[ NEW ANSWERS ] Q: How long after encopresis appears to be resolved should a patient continue to take the medicine prescribed to treat it? My daughter's encopresis had successfully resolved for 2 weeks, which was wonderful, but then I began to see evidence of soiling in her underwear; also, she seemed to lose her appetite somewhat. A: No set duration of treatment for encopresis has been determined. In most cases, a minimum of 3 months of continuous treatment is recommended, sometimes extending to 6-12 months of continuous treatment. Rather than abruptly stopping medications, usually the dose is gradually decreased over a period of several weeks to several months. During this time, the focus is on the child passing bowel movements at least once or twice each day without any pain, fear, or resistance. The child should be toileting on his or her own, without frequent prompting or reminders by parents. The symptoms you describe suggest your daughter is not completely evacuating when she uses the toilet; she may have gradually reaccumulated stool in her colon. Q: My 4-year-old brother has a problem with soiling his underwear. Because of this, he has to have baths 4-5 times a day and needs his bedding changed at least twice each night. This has become very hard on my mom, who also has 2 other children to look after. What sort of help might be available for this problem? A: Most children with soiling or stool seepage have what is called encopresis, and most children with encopresis have retentive encopresis, meaning that the soiling or seepage results because soft or liquid stool is leaking around firmer stool trapped in the colon. Most children with encopresis have at least some history of constipation or of passing very large bowel movements. In most cases, the treatment of retentive encopresis is based on 3 principles. First, completely evacuate the colon with oral cathartics or enemas. Second, use sufficient laxatives, stool softeners, or both to produce at least one soft stool each day without pain. Third, make the necessary lifestyle and behavioral changes so that the child is sitting on the toilet at least twice every day (preferably after breakfast and after supper) and passing bowel movements without pain or resistance. In older children, medical therapy in combination with counseling from a behavioral psychologist to enlist the child's help in his own cure is usually very worthwhile. Among older children, a crucial aspect of treatment is for the child to ultimately "take ownership" of this problem; otherwise, it will continue to occur, perhaps even recur after initial success. Q: My 10-year-old daughter has always had extremely large bowl movements, sometimes even larger than the toilet drain. I have to remove it from the bowel or break it up to flush the toilet. She can easily go 10 days or so between bowel movements. She never complains of pain or cramping, but she almost always has seepage in her underpants. I've tried laxatives, fiber, and other things; even enemas don't work. Physicians have told me she will outgrow this problem, but I wonder if another solution is available? A: From the information you have provided, your daughter probably has acquired megacolon. This means her large intestine has become stretched out of shape and is too large. In almost all children, this problem begins because the child experiences pain with passing bowel movements and then starts withholding stool. Because of the withholding, the large intestine gradually stretches out of shape, which results in very large bowel movements. Passing the large bowel movements is often very painful. If this process persists over time, a vicious cycle of withholding, passing large bowel movements, and having more pain develops. Once this cycle is established, disrupting it can be extremely difficult. The seepage you describe is almost certainly due to overflow, which is often called retentive encopresis. The seepage results from liquid stool leaking around firmer stool trapped in the colon. As is the case with your daughter, most affected children have at least some history of prior constipation or of having very large bowel movements. In most cases, the treatment of acquired megacolon and retentive encopresis is based on 3 principles. First, completely evacuate the colon with oral cathartics or enemas. Second, use sufficient laxatives, stool softeners, or both to produce at least one soft stool each day without pain. Third, make the necessary lifestyle and behavioral changes so that the child is sitting on the toilet at least twice every day (preferably after breakfast and after supper) and passing bowel movements without pain or resistance. In older children, medical therapy in combination with counseling from a behavioral psychologist to enlist the child's help in her own cure is usually very worthwhile. Among older children, a crucial aspect of treatment is for the child to ultimately "take ownership" of this problem; otherwise, it will continue to occur, perhaps even recur after initial success. Q: My 4-month-old son has been suspected of having Hirschsprung disease since he was 2 weeks old, when he was hospitalized for severe abdominal distension and bile vomiting. Ever since, he has been unable to pass stool or passes it very infrequently. He continues to have vomiting and abdominal distension. We give him lactulose daily to encourage regular bowel movements. He has had a biopsy and anorectal manometry, both of which had negative results for Hirschsprung disease. Our gastroenterologist now seems to be considering a diagnosis of some form of encopresis or perhaps even laziness resulting from his frequent irrigations. Is it possible for children this young to develop encopresis? A: Because encopresis implies the child is soiling his or her underwear, most pediatricians and gastroenterologists do not make the diagnosis of encopresis until the child is beyond the age of toilet training, which is generally age 3-4 years. From the information you have provided, your son's principal symptom is constipation. He is either unable or unwilling to regularly pass bowel movements. From the information you have provided, a diagnosis of Hirschsprung disease is quite unlikely. In most young children with constipation, the constipation develops because the child experiences pain when he or she passes bowel movements. Children may develop pain when passing bowel movements because they are passing large or hard bowel movements, they have a small tear at their anal opening (an anal fissure), or they have a diaper rash. If they repeatedly experience pain with the passage of bowel movements, a vicious cycle of withholding, passing large bowel movements, and having more pain develops. Once this cycle is established, disrupting it can be extremely difficult. I believe even young infants will withhold if they experience pain with the passage of bowel movements. I do not believe they do this consciously, but rather, they do it reflexively as a way to avoid pain. In young children, treatment must be focused on softening the stools and eliminating any pain associated with passage of bowel movements. This is usually accomplished with some form of stool softener such as lactulose, polyethylene glycol (Miralax), or milk of magnesia. Importantly, all of these medications work as stool softeners. They do not make the child pass a bowel movement; rather, they soften the stool so the child does not need to strain as hard, and, when the stool is passed, it does not cause pain. Q: I am working with a kindergarten student who has been diagnosed with sickle cell disease. He often experiences urinary and fecal incontinence. He wears pull-up diapers to school. The urine problem seems to be a complication of sickle cell disease. I have not been able to find any research indicating that the fecal incontinence can also be related to the sickle cell disease. He does well academically and seems to be a bright boy; however, at school, he averages 2 bowel movement accidents each day. This is becoming a problem for his kindergarten teacher and the school nurse, who have to clean him up and change his pull-up diapers. Please offer insight into this problem and its possible relationship to sickle cell disease. Also, any advice on therapy would be helpful. A: I am not aware of any research that indicates either urinary or fecal incontinence is more common in children with sickle cell disease. Among children who are neurologically and developmentally normal, soiling or seepage is almost always caused by encopresis. Most children with encopresis have retentive encopresis, meaning that the soiling or seepage results because soft or liquid stool is leaking around firmer stool trapped in the colon. Most children with encopresis have at least some history of constipation or of passing very large bowel movements. Many of these children also experience intermittent urinary incontinence, and, often, when the encopresis is adequately treated, the urinary incontinence improves or resolves. In most cases, the treatment of retentive encopresis is based on 3 principles. First, completely evacuate the colon with enemas or oral cathartics. Second, use sufficient laxatives, stool softeners, or both to produce at least one soft stool each day without pain. Third, make the necessary lifestyle and behavioral changes so that the child is sitting on the toilet at least twice every day (preferably after breakfast and after supper) and passing bowel movements without pain or resistance. In older children, medical therapy in combination with counseling from a behavioral psychologist to enlist the child's help in his own cure is usually very worthwhile. Among older children, a crucial aspect of treatment is for the child to ultimately "take ownership" of this problem; otherwise, it will continue to occur, perhaps even recur after initial success. [ PAST ANSWERS ] Q: My 9-year-old grandson has encopresis but seems to have better control during the summer months, when he is not in school. He is harassed a lot by his 2 sisters because they are responsible for doing his laundry. Also, his mother doesn't seem to care about his problem and does nothing, dietary or otherwise, to help. How can I help the family get along better? Also, is the mother's lack of concern grounds for child abuse? A: I cannot comment on whether this is child abuse; I would need much, much more information. Many children who suffer from encopresis seem to do better during the summer months or during vacations. This may be because during the summer and during vacations, children have free access to the bathroom whenever they want. During school, children often must ask permission to use the toilet. Moreover, many children are very embarrassed or unwilling to defecate in school bathrooms. As children with encopresis get older, it is extremely important that they take a greater level of ownership over their toileting. I strongly emphasize that school-age children establish very regular toileting times. I recommend once in the morning, before they go to school, and then again in the evening, when they return home from school or after supper. Importantly, this schedule must be followed every day. Q: My child has recently been diagnosed with encopresis and is taking polyethylene glycol 3350 (Glycolax). She has always had chronic stomachaches. Could this also be a symptom of encopresis? A: Many children with chronic constipation and encopresis have chronic or recurrent abdominal pain that improves once the constipation/encopresis has been adequately treated. A number of factors can contribute to abdominal pain in children with encopresis. If the intestine is overstretched with stool, some children experience abdominal cramps. Sometimes, this type of pain can be relieved with the passage of gas, stool, or both. Some children develop symptoms of gastroesophageal reflux, including intermittent heartburn, regurgitation, and/or vomiting. This results from extra pressure in the lower intestine and from slow emptying of the stomach. Q: My 4-year-old son has recently been diagnosed with encopresis. He has always been a fussy eater and has had constipation since age 18 months. We have altered his diet in order help with the problems; his doctor also prescribed lactulose, which gave him severe stomach pains and may have made matters worse. He now takes senna (Senokot) every other day, and I also give him fresh-squeezed orange juice to make his stools softer to pass. The doctor recommended that I give him Senokot twice a day every day, but this caused stomachaches. I now give it to him every other day. I have a visit scheduled with another doctor, who said he will give us another medicine, but I am starting to worry about relying on medicines for my son to pass stool. Also, he acts very embarrassed about toileting and seems to hate sitting on the toilet. I believe he is holding back his stool, refusing to have a bowel movement. He once went 8 days (even while taking laxatives) without passing stool, and when he passes gas, diarrhea comes out. He also is under the care of a dietitian, but the progress seems extremely slow. All he used to eat was French fries, but I recently got him to eat some roast and a sausage, which was encouraging. He starts school soon, and, because of his soiling problems, I am worried about how he will cope. Finally, he wets his bed at night, and I wonder if this is connected in some way with the encopresis? A: Once the cycle of fear, pain, withholding, and constipation has been established, diet therapy is rarely sufficient to produce regular soft bowel movements. Some form of laxative/stool softener is almost always necessary. Importantly, many of the medications routinely used for constipation are purely stool softeners. Lactulose is a type of sugar that is not digested very efficiently by the intestines, and, as a result, it remains in the intestine and keeps water with it. As a result of this extra intestinal water, stools become softer. Lactulose does not "make" the child pass a bowel movement; rather, it keeps the stools soft so the child can comfortably pass the bowel movement on his or her own. The most common adverse effects of too much lactulose are diarrhea, excessive gas, and bloating. A substantial number of children with enuresis (nighttime wetting) also have chronic constipation, and, many times, once the constipation has been adequately treated, the wetting improves or resolves completely. Q: My 12-year-old son has been diagnosed with abdominal migraines. Is this a real diagnosis or just a theory, and how can we be sure that we have the correct diagnosis? He has had 2 episodes of nausea and vomiting 4 years apart that lasted 4-6 weeks each. He was been tested for many diseases during his illness and hospitalizations. My question is, have all enzymes required for digestion been identified, and, if so, are tests available for testing levels of these enzymes? A: Abdominal migraine is a real diagnosis. Many gastroenterologists believe that abdominal migraine is on a continuum with something called cyclic vomiting syndrome. This is exactly as it sounds—cycles of vomiting. Typically, the vomiting begins very abruptly and the child vomits repeatedly for hours to days. Some children have very regular and predictable bouts of vomiting; others have sporadic and infrequent bouts. Between these bouts of vomiting, the child usually has no intestinal symptoms. Some affected children have a headache immediately prior to or during bouts of vomiting. Other children have an aura just before an attack begins. They may see spots, smell something unusual, or hear something unusual. Over time, many children with abdominal migraine, or cyclic vomiting syndrome, develop more classic migraine headaches. This often occurs around puberty. At that point, the bouts of vomiting may decrease in frequency or resolve completely. Unfortunately, no single test is available for abdominal migraine or cyclic vomiting syndrome. It is a clinical diagnosis; that is, the history, physical examination findings, and all diagnostic tests do not demonstrate any other abnormalities and all fit with a diagnosis of abdominal migraine or cyclic vomiting syndrome. Q: My 10-year-old son has had encopresis since he was very young. While his condition is controlled to the point where he no longer has problems at school, he still has problems on weekends. Why has he been able to resolve it in some situations and not others? When I talk with him he is still obviously very upset about the accidents but does not understand why they happen. One therapist thinks he is repressing anger, but he doesn't seem angry about anything other than how this affects him. I have searched high and low for information on the emotional effects this may have on my son. Do you have any insight to offer? A: Research suggests that in most children, encopresis is not caused by emotional problems. Rather, research findings from the University of Virginia and a number of other institutions suggest that many children experience emotional problems as a result of the encopresis. Often, once the encopresis is adequately treated, the emotional and behavioral problems improve. In some children, encopresis may persist because of their inability to recognize or attend to the normal urge to pass a bowel movement when stool moves down into their rectum and stretches it. This may be why children with attention-deficit disorder seem more prone to developing encopresis. Your son may do better during the week because he has a much more structured daily routine with very regular toileting times. Starting him on a regular toileting routine on weekends and during vacations may be helpful. I often suggest toileting for 5-10 minutes every morning after breakfast, and then toileting again every evening after supper. Toileting after meals takes advantage of the gastrocolic reflex—a reflex that signals the colon to empty when food hits the stomach. Q: My 7-year-old son has been having soiling problems for more than 4 years. He has accidents at school, daycare, and home. He claims he cannot feel when he needs to use the bathroom, and he does not even know when he has soiled himself. After a visit to the doctor, she diagnosed him with attention-deficit/hyperactivity disorder, thinking that the medication for this disorder would help him recognize when his body was telling him to use the bathroom. This worked for about 2 weeks, and then he started soiling his pants again. His doctor wanted us to go to a counselor, but our insurance wouldn't pay for it and we couldn't afford it otherwise. So, we asked for a referral to a gastroenterologist, who started my son on polyethylene glycol (Miralax). He also received a barium enema and had 2 rectal biopsies. The biopsy results were normal. Can my son still have encopresis even though he has normal rectal biopsy results? A: Based on the information you have provided, your son almost certainly has encopresis. The vast majority of children with encopresis have retentive encopresis, meaning the soiling is a result of long-standing constipation. With retentive encopresis, the soiling occurs because soft or liquid stool leaks around firmer stool in the intestine; typically, the child cannot feel the accidents until they happen. Encopresis seems to be more common among children with attention problems. The diagnosis of encopresis is clinical in nature, which means the diagnosis is based on a careful history and a careful physical examination. The tests your son underwent were probably performed to exclude other causes for his soiling. When a gastroenterologist or surgeon performs a biopsy of the rectum, he or she is usually trying to exclude Hirschsprung disease. Hirschsprung disease is sometimes called congenital megacolon or congenital intestinal aganglionosis. It is a rare disorder, occurring in approximately 1 in 5000-10,000 newborns. It is much more common in boys than in girls. Hirschsprung disease results when some of the nerves in the intestine (ie, ganglion cells) do not develop normally. These nerves are important for helping the intestine relax. In children with Hirschsprung disease, the intestine is constantly squeezed tight, preventing stool from passing. Almost all children with Hirschsprung disease have problems with constipation from the day they are born; as many as half the babies with Hirschsprung disease do not pass their first bowel movement during the first 36 hours of life. Soiling is actually quite rare in children with Hirschsprung disease. Q: My 9-year-old son is still having bowel movements in his pants. He did not have trouble with potty training, and he was completely trained until he was aged 4 years. For the past 5 years, he has bowel movements in his pant 4-5 times a week. I have taken him to several different specialists, but they have not found anything wrong with him. I was told that some children just do this. I have tried to control the problem by ignoring it and by taking away things he loves. Sometimes these methods work for a short time, but most of the time they do not help. He says he does not know he has to go to the bathroom until it starts coming out. I wonder why sometimes he can control it but other times he cannot. No dramatic changes have recently occurred in our home (eg, divorce, new baby). At a previous visit to the doctor, he had a rectal examination and the doctor pressed on his stomach, but that was the extent of his evaluation. Are any tests available to determine if he truly has a medical condition or if the problem is related to something else? A: The vast majority of children with soiling have retentive encopresis, meaning that the soiling is a result of an overflow of liquid stool around the solid stool that is trapped in the colon. Most affected children have at least some history of prior constipation or of passing large stools intermittently. In most cases, therapy is based on 3 principals: (1) completely evacuating the colon with enemas or oral cathartics, (2) using sufficient laxatives to produce at least one soft stool each day without pain, and (3) making the necessary lifestyle and behavioral changes so that the child is sitting on the toilet twice each day (preferably after breakfast and after supper) every day, without exception, and passing a bowel movement without pain or resistance. In older children, in conjunction with the use of laxatives and enemas, the aid of a behavioral psychologist to enlist the child's help in his or her own cure can be very worthwhile. A psychologist with the appropriate expertise can help the child understand how to use his or her muscles correctly while straining and can offer some additional behavioral modification techniques. Among older children, a crucial component of care is for the child to ultimately “take ownership” of the problem; otherwise, it will continue to occur. Various incentive programs can be established depending on the developmental age and the motivation of the child. Target behaviors should be spontaneous trips to the toilet and clean underwear. Q: My stepdaughter has encopresis, and she has seen a pediatric gastroenterologist. She has soiling accidents once a day, usually in the evening. She is currently taking 1 capful of polyethylene glycol (Miralax) each morning. In the event we forget to give her the medicine in the morning, should we give it to her at night and in the morning the next day or should we just skip the dose for that day? A: Polyethylene glycol (the active ingredient in Miralax) is a stool softener. This is a very large molecule that is not absorbed by the intestinal tract. As a result, the polyethylene glycol remains in the intestine and traps water with it. The retained water is actually softening the stool. For most children, a dose of Miralax given in the evening produces a bowel movement the following morning, and, a dose given in the morning produces a bowel movement in the afternoon or evening. Consequently, the timing of the Miralax (or any other stool softener) administration can be adjusted to produce bowel movements at desired times. Because most school-aged children prefer to not pass bowel movements while at school, the preferred protocol is to establish regular toilet times for 5 minutes every morning before school and for every afternoon after school or after supper. While the preference is that children receive their medicines at the same time every day, this is not critical. If a dose is missed, doubling-up the dosage to make up for the missed dose is not usually necessary. Q: My 9-year-old old son has encopresis. He has had it for 2 years. We have tried everything with him, but nothing has worked. He refuses to report his frequent soiling to us, he refuses to sit on the toilet for any length of time, and he hides his underwear to make us think he is not having accidents. He is being very stubborn, and we have now put him in diapers to try to stop the hiding of underwear. We recognize he has a medical problem, but we feel he needs to take some responsibility for the problem and he should be part of the solution. Can you offer any advice to alter his defiant behavior regarding this problem? A: The vast majority of children with soiling have retentive encopresis, meaning that the soiling is a result of an overflow of liquid stool around the solid stool that is trapped in the colon. Most affected children have at least some history of prior constipation or of passing large stools intermittently. In most cases, therapy is based on 3 principals: (1) completely evacuating the colon with enemas or oral cathartics, (2) using sufficient laxatives to produce at least one soft stool each day without pain, and (3) making the necessary lifestyle and behavioral changes so that the child is sitting on the toilet twice each day (preferably after breakfast and after supper) every day, without exception, and passing a bowel movement without pain or resistance. In older children, in conjunction with the use of laxatives and enemas, the aid of a behavioral psychologist to enlist the child's help in his or her own cure can be very worthwhile. A psychologist with the appropriate expertise can help the child understand how to use his or her muscles correctly while straining and can offer some additional behavioral modification techniques. Among older children, a crucial component of care is for the child to ultimately “take ownership” of the problem; otherwise, it will continue to occur. Various incentive programs can be established depending on the developmental age and the motivation of the child. Target behaviors should be spontaneous trips to the toilet and clean underwear. Q: My son is aged 3 years, and I have heard that most health professionals do not diagnosis encopresis until a child is aged 4 years. However, my son has had problems going to the bathroom since birth. His constipation causes significant crying and straining when he attempts to have a bowel movement. My son has been toilet trained for almost 9 months, but he still soils his pants and does not seem to realize he is having a bowel movement. He also has markings in his pants, even when he has not had a bowel movement for days. His stomach seems to be constantly bloated. All efforts (eg, rewarding good bathroom behavior) to help him correct this behavior have failed. He is starting nursery school soon, and I do not want him to feel self-conscious about this problem. Although I have scheduled a visit with his physician, please offer your opinion about this situation. A: The official psychiatric definition of encopresis, as listed in the Diagnostic and Statistical Manual of Mental Disorders, is “The repeated involuntary passage of feces into places not appropriate for that purpose . . . the event must occur at least once a month for at least six months, the chronologic age and mental age of the child must be at least four years . . . ” Most pediatric gastroenterologists do not set a specific lower age limit for childhood encopresis. The vast majority of children with soiling have retentive encopresis, meaning that the soiling is a result of an overflow of liquid stool around stool that is trapped in the colon. Most affected children have at least some history of prior constipation or passing large stools intermittently. This certainly sounds to be the case in this little boy. Q: Is it possible that my child developed encopresis as a result of a slight anal fissure when he was aged 2.5 years? He is now aged 4.5 years, and his pediatrician has suggested that his problem is related to potty training. However, I disagree because he was doing fine before the fissure. Also, can this condition run in families? A: The vast majority of children with soiling have retentive encopresis, meaning that the soiling is a result of an overflow of liquid stool around the solid stool that is trapped in the colon. Most affected children have at least some history of prior constipation or of passing large stools intermittently. It is very possible that your child’s problems developed as a result of anal fissures. In the vast majority of children, constipation and refusal to defecate develop because the child has pain when he or she passes bowel movements. Anal fissures are very small tears or cuts around the anal opening. In young infants, anal fissures often develop as a result of a severe diaper rash. Older children may develop anal fissures following a bout of diarrhea or when they pass a very large bowel movement that forces the anal sphincter to open too wide. Q: Can encopresis be caused by a child not wanting to have a bowel movement outside of his or her own home? My 6.5-year-old son does not like to go to the bathroom anywhere other than home unless we “can check if he has wiped enough.” He is having occasional accidents at school at the end of the day or when he is on “play dates” with friends after school. The problem is affecting him socially. Other children are being cruel to him about the problem. Is this a behavioral problem? Is self-imposed constipation causing this condition? A: Encopresis almost always develops as a result of long-standing constipation. The vast majority of children suffering from encopresis have a history of constipation or a history of passing large and/or painful bowel movements. In many cases, the child or the parents do not recall the constipation because it began so long ago. In many children, chronic constipation, and subsequently encopresis, develops not long after school entry. Many children will not or cannot go to the bathroom at school. (Many adults also will not use the bathroom at work or in public places.) Because affected children stop emptying themselves regularly, their large intestines slowly fill and enlarge. As the large intestine becomes progressively larger, liquid stool from the small intestine begins to leak around the more formed stool. In the beginning, this leakage is only a small amount that streaks or stains the underwear, and the parents assume their child simply is not wiping very well. As the intestine continues to stretch, the amount of leakage increases; eventually, the child begins having accidents in his or her underwear. In most cases, encopresis is not primarily a behavioral problem. Most children with encopresis do not have accidents out of spite or because they are lazy. Rather, many behavioral problems develop because of the encopresis. Most children are embarrassed by their accidents, but they do not know how to make the problem go away, and, as a result, they develop a number of potentially counterproductive coping strategies. Once the encopresis is adequately treated, many of these behavioral problems resolve. Q: I have a 10-year-old son, and I am worried that he hardly ever has bowel movements. He never complains about gas or pain, but his stomach is big and hard as a rock. The last time he had a bowel movement was approximately 3 weeks ago. I know he's holding it all in because he hates to use the toilet for some reason. Even though everything seems normal and he does not complain, I am still worried. What could be the problem, if any? A: In the vast majority of children, refusal to defecate develops because the child has pain when he or she passes bowel movements. Typically, the pain results from the passage of very large and/or hard bowel movements. Once children become afraid of passing bowel movements, the cycle of chronic constipation begins. Because the child is “holding back,” his or her large intestine slowly fills with stool and becomes stretched out of shape. When the intestine is stretched slowly and continuously, the walls of the intestine relax and begin the process of what medical professionals have termed “accommodating.” As the large intestine accommodates, it grows progressively larger. Doctors sometimes call this megacolon, meaning that the large intestine is much bigger than normal. This explains why children with chronic constipation can pass bowel movements that are extremely large, often larger than bowel movements passed by fully grown adults. These children's large intestines are stretched out of shape. I expect your son's stomach is “big and hard” because his large intestine is stretched out of shape as a result of chronic stool withholding. Q: I am a school nurse and have cared for a 10-year-old student who soils himself at school. He also has severe ichthyosis. His parents initially were reluctant, but recently they admitted he also has soiling problems at home. At school, he soiled himself twice in 1 month. The school guidance counselor called the mother to seek help, but the mother was again reluctant to agree her son has a problem. Do you have any suggestions on how to proceed with this situation? A: The vast majority of children with soiling have retentive encopresis, meaning that the soiling is a result of an overflow of liquid stool around the solid stool that is trapped in the colon. Most affected children have at least some history of prior constipation or of passing large stools intermittently. In most cases, therapy is based on 3 principals: (1) completely evacuating the colon with enemas or oral cathartics, (2) using sufficient laxatives to produce at least one soft stool each day without pain, and (3) making the necessary lifestyle and behavioral changes so that the child is sitting on the toilet twice each day (preferably after breakfast and after supper) every day, without exception, and passing a bowel movement without pain or resistance. In older children, in conjunction with the use of laxatives and enemas, the aid of a behavioral psychologist to enlist the child's help in his or her own cure can be very worthwhile. A psychologist with the appropriate expertise can help the child understand how to use his or her muscles correctly while straining and can offer some additional behavioral modification techniques. Among older children, a crucial component of care is for the child to ultimately “take ownership” of the problem; otherwise, it will continue to occur. Various incentive programs can be established depending on the developmental age and the motivation of the child. Target behaviors should be spontaneous trips to the toilet and clean underwear. Q: My 4-year-old daughter has had gastroesophageal reflux disease (GERD) since birth. She was treated with cisapride (Propulsid), cimetidine (Tagamet), an aluminum and magnesium antacid (Mylanta), and thickened food. She has also had constipation since birth. My pediatrician suggested the constipation was caused by the GERD and resultant delayed gastric emptying. We attempted to control her diet to resolve the constipation problem, but this has been unsuccessful. Her stomachaches continued, and she began therapy with ranitidine (Zantac) and then famotidine (Pepcid). Her constipation continues to be a problem, and I wonder if this might be encopresis. When she has a bowel movement, it is large and unusually smelly. She also soils herself on occasion. Although I am reluctant to take her to a pediatric gastroenterologist because I do not want to subject her to unnecessary invasive testing (and, possibly, anesthesia), do you think this might be appropriate? Also, could the GERD (and medications) possibly be related to encopresis? A: The vast majority of children with soiling have retentive encopresis, meaning that the soiling is a result of an overflow of liquid stool around the solid stool that is trapped in the colon. Most affected children have at least some history of prior constipation or of passing large stools intermittently. Most, if not all, of your daughter's abdominal symptoms may be a consequence of her chronic constipation. Chronic constipation can certainly worsen the symptoms of GERD and can produce delayed gastric emptying. In a recent published report, the authors described a large number of children with chronic gastroesophageal reflux whose symptoms completely resolved once their constipation was adequately treated. In animals, the inflation of a balloon in the rectum results in delayed gastric emptying. Similarly, in studies in which healthy college students are asked to voluntarily withhold their stool for 7 days, their gastric emptying progressively slows. Once they evacuate, their gastric emptying quickly returns to normal. Moreover, a number of studies have shown that gastric emptying is substantially delayed in adults with chronic constipation, and, once their constipation is adequately treated, gastric emptying often improves or even returns to normal. Regarding the issue of if and when a child should be referred to a pediatric gastroenterologist, it is always appropriate to seek a second opinion if you are uncomfortable with the information or the treatment plan your child's physician has provided. Many pediatricians and family physicians are comfortable treating children with intestinal problems; however, pediatric gastroenterologists specialize in the evaluation and management of intestinal problems in infants and children. As many as one third of all children seen by pediatric gastroenterologists have constipation or encopresis. Q: My 7-year-old son has started having bowel movements while he is taking a shower. This started approximately 2 weeks ago, and it occurs almost every night. He says he does not know why he is doing this and that he cannot help it. Could he possibly be engaging in some sort of self-exploratory behavior while showering that may stimulate a bowel movement? Also, I am an expectant mother and I wonder if my son's excitement over the birth of his new brother or sister may be contributing to the problem. Finally, my son has attention-deficit/hyperactivity disorder (ADHD). A: The vast majority of children who soil themselves are experiencing retentive encopresis, meaning that the soiling results from the leakage of soft stool around more-formed stool that is trapped in the colon. Most affected children have at least some history of prior constipation and/or passing large or painful stools intermittently. Encopresis appears to be more common among children with attention problems such as ADHD. While the reason for this is not clear, a logical theory is that children who have trouble maintaining attention may have difficulty attending to normal body cues. When children are in the bathtub or in the shower, they often relax their anal sphincter muscles because of the soothing nature of the warm water. As a result of this relaxation, some soft stool in rectum make leak out. Young children with chronic constipation commonly defecate while in the bathtub. Q: I am the daytime guardian of a 4-year-old boy who refuses to have bowel movements. After approximately 5 days, he eventually has a large bowel movement in the middle of the night, described as a 'blow out' by his mother. One doctor suggested having the child wear diapers at school and at home. I feel this will be humiliating for the child. What other information might be valuable in this situation, and what options are available to the parents of this child? A: In the vast majority of children, constipation and refusal to defecate develop because they have pain during attempts to pass bowel movements. Once a child becomes afraid of passing bowel movements, he or she often holds back. That is, the child does not completely empty his or her bowels when going to the bathroom. Some have termed this withholding. Because the child is holding back, the large intestine slowly fills up with stool and is stretched out of shape. As the child repeats this withholding cycle over the long term, he or she stops regularly emptying the lower intestine. This means the rectum usually remains full. Normally, when a person passes a bowel movement, the rectum is completely emptied; thus, most of the time the rectum is empty. Periodically (ie, once daily, twice daily, every other day), some stool moves into the empty rectum and stretches it. This stretching is what provokes the feeling or urge to have a bowel movement. In normal situations, this urge to use the bathroom comes on slowly and does not hurt. The normal response is to go to the bathroom and defecate, which empties the rectum. Because children with chronic constipation almost always have stool in their rectums, the nerves that send the signal to the brain are constantly being stimulated and are constantly receiving the signal to use the bathroom. Over time, the child learns to ignore this signal. This is not a conscious decision. For example, it is much like sitting in a room with a buzzing light. For the first several days, one hears the buzzing; however, after a while, one learns to ignore it. That is, it is tuned out of the person's conscious thoughts. Similarly, over time children tune out the normal signal to pass a bowel movement. Once this occurs, the urge to defecate comes in a very different way. It comes when the large intestine gets tremendously stretched. In most children, this type of urge comes on suddenly and is extremely uncomfortable. When young children have this feeling, they may become very unhappy, begin sweating or become pale, disappear into a quiet room or closet, or grab the back of a chair or another piece of the furniture and stand on their tip toes. These are all responses to the pain they are experiencing. They are having cramps and a tremendous urge to pass a bowel movement, but, because of the pain associated with passing bowel movements, they are withholding. Typically, they are not withholding out of spite, but rather, out of fear. Eventually, the cramps become so strong that the child passes a bowel movement. However, often times it is very large and sometimes very hard; therefore, he or she experiences significant pain. This pain reinforces the child's fear of passing bowel movements, and the cycle repeats itself again and again. As this cycle of pain and fear continues, the process of passing bowel movements becomes more and more abnormal. Once this cycle is established, it can be extremely difficult to disrupt. In most cases, the keys to treatment are to (1) completely evacuate the child's colon with enemas or cathartics, (2) use sufficient laxatives or stool softeners so that the child is passing 1-2 soft stools every day without pain, and (3) establish regular bathroom times so that the child sits on the toilet regularly at the same times every day. In some young children, consulting with a behavioral psychologist experienced with this problem may be helpful. Importantly, remember that young children are magical thinkers and cannot connect cause and effect like adults. Thus, once this cycle of pain, fear, and withholding is well established, deciphering what connections the child has made with passing bowel movements is extremely difficult. Moreover, one fact that remains clear is that the child often perceives treatments as things adults are doing to him or her rather than for him or her. Sometimes, experienced psychologists can help determine what children are thinking and can involve them more actively in their own cure. Q: My 13-year-old stepson has had encopresis since age 4 years. He did not receive treatment for this problem. Currently, he soils his underwear daily and he sometimes hides the evidence to avoid embarrassment. Additionally, when he does have a bowel movement, it is very large and sometimes plugs the toilet. Finally, he has an obvious odor of soiled underpants. This situation seems unusual and unhealthy. Because he is a teenager and is sensitive, I would like to address the problem discretely to avoid embarrassing him. What advice or information can you offer? A: Encopresis almost always develops as a result of long-standing constipation. The vast majority of children with encopresis have a history of constipation or a history of passing large and/or painful bowel movements. In many cases, the child or the parents do not recall the onset of the constipation because it occurred long ago. When a child is constipated and passes large and/or painful bowel movements, he or she may not completely empty their rectum when they go to the bathroom. Over time, the large intestine slowly fills with stool and stretches out of shape. As the large intestine stretches more and more, liquid stool from the small intestine may begin to leak around more formed stool in the colon. In the beginning, the leakage is usually a small amount that streaks or stains the underwear, and most parents just assume their child is not wiping properly. As the intestine continues to stretch, the amount of leakage slowly increases so that eventually children begin having accidents; that is, they pass entire bowel movements in their underwear. Because these accidents represent leakage of soft stool through the colon, children do not usually feel the accidents happening; rather, they just seem to happen without provocation or urge. These soiling accidents tend to occur most often during the afternoon when the child is active and moving around, and they occur only rarely at night while the child is asleep. In most cases, encopresis is not primarily a behavioral problem. Most children with encopresis do not have accidents out of spite or because they are lazy. Rather, many behavioral problems develop because of the encopresis. Most children are embarrassed by their accidents, but they do not know how to resolve the problem. As a result, they develop a number of potentially counterproductive coping strategies. Once the encopresis is adequately treated, many of these behavioral problems resolve. While most encopresis begins with constipation, by the time soiling develops, most children are no longer experiencing significant pain with bowel movements. In children with encopresis, avoidance of the toilet is a habit that began long ago. Also, one must remember that children with encopresis often do not have the normal urge to defecate. Many different methods are available to treat childhood encopresis; however, most treatments involve 3 basic objectives. The first is to empty the large intestine. The second is, once the large intestine has been emptied, to establish regular bowel movements. The third is to maintain very regular bowel movements. Many different strategies can be used to accomplish these 3 objectives. While most children with encopresis have some behavior problems associated with their toilet habits, behavioral therapy alone is not usually sufficient to eliminate the problem. Most commonly, laxatives are needed to reestablish regular bowel movements. In most cases, as soon as the colon is completely evacuated, the encopresis improves or resolves. However, continuing treatment long enough to ensure that regular bowel habits are established and intestinal coordination is recovered is important. Q: My son was born with cerebral palsy and currently is aged 12 years. He has limited use of his right leg and arm. He also has some short-term memory problems. However, overall, he is a reasonably intelligent boy. The problem is that he still soils himself, and this situation is causing significant problems at school. Other children are mocking him, and this is dramatically lowering his self-esteem. Oddly, he does not know it when the soiling occurs. Sometimes he will not have an accident for several days, but other times, he will have 3-4 in one week. His doctors cannot find anything physically wrong with his colon and believe the problem is more psychological. I wonder if my son has encopresis; his symptoms seem similar. Unfortunately, he was not in my care for the first 4-5 years of his life so I do not know if he had major constipation with pain as a young child. I am unsure if his problem is arising as part of his cerebral palsy, as encopresis, or as some other condition. Please offer any advice or information you think may be helpful. A: Encopresis almost always develops as a result of long-standing constipation. The vast majority of children with from encopresis have a history of constipation or a history of passing large and/or painful bowel movements. In many cases, the child or parents do not recall the constipation because it occurred so long ago. With encopresis, soiling episodes occur when soft stool leaks out of the rectum. Typically, children do not feel the accidents as they happen; rather, they just seem to happen without provocation. These soiling accidents tend to occur more often during the afternoon when the child is active and moving around; only rarely do they occur at night while the child is sleeping. Chronic constipation is quite common among children with cerebral palsy and other conditions associated with similar muscle control problems. As a result, encopresis is somewhat more common in children with cerebral palsy than in children without similar muscle problems. However, note that most children with encopresis do not have other medical, physical, or emotional problems. Q: Our 3.5-year-old daughter has had constipation since age 1.5 years. Over this time, she has become reluctant to pass stools and says "it hurts" She has been taking polyethylene glycol powder (Miralax) for a year, and we have also tried numerous home remedies. She was scheduled for a barium enema, but we canceled the procedure because her symptoms appeared to lighten for a month. Since then, her symptoms have gotten worse and we are now considering rescheduling the procedure. However, our fear is that the test results will not indicate a problem and we will have put our daughter through an extremely upsetting ordeal for no reason. Is our daughter's constipation a problem that will eventually resolve on its own over time, or should we reschedule her for the barium enema? A: In the vast majority of children, constipation and a refusal to defecate develop because they have pain when they pass bowel movements. If this persists over time, a vicious cycle develops, characterized by avoiding the passage of bowel movements, passing large bowel movements, experiencing more pain, and then repeating the process. This cycle is termed withholding, and once it is established, disrupting it can be extremely difficult. Typically, a barium enema is performed to ensure the child does not have narrowing of or blockage in the lower intestinal tract, which could be causing the constipation. In children, the most common condition associated with lower intestinal narrowing that produces chronic constipation is Hirschsprung disease. Hirschsprung disease is sometimes called congenital megacolon or congenital intestinal aganglionosis. Hirschsprung disease is a rare disorder that occurs in approximately 1 in 5000-10,000 newborn babies. Comparatively, constipation occurs in as many as 1 in 5-10 children. Hirschsprung disease is much more common in boys than in girls. Hirschsprung disease results when some of the nerves in the intestine (ie, ganglion cells) do not develop normally. These nerves are important in helping the intestine relax. In children with Hirschsprung disease, the intestine is constantly squeezed tight, preventing stool from passing. Almost all children with Hirschsprung disease have problems with constipation from the day they are born; as many as half do not pass their first bowel movement during the first 36 hours of life. Most commonly, if doctors are considering a diagnosis of Hirschsprung disease, they request that a barium enema be performed. This is a radiographic procedure (using x-rays) in which the radiologist inserts a small tube into the child's rectum and pumps barium (an inert dye) into the lower intestine. The radiologist watches the dye on the x-ray film and looks for an area of narrowing, which is suggestive of Hirschsprung disease. If the results of the barium enema suggest Hirschsprung disease, a rectal biopsy is usually performed. In this procedure, a small piece of the lower intestine is removed and examined under a microscope to check for the presence or absence of ganglion cells. If ganglion cells are present, the child does not have Hirschsprung disease. Sometimes, anorectal manometry is also performed. This is a painless test that measures whether the intestine is able to relax normally. Remember, Hirschsprung disease is characterized by an absence of nerves, which prevents the intestine from relaxing normally. If the child has Hirschsprung disease, some form of surgery is usually required to eliminate the problems with constipation. Q: What is constipation? A: Many people think of constipation as not passing a bowel movement every day. However constipation implies not only infrequent bowel movements, but also having difficulty or experiencing pain with the passage of bowel movements. Pain is usually the initial problem when bowel movements are hard and difficult to pass. Each person has his or her own schedule for bowel movements, and many healthy people do pass a bowel movement every day. A constipated child might pass a bowel movement every third day or less often. More importantly, the constipated child tends to pass large and hard stools and experience pain while doing so. Q: Is it true that children with encopresis start soiling to get attention or because they are lazy? A: Encopresis is a very frustrating condition for parents. Many parents become angry at the repeated need to bathe the dirty child and to clean or discard soiled underwear. Many parents assume the soiling is the result of the child being lazy or that the child is soiling intentionally to annoy them. In most cases, this is not the case. Children with encopresis do not have their accidents out of spite or because they are lazy. Children with encopresis are no more likely than other children to have major behavioral or emotional problems. In most cases, encopresis is involuntary; the child does not soil on purpose. Behavioral problems may develop because of the encopresis, but do not cause the encopresis. Once the encopresis is treated, many of the behavioral problems will resolve. Q: Can my child become dependent on laxatives if she uses them too long? A: Almost all laxatives work by keeping large amounts of water in the stool. Therefore, laxatives can be used for long periods of time without harm to the child. There is no evidence that any of the laxatives described in the Medications section of this learning center can result in dependency with long-term usage. Q: Can the effects of laxatives diminish as my child uses them over a long period of time? A: No studies have ever convincingly demonstrated that any of the laxatives described in the Medications section of this learning center will lose their effectiveness if used for an extended time period.

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