Facts you should know about elimination disorders in children
Most kids with encopresis also have constipation.
- Constipation is defined as "a group of disorders associated with persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of a structural or biochemical explanation."
- Constipation is a relatively common event estimated to be responsible for 3%-5% of all visits to a pediatrician's office.
- Encopresis has been defined as "the repetitive, voluntary or involuntary, passage of stool in inappropriate places by children 4 years of age and older, at which time a child may be reasonably expected to have completed toilet training and to exercise bowel control."
- Most studies indicate approximately 4% of all children 4-17 years of age will experience encopresis.
What are elimination disorders in children?
There are two types of disorders of elimination that may affect children. One
category reflects problems with stooling, relatively common constipation and less
frequently occurring encopresis (also known a fecal incontinence or soiling).
The other category of elimination disorders in children reflects problems with
urination and is known as enuresis. The article will review only problems
associated in children dealing with stooling.
Problems with urination in
children are reviewed elsewhere.
What are the risk factors and
causes of constipation and encopresis?
Most children with encopresis have underlying constipation. Why some children
develop encopresis does not seem to reflect differences in either physiology or
psychology. Pediatric GI specialists have noted three areas of intestinal
maturation that may set the stage (in some children) for the onset of
constipation and (in some, ultimately) encopresis. These areas include the
following:
- Changing from a pure breast milk/formula diet to one that includes and
ultimately relies on the majority of calories from solid foods: The increase in
solid foods promotes an increase in stool volume and consistency that may
require greater effort for stool expulsion. - The process of toilet training:
The emotional turmoil for some families in what is generally a natural
evolutionary process may engender a myriad of emotional responses in the child
who is toilet training. The often conflicting desire to please
parents but
establish autonomy may “raise the stakes” too high for the toddler to succeed.
The fact that many preschools require successfully toilet trained students may
engender parental stress since many parents utilize preschool as a safe locale
for their child during the adult’s workday. One study demonstrated that 35% of
children who refused to toilet train developed chronic constipation and were at
a substantially higher likelihood of developing encopresis. - School
attendance: Pediatricians daily hear stories about children who refuse to use
the school toilet for either urinating or bowel movements. The lack of privacy,
taunting, and often noisy chaos is just too intimidating when compared with the
home environment.
Regardless of the cause, many children with constipation will ultimately pass
either an overly large and/or hard stool, resulting in a painful experience. The
rational step (from the child’s perspective) is to avoid stooling and thus avoid
further pain. Consequently, stool accumulates in the rectum and becomes
desiccated and thus more difficult and more painful to pass. This recurrent
cycle reinforces the child’s behavior to avoid stooling at all costs. Children
who develop encopresis may develop abnormal stretching and enlargement of the
rectal area that reduces the reflex urge to stool. As a consequence, the impacted
stool mass may allow “upstream” semisolid stool to leak around the “downstream”
stool obstruction, causing soiling in clothes as well as occasional chunks of
stool to also be passed without the child’s knowledge or desire.
Fecal Incontinence Symptoms & Signs
Fecal incontinence refers to the inability to hold feces (stool) in the rectum. This is typically due to failure of voluntary control over the anal sphincters, permitting untimely passage of feces and gas. Fecal incontinence is also known as rectal incontinence or bowel incontinence. Fecal incontinence is not a disease itself but is a symptom that can occur as a result of different kinds of diseases or injuries. Incontinence of stool can result from damage to the nerves or muscles of the rectum and anus, or conditions affecting the intestines. Overflow incontinence, also known as paradoxical diarrhea, occurs in people with chronic constipation when stool fills the rectum, hardens, and becomes impacted. Liquid stool then may leak around the fecal mass, producing symptoms similar to incontinence.
Read more about the causes of fecal incontinence »
What are the symptoms and signs of constipation?
Pediatric gastroenterologists (GI doctors) indicate that symptoms of
constipation generally involve six characteristics of abnormal stooling present
in infants and toddlers for at least one month and children 4 to 18 years of age
for two months. A minimum of two criteria must be present to fulfill the
definition of constipation. These stooling patterns/problems include the
following:
- Two or
fewer bowel movements per week - One episode of stool incontinence after
mastering toilet-training skills - A history of excessive stool retention which
may be accompanied by characteristic retentive posturing (“the poop dance”) in
older children - A history of passage of painful or hard bowel movements
- A
history of large stools which may obstruct the toilet - Palpation of a large mass of stool in the rectum during digital rectal exam
What are the symptoms and signs of encopresis?
Specialists who deal with encopretic children note that the above criteria
for constipation are also characteristic of encopresis. In one recent study
focusing on constipation, many of the children in the study first presented to
their physician with a history consistent with encopresis. There are, however,
several historical elements that are unique to encopresis. These include the
following:
- Some children with encopresis may successfully stool every day, however, evacuation
of their bowel is incomplete. - Encopretic children commonly “defecate in places
inappropriate to the social context at least once a month” (for example, the classroom). - Children with encopresis seem oblivious or nonchalant to either obvious stool
staining of their clothes or the heavy stool odor they produce. - There is no
underlying organic medical condition that explains the child’s encopretic
pattern.
How do medical professionals diagnose elimination disorders?
A complete evaluation of a child with constipation or encopresis involves a thorough history, a detailed physical examination, and may include laboratory testing. The child's pediatrician may generally handle the analysis of these elements. A pediatric GI specialist consultation may be indicated should a more ominous cause for the elimination disorder be discovered or if the evaluation produces conflicting data and thus obscures the establishment of the exact cause and thus management for the child's problem.
The history to be explored during an evaluation of elimination disorders includes: (1) age and abruptness of onset, (2) frequency and character of the current stool pattern in comparison to that noted prior to the onset of symptoms, (3) relationship to ingestion of meals as well as types of food in the child's diet, (4) unusual weight loss or gain, (5) associated abdominal complaints (for example, abdominal pain), (6) urological issues (many children with elimination disorders may also have enuresis — involuntary loss of bladder control), (7) psychosocial family dynamics (for example, parental/sibling/peer response to the problem), and (8) gentle exploration for any possibility of sexual abuse — regression, depression, sexually acting out, etc.
The goal of a complete physical exam is to eliminate the possibility of anatomical or functional causes for the elimination disorder. Children affected by cerebral palsy, global hyponia (low muscle tone), mental retardation, and anatomical malformations (for example, spinal cord abnormalities or displacement of the anus) must be considered and ruled out as a cause for the child's symptoms. Physical examination of the abdomen will often demonstrate a large stool mass. A rectal exam will commonly demonstrate an enlarged rectal volume that is packed with stool. Absence of anal muscular tone should be a "red flag" for a potential neurological disorder. As noted above, appropriate anal location should be documented. Likewise, the physician should perform an evaluation for hidden spinal cord malformations (for example, tuft of hair over the lower spine).
Most children with either constipation or encopresis do not need laboratory or radiographic evaluation unless the history and/or physical examination warrant further analysis (for example, an MRI for spinal cord malformations). Blood studies to evaluate thyroid function may be a consideration on an individualized basis. An abdominal X-ray may be helpful to measure the child's stool burden. For those children with urologic problems, a culture and urinalysis are reasonable studies. A pediatric gastroenterologist may perform a study of anal and rectal muscle tone (anal/rectal manometry) to assess the anal/rectal response to inflation with air in children who do not respond to routine therapy.
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What is the treatment for elimination disorders in children?
Successful treatment of elimination disorders includes reestablishing an
appropriate bowel evacuation regimen and development of a program to ensure
maintenance of such a stool elimination pattern. A program that may include the
use of laxatives, changes in diet, toileting behavior adjustments, and close
follow-up has been shown to provide the highest rate of success. The therapeutic
approach is often defined by the age of the child.
Breastfed infants are less
likely to have stooling problems when compared with their formula-fed peers.
Diluted prune juice (50:50 with water) will promote a softer and increased
volume stool. Rectal stimulation with either a rectal thermometer or glycerin
suppository may be an appropriate technique to address a stool-impacted infant.
Mineral oil is not recommended for infants due to the possibility of
gastroesophageal reflux (GER) and possible lung pathology if aspirated. Careful
attention to the child’s stooling pattern is worthwhile when solid foods are
introduced into the young infant’s diet.
Preschoolers, grammar-school-age, and older children with elimination
disorders are generally approached in a similar fashion. If the child is
chronically impacted, the use of an orally administered cathartic (for example, magnesium
citrate) will “clean out” the colon. Colonic enemas have fallen out of favor due
to the emotional stress that may be associated with their use. Follow-up daily
use of water retaining laxatives (for example, polyethylene glycol without electrolytes
marketed as PEG-3350 or Miralax) is common. This approach allows the chronically
distended colon to gradually return to a normal volume — thus allowing
redevelopment of stretch receptors to respond to the local rectal/anal
enlargement associated with stool arrival to the area. These water-retaining
laxatives may be needed for several months before considering a gradual
tapering. A thorough review of the child’s diet is important. Avoidance of large
amounts of constipating items is paramount. Such foods would include excessive
milk/dairy products, starches (bread, pasta, etc.), and “fast foods,” which are
often high in saturated fats. Grandmother’s suggestion to “eat your fruits and
vegetables” has solid medical credence. An adequate intake of water as well as
daily vigorous physical activity will also promote colonic health. Establishment
of a daily routine of “toilet time” has been shown to be very helpful. Spending
between five to 10 minutes on the toilet is a generally accepted goal. For young
children, a reward system is often helpful. The reward should be a response for
sitting on the toilet for the allotted time — not the production of stool.
Passage of a daily normal character stool without discomfort is the intended
goal of bowel reeducation.
The use of probiotics has received scientific study in the last few years.
Pediatric studies are less convincing than those utilizing adult patients and
many studies present conflicting results. There has been no documentation of a
deleterious effect of probiotic usage in children or adults.
Is it possible to prevent elimination disorders in children?
While there are no guarantees in this world (except death and taxes, as Benjamin Franklin reportedly said), there are several measures that can be taken to lessen the likelihood of constipation and/or encopresis. Breastfed infants have fewer stooling issues than their formula-fed counterparts. Careful monitoring of intestinal changes associated with the introduction of solid foods (between 4 to 6 months of age) is helpful. The process of toilet training should be viewed as the socially coordinated behavior of a purely biologic function. Forceful threats, intimidation, shaming, and extreme pressure should not be part of the toilet-training process. Many a toddler discovers that they, and not their parents, have ultimate control of when and where they will have a bowel movement. Forcing the issue will often only complicate matters. Frustrated parents should remember that very few high school seniors wear Depends to the senior prom. As noted above, a healthy diet emphasizing proper hydration, whole grains, fruits and vegetables, and an active lifestyle will promote normal stool production and elimination.
What is the prognosis for children with elimination disorders?
With parental education regarding risk factors and awareness of techniques
maximizing their avoidance, the prognosis for children with elimination
disorders is positive. Likewise, effective therapy has been demonstrated to be
successful in both the short and long term, allowing reestablishment and
maintenance of normal bowel function.
