child poos in their pants after the age when you expect them to be toilet trained. It usually occurs between 2 and 8 years of age but can begin earlier or later. Most schools have several children with this problem yet there are very few adults with it. If nothing is done, your child will sooner or later improve. However, we can speed up this process considerably and prevent the social difficulties associated with soiling.
What causes it?
It is caused by chronic constipation and an overloaded bowel.
What happens?
Poo usually comes down the colon in single file. At some stage, it may even be years ago, your child may have begun to hold on to a poo to try and avoid passing it. They may have done this because a hard poo has hurt them, or they were too busy playing to bother going to the toilet. Whatever the original cause, the result is that the poo accumulates in the rectum and dams up the normal flow so the bowel becomes overloaded.
When this happens, the rectum becomes so stretched that the sensation of fullness is gone then your child has no idea when they need to have a poo. They will have no control over a poo being passed so can have accidents at any time of the day.
The bowel motion further upstream in the colon is more liquid and this trickles down between the hard poo onto the underwear so even though constipation is the problem, your child can have runny poos and "skid marks" in their pants. It is not the child's fault. Laziness is not the cause and no amount of bribery or punishment is likely to alter the pattern.
What is the treatment?
Treatment focuses on three main areas.
1. Unblocking and emptying the bowel then ensuring that it is kept empty for several months to allow the muscles of the rectal wall to recover. This is done using laxatives.
Laxatives are medications that help the body to get rid of poo. They are a standard and essential part of the treatment of constipation and have been shown to speed up improvement better than dietary changes alone. Most are available over the counter at a chemist (pharmacy) but advice about dosage from a nurse or doctor is helpful.
There are two main ways in which laxatives for childhood constipation work:
Some soften the hard poo and make it easier to pass (poo softeners)
some help the bowel push the poo out (stimulants or emptiers)
See Newsletter 3 on Laxatives and
Newsletter 19 on Movicol Half
2. Establishing a regular routine of sitting on the toilet.
See Newsletter 23 Parent letter
3. Diet and exercise are extremely important in keeping stools soft and regular. Also, make sure your child gets plenty of fibre rich foods such as fresh fruits, dried fruits like prunes and raisins, dried beans, vegetables, and high-fibre cereal. Because kids often cringe at the thought of fibre, come up with creative ways to incorporate these foods into your child's diet so that it doesn't become a chore to eat the high-fibre fare needed to treat encopresis:
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-fibre 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-fibre 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. Put lentils in your child's favourite soup. Make bean burritos with whole-grain soft-taco shells.
How long are laxatives for constipation necessary?
For as long as it takes. Children often need laxatives for months to years rather than weeks.
Remember that the purpose of laxatives is to allow your child to develop a normal habit of emptying their bowel regularly so that the overstretched bowel can return to a normal size.
Ideally a child should be aiming for one soft but formed poo per day. Laxatives are required until the body can manage this without help. You may need to adjust the dose over time. Often children get sick of taking medication, or dislike the taste. Try to make the medication taste better by serving it with milk or juice, or ask your doctor or nurse about an alternative laxative. Incentive or star charts can be a good way of encouraging your child to take medicine regularly.
Where to go for more information
Parent to Parent -
Parent to Parent offers a support service to parents of children with a range of conditions and can put you in touch with parents experiencing similar situations. Website: http://www.parent2parent.org.nz/
ERIC (Education and Resources for Improving Childhood Continence)
- ERIC has a number of leaflets that can be downloaded. It provides information for parents, children and adolescents and for health professionals. Website: http://www.eric.org.uk/
Kidshealth - Offers a range of information on child and youth health. Soiling can be viewed at: http://www.kidshealth.org.nz/index.php/ps_pagename/contentpage/pi_id/304
Children's Health Camps - This site describes the programme that is used for children who have constipation and soiling problems and are attending health camp
This is a booklet available from KEEA, see Tim's Problem
Acknowledgements:
The Paediatric Society of New Zealand
Starship Foundation
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