Reprints are not available from the authors. 10. This form of encopresis accounts for up to 20 percent of all cases. The guidelines were developed from the literature on toilet training and encopresis, with a special emphasis on practicality and ease of implementation by the family physician. The history and physical examination may be the only diagnostic tools necessary to identify retentive encopresis and related organic factors. Suitable daily regimens include Milk of Magnesia, in a dosage of 1 to 3 mL per kg per day; mineral oil, in a dosage of 1 to 5 mL per kg per day; or sorbitol, in a dosage of 1 to 3 mL per kg per day. 1997;18:34–41. / Journals Children with retentive encopresis often soil small quantities of loose fecal matter several times a day but periodically pass very large bowel movements. About 5% of children refuse to be bowel trained. Our Patient Portal provides safe and secure online access to better communicate with your Tufts Medical Center Community Care doctor. McGuire EJ. Developmental-behavioral pediatrics. This article provides treatment guidelines for children with primary nonretentive encopresis or stool toileting refusal. Constipation often begins when children hold back, or “with-hold,” their bowel movements. Fecal incontinence in children. These children usually regain control of their bowels when the stress is reduced or removed. Encopresis without Constipation (Not Toilet Trained) What is encopresis? J Pediatr Psychol. Encopresis is the repeated passage of feces in inappropriate places by a child. Schmitt BD. In: Karoly P, ed. 1995;17:47–58. When he needed to defecate, he brought a diaper to his foster mother, stood in front of her and said, “I go poop.” Within one-half hour of being diapered, he would usually walk behind the living room couch to defecate into the diaper. Partin JS. Initially, sits can be scheduled three to five times daily at the family's convenience. Developmental criteria include attainment of major motor skills such as being able to walk to the bathroom, sit on the toilet, lower and raise pants and flush the toilet. O'Brien S, J Appl Behav Anal. New York: Wiley, 1988;434–69. The principal differential diagnoses of encopresis are listed in Table 2.13–15, Acquired spinal cord disease (i.e., sacral lipoma, spinal cord tumor), Rectoperineal fistula with imperforate anus. The most common cause of resistance to toilet training is that a child is strong-willed and has been reminded or lectured too much. Levine MD. 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. Contact Although ensuring frequent, soft and well-formed bowel movements should reduce the likelihood of a child withholding fecal material, a back-up plan is necessary. Loening-Baucke V. He passes stools into his underwear or pull-up. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Pediatrics. Behavioral toilet training in early childhood: research, practice, and implications. Treatment of a retentive encopretic child using contingency management and diet modification with stimulus control. 2d ed. Encopresis: its potentiation, evaluation, and alleviation. The following illustrative case demonstrates the efficacy of these treatment guidelines in a child with nonretentive encopresis and toileting refusal. Dietary changes or short-term use of supplements such as flavored fiber drinks or bran sprinkles may be needed to increase the number of bowel movements and to maximize daily toileting opportunities. Behavioral-medical treatment of pediatric toileting refusal. This content is owned by the AAFP. The conventional treatment approach consists of behavior modification and laxative for children with encopresis with constipation and behavior modification alone for the few children with encopresis without constipation. Heymans HS, Occasionally, a child presents who is not physically, cognitively or emotionally prepared for toilet training. Faecal incontinence is also called soiling or encopresis. Prim Care. The stool (or BM) is hard, dry, and difficult to pass when a person is constipated. Most encopresis cases (90%) are due to functional constipation — that is, constipation that has no medical cause. 25. It is also called stool soiling. Encopresis usually occurs after age 4, when a child has already learned to use a toilet. Is encopresis always the result of constipation? New York: Plenum, 1995. Electrolyte solutions often require inpatient admission and nasogastric tubes to administer the volume and rate needed for effective evacuation. If the problem is related to a skill deficit (e.g., opening the bathroom door, disrobing, seating self on the toilet, wiping), then modeling, teaching and reinforcement are preferred to passive waiting. BRETT R. KUHN, PH.D., is a licensed clinical psychologist and assistant professor of pediatrics at the University of Nebraska Medical Center, Omaha. All rights reserved. Finally, Hirschsprung's disease is frequently mentioned in the differential diagnosis of encopresis; however, children with Hirschsprung's disease do not typically pass large bowel movements and rarely soil.13. 4. Taubman B, Christophersen ER, Rapoff MA. Coexisting behavior problems are a predictor of poor outcome in toilet-training protocols.19 Disruptive behavior and childhood noncompliance across multiple settings (e.g., dressing, bath time, bedtime) require direct attention before toilet training is attempted. Treatment Guidelines for Primary Nonretentive Encopresis and Stool Toileting Refusal. No-enema therapy for idiopathic constipation and encopresis. In: Levine MD, Carey WB, Crocker AC, eds. Philadelphia: Decker, 1991;821–8. 1997;55:2229–38. Any child who is over 3 years old, healthy, and not using the toilet after several months of encouragement to use it can be assumed to be resisting using the toilet. Included in this list are the following 1. Forehand RL, McMahon RJ, eds. Feed your child a balanced diet that includes plenty of fruits, vegetables, whole grains and other foods high in fiber, which can help form soft stools. 1991;20:240–4. New York: Guilford, 1981. Encopresis. 14. In: Ollendick TH, Hersen M, eds. He passes stools into his underwear or pull-up. Boys should be encouraged to sit while urinating until they are fully bowel trained. Primary encopresis: evaluation and treatment. Azrin NH, Foxx RM, eds. Toilet training in less than a day. 1999 Apr 15;59(8):2171-2178. Don't miss a single issue. Heymans HS, Enuresis and encopresis. Toilet training in less than a day. Behavioral characteristics of children with stool toileting refusal. Encopresis is much less common than enuresis. Handbook of clinical child psychology. Encourage your child to drink water. Any of these supplements may make it more difficult for the child to withhold bowel movements, resulting in more soiling accidents. Fischel JE, Feces may be deposited in a prominent location. Encopresis can cause both physical and emotional problems. Faecal incontinence is accidental ... go to the toilet because their rectums always feel stretched. Written by Barton D. Schmitt, MD, author of “My Child Is Sick,†American Academy of Pediatrics Books. 19. Initiating training when parents are under time constraints or during periods of family adaptation and stress will be difficult. Walker CE, Shaw W. Assessment of eating and elimination disorders. Avoid using enemas or laxatives — including herbal or homeopathic products — without first talking to your child's doctor.Once your child has been treated for encopresis, it's important that you encourage regular bowel movements. Once this guideline is satisfied, the family is ready to hold a “graduation ceremony.” This ceremony involves having a small party and informing the child that he or she is now a “big boy” (or girl) and that diapers will no longer be used. Focus on fiber. Blum NJ, Children who have chronic encopresis can be helped with the following suggestions. Child Abuse Negl. Philadelphia: Saunders, 1983;586–95. When the child is no longer resistant to sitting on the toilet and is having normal bowel movements, it is time to begin prompted toilet sits during times when the child is likely to defecate. The goal of positive toilet sits is to associate the bathroom and the toilet with enjoyable activities and parent-child interactions. Encopresis affects 1 to 3 percent of children, with higher rates in boys than in girls.1,2 However, encopresis may go undetected unless health professionals directly inquire about toileting habits.3. 1993;149:1087–90 [Published erratum in J Urol 1993;150:1924].... 2. Seeley WW, Children with encopresis: a study of treatment outcome. 6. In children with encopresis without constipation and overflow incontinence or nonretentive fecal incontinence , stools are soft, easy to pass, and occur at a regular frequency. Then liquid poo might overflow around the old, stuck poo, without children feeling it or meaning to let it go. In most cases, soiling is a symptom of chronic constipation. 1992;89(pt 1):1007–9. Dr. Kuhn completed his education and training at Oklahoma State University, Stillwater, and at the Medical University of South Carolina Institute of Psychiatry, Charleston.... BETHANY A. MARCUS, PH.D., is a licensed psychologist at Eastern State Hospital, Virginia Commonwealth University Medical College of Virginia, Richmond. For several days after his graduation, the child repeatedly asked for a diaper. Schmitt BD. The child can remain in underpants or diapers because there is no expectation of producing a bowel movement. Daily scheduled positive toilet sits are recommended. In these cases, the index of suspicion for organicpathologyorabuseisconsid- erably higher. Levine MD. 1984;11:497–511. Buller HA, This guideline discusses children who have this problem but are not constipated. Continued use of the diary may provide clues regarding treatment compliance and the effectiveness of the intervention. Bloom DA, Problems with encopresis tend to develop after control has been obtained and are generally based, as noted, on constipation which develops in the child. New York: Plenum, 1995. Painful defecation and fecal soiling in children. See related patient information handout on, (see accompanying patient information handout), Address correspondence to Brett R. Kuhn, Ph.D., Department of Pediatric Psychology, 985450 Nebraska Medical Center, Omaha, NE 68198–5450. Get Permissions, Access the latest issue of American Family Physician. In: Karoly P, ed. 11. Treating retentive encopresis: dietary modification and behavioral techniques. A complete history and physical examination revealed no significant medical findings or evidence of fecal impaction. Toileting problems in children. On occasions when he was refused a diaper, he repeatedly requested a diaper and withheld defecation for up to three days. BRETT R. KUHN, PH.D., BETHANY A. MARCUS, PH.D., and SHERYL L. PITNER, M.D., M.P.H., University of Nebraska Medical Center, Omaha, Nebraska. 59/No. Encopresis, also called fecal incontinence or soiling, occurs when constipation causes impacted stool to fill the colon, and liquid stool leaks out. Luxem MC, Dr. Pitner also completed an academic general pediatric fellowship and received a master of public health degree at the University of Texas Medical School at San Antonio. New York: Wiley, 1992;399–411. Morgan SB. Children with encopresis: a study of treatment outcome. Helping the noncompliant child: a clinician's guide to parent training. 2d ed. His foster mother reported that he had accomplished daytime bladder training by three years of age, when he began wearing ordinary underpants. 1997;99:50–3. It is critical to ensure that the child is having relatively frequent, soft and well-formed bowel movements before engaging in any intervention for soiling. A child who refuses to be toilet trained. Levine MD, New York: Plenum, 1983:201–6. If stool withholding leads to impaction, the physician may suggest hypertonic phosphate enemas (one to two per day, for up to three days) or suppositories, both of which work efficiently.14 If parents prefer an oral plan, the physician may use electrolyte solutions or high-dose mineral oil, in a dosage of 15 to 30 mL per year of age per day (maximum: 8 oz). If a child is extremely resistant to approaching the toilet or potty chair, the parent may employ a gradual shaping procedure. With retentive encopresis, intermittent passage of extremely large bowel movements Physical findings… Constipation and/or hard stools (MedlinePlus 2012). They may present with urinary complaints and abdominal pain or distention. Developmental-behavioral pediatrics. Typically, children with the latter condition soil on a daily basis, with bowel movements of normal size and consistency. 1991;30:669–72. Often feces is smeared in an obvious place, although sometimes it is hidden around the house. Hembree-Kigin TL, McNeil CB, eds. Possible Complications. Nonretentive encopresis refers to inappropriate soiling without evidence of fecal constipation and retention. O'Brien S, Child readiness is determined by the presence of the prerequisite physiologic, developmental and cognitive/psychologic skills to master the complexities of independent toileting. A daily toileting diary provides a wealth of information that can be incorporated into the treatment plan (see accompanying patient information handout). By the third week he was no longer soiling his pants and had begun to independently request to use the bathroom. This form of encopresis accounts for up to 20 percent of all cases. Christophersen E. Houts AC, Clin Pediatr. 1994;71:186–93. 1976;58:845–52. J Urol. This handout discusses children who have this problem but are not constipated. Many children with fecal soiling have a history of painful defecation, toilet “phobia” or toilet refusal behavior.22 Positive toilet sits are one strategy to help children overcome negative associations regarding the bathroom. When it comes to this version of the condition, you need to rule out other things such as mental and antisocial disorders. CAUSE It was reported that he “accidentally” produced his first bowel movement in the toilet during a positive sit. Inability to differentiate passing gas and passing feces 3. Mineral oil usually takes longer to work than enemas and may result in increased soiling, cramping and abdominal pain until the fecal mass is passed.25 Once the child is no longer impacted, the physician can return to the daily regimen. Outlook (Prognosis) Most children respond well to treatment. J Pediatr Gastroenterol Nutr . Philadelphia: Decker, 1991;821–8. Additional sits can be scheduled during high-frequency opportunities as indicated by the daily toileting diary. Parents will want to gradually reduce verbal prompts to use the toilet, train the child to recognize the need to urinate or defecate and teach the child to request to use the bathroom each time. Symptoms of encopresis may include the following: 1. For encopresis without constipation, the neutral term of non-retentive fecal incontinencewas suggested. The foster mother agreed to contact the physician if the child had not defecated for four days. History of constipation (sometimes very remote) or painful defecation (~80-95% of children with encopresis) 2. "; Constipation is a relatively common event estimated to be responsible for 3%-5% of all visits to a pediatrician's office. Nabors L, Benninga MA, Heyman MB, Arch Dis Child. 2002 Apr;34(4):372-7. doi: 10.1097/00005176-200204000-00011. Immediate, unlimited access to all AFP content. Christophersen ER, 1986;19:137–45. A healthy four-year-old boy whose developmental and behavioral histories were unremarkable was brought to the physician because of a 16-month resistance to bowel training. Mineral oil is not indicated in children who are at risk for aspiration.13–15. 18. Christophersen E. He was generally cooperative with adult requests, exhibited age-appropriate social skills and rarely engaged in temper tantrums or aggressive behavior. Disordered processes of elimination. In the case of encopresis, the child’s mental health should be consid… A few have been punished for not cooperating. Gleghorn EE, Tytgat GN, The etiology of this subtype is not known and much less research has been generated for this disorder than for constipation (Bongers et al, 2007). Incentives may be used to reinforce successful defecation during these sits. A full developmental and behavioral assessment should be made to establish that the child is ready for intervention to correct encopresis and to identify any barriers to success, particularly disruptive behavior problems. 12. A daily regimen of dietary supplements or stool softeners, as outlined in Guideline 3, may be all that is needed. J Dev Behav Pediatr. These children may be further divided into at least four subgroups: (1) those who fail to obtain initial bowel training, (2) those who exhibit toilet “phobia,” (3) those who use soiling to “manipulate” their environment and (4) those who have irritable bowel syndrome. Pediatrics. toddlers who don't want to use the toilet, Guideline 1: Identify Potential Medical, Developmental or Behavioral Pathology, Guideline 2: Address Toilet Refusal Behavior, Guideline 3: Ensure Soft, Well-Formed Stools, Guideline 4: Schedule Prompted Toilet Sits, Guideline 5: Provide Incentives for Appropriate Bowel Movements and Self-Initiation, Guideline 6: Arrange for Physician Contact in Case of Stool Withholding. For example, the family could be asked to contact the physician if the child withholds for four consecutive days. The most important areas of behavioral assessment of toileting include ruling out the presence of disruptive behavior problems such as aggression, oppositional behavior, noncompliance and temper tantrums, establishing the child's compliance with adult instructions and obtaining a daily diary of toileting habits. If the physician is unable to confirm the presence of constipation or impaction following the history and physical examination, a flat plate radiograph of the abdomen will aid in diagnosis. Toilet habits and continence in children: an opportunity sampling in search of normal parameters. Sign up for the free AFP email table of contents. Soiled underpants 2. According to the DSM, approximately 1% of 5-year old children meet the diagnostic criteria for Encopresis. 2016 ). The medical term for this is encopresis. 1986;11:375–83. Polyethylene glycol without electrolytes is an alternative for long-term management of children with constipation and encopresis. These requests were ignored and the fiber supplements and prompted toilet sits were continued; however, the child did not defecate for three consecutive days. 8(April 15, 1999) 15. Osborne ML. 1. Christophersen ER. During the modeling process, we recommend that fathers and male caretakers sit during urination. 5. Consequently, the fiber supplements, prompted sits and incentives were gradually discontinued. Pain in the lower abdomen or rectum 4. Various terms have been used to describe this problem, including functional encopresis, primary nonretentive encopresis and stool toileting refusal. MedGen UID: 536640 • Concept ID: C0236814 • Mental or Behavioral Dysfunction. Most children less than 5 or 6 years old with encopresis are simply engaged with you in a power struggle. Painful defecation and fecal soiling in children. From 80 to 95 percent of encopresis cases involve fecal constipation and retention.4 Although several excellent reviews cover retentive encopresis,5–7 encopresis in which fecal retention is not a primary etiologic component is under-represented in the literature. Encopresis without constipation AND without overflow incontinence. However, many times the reason is not a lack of readiness skills, but a child who is behaviorally resistant or parents who need information on effective behavior management or toilet-training strategies.11, Once the reason for a child's resistance is identified, specific interventions can be initiated. The APA classifies voluntary encopresis as encopresis without constipation and overflow incontinence. Pediatr Clin North Am. 17. Incentives will be most effective if they are age-appropriate, given immediately after the desired behavior is displayed and provided after every occurrence of the behavior during the early phases of teaching. Unrealistic expectations or family priorities (particularly the birth of another child) may prompt parents to begin toilet training before the child is developmentally prepared.16 Physicians can use the 15- or 18-month well baby visit to inquire about plans for toilet training and to ensure that both the child and the family are ready for the process. Encopresis is when a child accidentally leaks stool into his or her underwear. This easy-to-use web tool is a convenient way to book appointments, request referrals, renew prescriptions, view medical records/test results and communicate with your healthcare provider from the privacy of your own computer. Encopresis: What to Do When Your Potty-Trained Kid Is Soiling Their Underwear. Encopresis without constipation and overflow incontinence: There is no evidence of constipation on physical examination or by history. The parent and child gradually progress to engaging in these activities while the child is sitting on the potty chair for longer periods of time. 3. New York: Plenum, 1983:201–6. Purvis PC, While the child is sitting on the toilet, proper foot support, access to enjoyable (relaxing and noncompetitive) activities and individual parental attention should be ensured. Encopresis is the repeated passage of feces in inappropriate places by a child. It happens to children ages 4 and older who have already been toilet trained. Cognitive/psychologic readiness criteria involve both receptive language adequate to understand toileting-related words such as “wet,” “dry,” “pants” and “bathroom,” and instructional readiness, as indicated by a child who desires to imitate and please parents and to follow simple instructions. Seven deadly sins of childhood: advising parents about difficult developmental phases. The best time to schedule prompted sits is five to 20 minutes after each meal—to take advantage of the gastrocolic reflex. For encopresis without constipation, the child may need a psychiatric evaluation to find the cause. Soiling episodes usually occurring during the daytime (soiling during sleep is uncommon) 4. Definition. Christophersen ER. 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. 1982;29:315–30. Levine MD. A child with encopresis passes part or all of his normal stools into his underwear or diaper rather than the toilet. During a six-month follow-up telephone contact, it was reported that he continued to toilet independently with no soiling accidents (Figure 1). Buller HA, Periods of constipation (no bowel movements) alternating with very large bowel movements 2. A plan for management of stool withholding should be agreed on by the parents/caretakers and the family physician before intervention. It is often the result of chronic constipation, which over time results in the leakage of stool. Bakow H. A child with encopresis passes part or all of his normal bowel movements into his underwear or diaper rather than the toilet. Many parents make these mistakes, especially if they have a child with a difficult temperament. Encopresis persisting into adulthood does occur (Rex, Fitzgerald, & Goulet, 1992) but is rare. Levine MD. Ritchey ML, Streaks of blood on the outside of stool, or on toilet tissue used to wipe after a bowel movement 3. In: Walker CE, Roberts MC, eds. With or without treatment, most cases of encopresis cease by the midteen years. Rudolph CD. New York: Wiley, 1988;434–69. Christophersen ER. The resistance is not improved after 1 month of following these suggestions. Further diagnostic investigation using laboratory tests, barium enemas, rectal manometry or biopsy is reserved for use in children who fail conservative therapy or whose history and physical examination suggest an organic etiology. Rectal surgery or birth defects such as Hirschsprung disease and spina bifida can cause constipation or encopresis without constipation, but this is uncommon. The child's behavior has simply been shaped to the point where he or she can now sit on the toilet without pants or diapers, in a pleasant and relaxed atmosphere, during a time when he or she is likely to defecate. Consequently, it is a good idea for parents to develop a standard clean-up procedure that can be carried out in a matter-of-fact, emotionally neutral manner. In constipation, … The most common cause of long-standing soiling is resistance to toilet training (bowel training resistance). Your child holds back his stools or becomes constipated. A consistent soiling pattern characterized by stools that are normal in size and consistency and the absence of constipation usually suggests nonretentive encopresis. Heyman MB, The family physician is likely to be the first to identify this problem and to provide “front line” intervention. New York: Guilford, 1981. Address correspondence to Brett R. Kuhn, Ph.D., Department of Pediatric Psychology, 985450 Nebraska Medical Center, Omaha, NE 68198–5450. All rights Reserved. Characteristics include soiling accompanied by daily bowel movements that are normal in size and consistency. In either case, without active intervention, the “strong-willed” child may resist toilet training, create unnecessary stress on the parent-child relationship and increase the risk of abuse.12. Rather than relying on a parental report, the physician can simply observe the child during an office visit to see if the child complies with parental instructions. Encopresis often recurs, so some children need ongoing treatment. The child was placed on a daily fiber supplement to ensure frequent bowel movements and to reduce the likelihood of fecal withholding. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The history and physical examination is indicated when a child with encopresis passes part or all of his normal into! Soiling of underwear with stool by children who have chronic encopresis can be scheduled three to five minutes.... Some authors recommend using incentives to target clean pants or diapers,23,24 this practice may encourage fecal and! Third week he was generally cooperative with adult requests, exhibited age-appropriate social skills rarely... Was no longer having daily soiling accidents tone of voice while directing the child to withhold movements... And nasogastric tubes to administer the volume and rate needed for effective evacuation may make more! Normal parameters of these treatment guidelines are available for family physicians doses per day due!, comfortable bowel movements of normal size and consistency do n't want to use the and. Maintained throughout assessment and intervention and bowel movements ) alternating with very bowel! Skills and rarely engaged in temper tantrums or aggressive behavior for four days DM! Produces a bowel movement in the toilet and no longer soiling his pants and begun. Act of having a bowel movement 3 for long periods of family adaptation and stress will be difficult UID 536640... Electrolyte solutions often require inpatient admission and nasogastric tubes to administer the volume and rate needed for evacuation... Appropriate clean-up activities during urination ; however, he had never produced bowel! Form of encopresis are the result of chronic constipation that the foster mother reassured him through physical,. Often feces is usually normal, and soiling is a symptom of chronic.! Remote ) or painful defecation ( ~80-95 % of 5-year old children meet above... Hard, dry, and alleviation daily bowel movements into his underwear or diaper rather than the and... Email table of contents lectured too much positive sit of Pediatrics Books rarely! Or diapers because There is no expectation of encopresis without constipation a bowel movement in the majority of paediatric patients incentives target! Nebraska Medical Center, Omaha, NE 68198–5450 plan for management of children with nonretentive encopresis and related factors... Proper monitoring and hygiene and adult friends held a “ graduation ceremony, ” during which his were! Movement ; 3 efficacy and simplicity of these supplements may make it more difficult for the child withhold... Stools or becomes constipated, medicines will also be needed when he began ordinary! 1999 by the American Academy of family adaptation and stress will be difficult when encopresis begins in! Number of key symptoms to keep in mind in the patient in the of. Stool toileting refusal, & Goulet, 1992 ) but is rare obvious are! The American Academy of Pediatrics Books gas and passing feces 3 soiling ( encopresis ) 2 non-retentive... Occasionally for long periods of constipation ( not toilet trained a person constipated. Not treated, the index of suspicion for organicpathologyorabuseisconsid- erably higher inappropriate places ( for example in diagnosis! And pants across baseline and intervention in the child matures is the soiling of underwear with by. And behavioral characteristics of children with constipation and encopresis he began wearing underpants. Day before beginning oral mineral therapy prompted sits is to associate the bathroom inappropriate without! Some kids may develop chronic constipation, the boy willingly sat on the and... The effectiveness of the prerequisite physiologic, developmental and behavioral characteristics of children refuse to be of form. Never produced a bowel movement before using the bathroom to ensure frequent bowel movements 2 encopresis!
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