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Encopresis: What Doctors Get Wrong

By Steve Hodges, M.D.

encopresis is never a child's fault

Little is more traumatizing for a kid than having poop accidents. My patients who struggle with bedwetting and pee accidents, at least those over age 4, tend to be distressed by the accidents, but it’s my encopresis patients who suffer the most.

These kids are often teased by their peers, shamed and blamed by adults who believe they’re “doing it for attention,” referred to therapists who can’t help, subjected to useless treatments, or left untreated. Their frustrated parents suffer, too.

As one mom described, “I saw my daughter withdraw from goofing around, especially roughhousing with her daddy and brothers. She was always afraid she smelled and would shy away from affection. It broke my heart.”

All this is particularly awful since encopresis is preventable and, when recognized early and treated aggressively, pretty darned easy to resolve. Truly no child should have to deal with chronic poop accidents.

Yet so many do. About 4% of 5- and 6-year-olds have encopresis, research indicates, as do 1.5% of kids ages 7 to 12. But these estimates are low; research also shows that less than half of children with encopresis actually visit a doctor for the problem. Heck, just yesterday I saw a 10-year-old for an entirely different condition, and his mom only mentioned his poop accidents in passing. The boy’s parents hadn’t realized the accidents were treatable.

Misconceptions abound about encopresis — what causes this condition and how to resolve it. As a result, countless cases are left to linger until they become difficult to treat. I’ve never encountered a case of encopresis that couldn’t be fixed; it’s just a matter of how quickly. As the heartbroken mom above told me, “It could've been dealt with so much faster if I only I had known.”

In this post I discuss what is important for families, schools, and medical professionals to know about encopresis.

The most critical fact: Encopresis is a medical condition, not a psychological or behavioral issue.

Many of my patients have been referred to behavioral therapists by their pediatricians, GI docs, or schools, on the premise that they are pooping in their pants intentionally and will stop “when they want to.”

“Our doctors told me our daughter was struggling with control issues, mental issues, that she was lazy,” recalls one mom, a member of our Facebook support group.

Another mom posted: “The first pediatrician we saw said my daughter was doing it on purpose for attention.”

Just today I received this email from the conflicted mom of a 5-year-old: “I'm torn between thinking my son is just lazy when he's at home and soils his pants and thinking it's not his fault as possibly he's less aware of the leakage.”

Let me be clear: Children do not poop in their pants on purpose. However, I do understand why adults might suspect otherwise. Kids with encopresis don’t feel the poop coming out and may not even smell it, so they often act as if nothing’s happened. To adults, it just seems impossible that a child could fail to notice she just pooped in her pants.

But this scenario is quite common and easily explained.

In children who are anatomically and neurologically normal, encopresis has only one cause: chronic, severe constipation. When children regularly delay pooping (usually because it’s painful), stool piles up in and stretches the rectum. A stretched-out rectum is like a stretched-out sock: It loses springiness. The floppy rectum can’t squeeze down to expel the entire load of poop, so some of it remains in the rectum. And because the intestinal walls have lost tone, some of the poop just falls out.

A floppy rectum also loses sensation, so the child doesn’t feel the urge to poop. This lack of sensation drives a vicious cycle: Even more poop piles up, further stretching the rectum and compromising its tone and sensation. More poop falls out.

(Also, the stretched rectum may press against and aggravate the bladder, triggering bedwetting and pee accidents. Most of my encopresis patients also wet the bed, though, oddly, many referring physicians never connected the two problems.)

One mom told me she’d find “hard little rabbit pellets” all over her house when she would vacuum. When her son, a second grader, would jump on the trampoline, the pellets would fall out, totally unbeknownst to him.

Why don’t children with encopresis smell the poop? Because they get used to it, the way smokers become desensitized to the odor of cigarettes us. (Of course, smoking also damages nerves related to smell, but the effect is similar.)

Even when parents know, intellectually, their child cannot stop the accidents, some parents find it hard to completely believe and to conceal their frustration. They may send subtle signals, via their facial expressions, sighs, or comments about laundry, that kids internalize.

As one mom candidly noted, “We are working very hard on our reaction to our daughter and the accidents. My husband still feels she has more control and more awareness than she does.”

It can take a lot of work on a parent’s part to assure a child she shoulders no blame for encopresis — and even then, the child may not believe it.

“My daughter’s self-esteem has taken a huge hit,” one mom posted. “She's afraid no one will be her friend because she might smell and that no one will invite her to parties or play with her. . . She often tells me during regressions in treatment that she's a bad kid, because her body is broken. We just give her a lot of love and understanding and tell her we are in this together and she will get better.”

She definitely will get better — but only with aggressive and extended treatment.

Here’s the second most important fact about encopresis: Miralax won’t suffice.

Doctors generally offer encopresis patients one of two approaches: no treatment or inadequate treatment.

Those who believe encopresis is a behavioral issue refer these kids to counselors or urge parents to wait it out. As one mom posted, “We were told my son would ‘grow out if it’ by the time he was 10 or 11, which was five years away. I felt dismissed by doctors, as though it was not a real medical problem.”

I don’t think that’s the norm; most physicians do recognize encopresis is caused by constipation. Problem is, they vastly underestimate the severity of the clog. So, they routinely. prescribe a small daily dose of Miralax. When that doesn’t work? More Miralax. Then more!

“When our daughter started soiling we were put on 1/4 cap of Miralax,” one mom posted. When that failed (“a joke,” the mom wrote), the doctor, a pediatric gastroenterologist, prescribed 1/2 cap day. Finally, he suggested a constipation smoothie recipe including mineral oil. None of it worked.

High-dose Miralax cleanouts — for example 7 capfuls mixed with Gatorade over 24 hours — can help somewhat, and I used to recommend them. (I spell out this regimen in It’s No Accident.) But with experience, I’ve come to understand even mega-doses are inadequate.

That’s because Miralax often cannot fully empty the rectum. It just softens poop. In some cases, it actually increases poop accidents, by creating more watery poop that oozes around the hardened clog. It does nothing to break up the softball-sized mass of stool.

Imagine using a squirt of soap and a trickle of water to dissolve the crusty, week-old remnants of refried beans on a dinner plate. That’s about how useful Miralax is.

“My daughter was given Miralax by three different doctors,” one mom posted. “It helped in the beginning but ultimately, made things worse. It doesn't fix the underlying issue.”

The underlying issue is the stretched rectum. Doctors tend to focus on softening stool so that pooping is less painful and children will stop withholding. That’s important — sure — but softening stool isn’t enough. The stretched rectum must be given time to shrink back to size. And that can only happen when it is fully cleaned out every day for months.

Yes, fully cleaned out. Every day. For months.

How can you accomplish that? Enemas.

Yes, I realize no parent wants to stick a tube up their child’s bottom! And many doctors — wholly without evidence — consider enemas to be “traumatizing,” so they don’t even think of recommending them.

But if you want to fix encopresis, give your child a pediatric enema every day for 30 days. If the poop accidents are relatively new, they are almost certain to stop within a month. But that doesn’t mean you’re done. Once the accidents cease, you taper: an enema every other day for 30 days, followed by twice-weekly enemas for another 30 days.

The regimen I’ve just described is called the Modified O’Regan Protocol, detailed in The M.O.P. Book, and it resolves new cases of encopresis fast. When the condition has been going on for months or years, however, children may need need more powerful enemas, with solution that contains stimulants such as glycerin or castile soap. This amped-up regimen, M.O.P.+, is also described in The M.O.P. Book. (Incidentally, M.O.P.+ also can help those children who have encopresis due to anatomical conditions, such as imperforate anus or cloacal anomalies, or neurological conditions such as spina bifida.)

Whether you follow M.O.P. or M.O.P.+, you can’t stop treating encopresis when the accidents stop. Withholding poop is a habit — a habit that dies hard. Most children with encopresis have been constipated for years, since shortly after they were potty-trained. (Potty training is prime time for children to become constipated.) It often takes a few years for the holding habit to catch up to these kids; most of my encopresis patients were toilet trained “successfully” and easily around age 2 or 2 ½ and did not develop problems until age 4 or 5, when the poop pile-up literally reached “critical mass.”

Children with encopresis are so accustomed to holding that even when pooping is no longer painful, they still instinctively avoid it. Or, they’ve lost the ability to relax their pooping muscles and have trouble evacuating, in which case, as I explain in The M.O.P. Book, pelvic floor physical therapy can help.

To minimize risk of a relapse, I recommend encopresis patients complete the full 90-day M.O.P. protocol and then remain on Miralax or an alternative osmotic laxative for at least six months. They should also poop with their feet firmly planted on a tall stool, so they are placed in a squatting position (as we all should be doing!). Of course, a whole-foods diet high in fruits and vegetables is important, as is drinking plenty of water.

Do not reward your child for staying clean and dry! Unfortunately, the American Academy of Pediatrics appears to condone rewards. The encopresis section of states that some parents offer "a star or sticker on a chart for each day [the child] goes without soiling and a special small toy, for example, after a week. This approach works best for a child who truly wishes to solve the problem and is fully cooperative in that effort.”

I disagree! Rewarding a child for staying dry implies that accidents are within a child’s control; they are not. All children with encopresis “truly wish to solve the problem”; nobody wants to have poop accidents! Offering a reward for clean underwear may actually prompt the child to withhold even more and certainly will make a child feel like a failure if he does have an accident.

Poop accidents are more distressing for children than pee accidents, but the good news is, encopresis resolves more quickly, bringing relief to families as they may continue working to resolve bedwetting

Remember the girl who felt bad about all the laundry her mom had to do? It took her four months of enemas — a month longer than the basic M.O.P. program — but she has stopped having poop accidents. “I'm happy to report that I'm seeing her confidence return,” her mom wrote, “She wants to do things again, like dance and gymnastics, that she had quite doing because of the accidents.”

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