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What is constipation and fecal soiling?
Constipation is defined as either a decreased frequency of bowel movements or painful passage of bowel movements. Children 1–4 years of age typically have a bowel movement 1–2 times a day, and more than 90% of children go at least every other day. When children are constipated for a long time, they may begin to pass stool in their clothing. This is called fecal soiling, and children are typically unaware that they are going to have an accident. Another common term is encopresis, which refers to fecal incontinence that is not due to any particular disease. This form of soiling may be voluntary (passage of normal stools in clothing) or involuntary (often loose, liquid stools). Voluntary encopresis may represent significant psychological problems. Involuntary encopresis is much more common and is associated with chronic stool withholding and associated leakage.
Does behavior play a part in constipation and fecal soiling?
Children with constipation and fecal soiling have no control over these bowel movements and should not be punished for soiling episodes. They are often embarrassed by the accidents and may hide soiled underwear, which can be unpleasant for other family members. Another common upsetting behavior is refusal to change dirty clothing, even though the odor is bothersome to others. Children may also wet the bed at night or wet their clothing during the daytime, which is called enuresis. Playmates or siblings may tease children who have accidents, which can lead to embarrassment, school refusal, fighting, and other problems. As the child and family battle over the child’s bowel control, the conflict may extend to other areas of the child’s life as well. Schoolwork may suffer, or the child may become angry, withdrawn, anxious, or depressed, often as a result of being teased and feeling humiliated.
How are constipation and fecal soiling treated?
Treatment of constipation and fecal soiling is a three-step process that may take several months to a year to improve, if not longer.
Step 1: The Initial Cleanout removes impacted stool from the colon.
Step 2: Maintenance Therapy prevents stool build-up by keeping stool soft, thus reducing withholding behavior and allowing the colon to return to its normal shape and muscle tone. During this step, it is important to encourage regular bowel movements in the toilet.
Step 3: Counseling and Behavior Modifications may help children who are embarrassed or feel they are “bad” because of the soiling. A counselor can help structure the treatment plan and help the child cooperate.
STEP 1: Initial Cleanout
Large, rock-like stool in the colon must be softened and broken down before it can be passed. Usually the cleanout is approached from above and below.
Oral agents, such as mineral oil, magnesium citrate, Milk of Magnesia, MiraLAX™ (polyethylene glycol), and lactulose, are used to soften stool by pulling water into the stool. These agents are well-tolerated for long periods of time without developing dependence. They are not absorbed by the bloodstream and stay in the colon, though a small amount of magnesium may be absorbed from Milk of Magnesia.
Some children do not like the taste of mineral oil or Milk of Magnesia. Although some medicines come in flavors that your child may like, they can be expensive. These medicines can be combined with chocolate or strawberry drink mix or with Jell-O powder. Alternatively, mineral oil can be blended with orange juice concentrate, ice cream, or chocolate milk. MiraLAX™ is the most commonly used medication to treat constipation today. This colorless, tasteless powder is offered over-the-counter and can be mixed into a drink of choice.
Enemas or suppositories also can be used in the initial cleanout phase. Since they only work on the lower part of the colon, near the rectum, they help “jump-start” the process by softening withheld stool. There are many ways to achieve the initial cleanout. Your doctor will discuss the best plan with you and your child.
STEP 2: Maintenance Therapy
The objective of maintenance therapy is to prevent stool buildup, allow the colon to return to its proper shape and function, and encourage the child to have bowel movements in the toilet. Many medications used in cleanout are also used for maintenance, only at lower doses.
Maintenance therapy involves several steps:
1. Increase or decrease the medication to obtain 1–2 soft-formed daily bowel movements.
2. If the child is toilet-trained, he/she should be encouraged to sit on the toilet for 5 minutes and try to have a bowel movement, 15–30 minutes after a meal or snack. Try to do this at least twice daily.
Potty practice guidelines:
- After meals, especially after breakfast, is the best time for this “toileting practice” or “sit” – a full stomach makes most people feel the need to have a bowel movement.
- A large, warm drink also may help induce this feeling.
- After a warm bath may be another good time to attempt a bowel movement.
- Place a box or stool under the feet of smaller children to raise their knees higher than their hips, which will help them bear down.
- Very small children may feel safer if they face backwards on the toilet or use a potty chair.
3. Increase fiber intake by encouraging consumption of whole grains, fruits, vegetables, peanut butter, dried fruits, and salads. Give children at least two fiber servings every day.
Fiber serving suggestions:
- Bowl of bran cereal
- One tablespoon wheat bran mixed in food (yogurt, soup, salad)
- One tablespoon of psyllium
- Bran muffin
- Commercial fiber supplement, such as fiber cookies, or one serving of Metamucil or Citrucil in 8 ounces of water (see package directions).
4. Increase fluids in the diet, especially water and water rich foods, which usually are fiber-rich.
5. Increase physical activity – exercise helps the colon move.
6. It is important to encourage older children to take responsibility for their own actions. An older child should be responsible for regularly taking medicine, sitting on the toilet, and cleaning up stool accidents. Each family must decide what level of responsibility to expect of the child. Having a calendar to mark doses and “sits” can help keep track.
STEP 3: Counseling
The child’s condition often becomes a family problem – a counselor may help reduce the tension that children and families feel because of constipation and fecal soiling. It is important to try to avoid anger or punishment around accidents, even though this may be difficult. The child may have learned to control other people by having accidents. Most often, however, the child is not misbehaving but simply cannot feel the stool coming out.
Some children have behavioral and emotional difficulties that interfere with the treatment program. Psychological counseling can help these children deal with issues such as peer conflicts, academic difficulties, and low self-esteem, all of which can contribute to constipation and soiling.
Children respond well to a carefully planned, consistent system of rewards for appropriate behaviors. Parents can develop behavior modifications or reward systems that encourage a child’s proper toilet habits. It is the child’s responsibility, however, to take medicine and attempt regular toileting.
Constipation and fecal soiling are curable! Although it may take several months or longer for bowel function to become normal, children who follow the treatment plan will be able to control their bowel movements. Further, many children may benefit from long-term medication, especially if the child is regularly taking other medications that can cause constipation. Relapsing is not uncommon – repeating the initial cleanout, followed by maintenance therapy, will bring back control. Some children will continue to have constipation into adult life, although a continued high-fiber diet and use of stool softeners as necessary can help. Alternatively, some less common diseases have symptoms similar to constipation and fecal soiling. If a child does not respond to treatment, testing may be recommended.