What is encopresis

If a child over 4 years of age has been toilet trained, and still passes stool and soils clothes, it is called encopresis. Encopresis is another name for fecal soiling — or an accidental bowel movement. Encopresis isn’t a disease, but rather a symptom that may have different causes. Encopresis is the repeated passing of stool (usually involuntarily) into clothing. The child may or may not be doing this on purpose. Typically encopresis happens when impacted stool collects in the colon and rectum: the colon becomes too full and liquid stool leaks around the retained stool, staining underwear. Eventually, stool retention can cause swelling (distention) of the bowels and loss of control over bowel movements.

It’s difficult to say for certain how many children suffer from encopresis because many cases of encopresis are not reported. There seems to be a stigma attached to this condition that prevents many parents from reaching out and talking to other parents whose children may have had the same problem. It is believed encopresis affects only about 1% to 2% of kids under age 10, but problems with encopresis and constipation account for more than 25% of all visits to pediatric gastroenterologists (doctors who specialize in disorders of the stomach and intestines).

Doctors estimate that between one and three percent of kids have this problem at one time or another in childhood. The problem is much more common in boys than in girls.

There are two main causes of encopresis in a child:

• Long-term constipation — Your toilet-trained child becomes constipated which stretches his intestine and rectum until he cannot effectively hold the stool and it leaks out.
• Toilet refusal (much less common) — Your child has never been toilet trained and refuses to have a bowel movement in the toilet, which leads to constipation and encopresis.

While encopresis itself isn’t usually painful (unless the leaking stool leads to a rash on your child’s skin), the constipation that leads to it may be.

Constipated children have fewer bowel movements than normal, and their bowel movements can become hard, dry, difficult to pass and so large that they can often even block up the toilet. Here’s a common scenario:

1. Your child’s stool can become impacted (packed into her rectum and large intestine).
2. Your child’s rectum and intestine become enlarged due to the retained stool.
3. Eventually, her/his rectum and intestine have problems sensing the presence of stool, and the anal sphincter (the muscle at the end of the digestive tract that helps hold stool in) becomes dilated, losing its strength.
4. Stool can start to leak around the impacted stool, soiling your child’s clothing.
5. As more and more stool collects, your child will be less and less able to hold it in, leading to accidents. Because of decreased sensitivity in your child’s rectum due to its larger size, she may not even be aware she’s had an accident until after it has occurred.

Because of decreased sensitivity in your child’s rectum, she may not even be aware she’s had an accident until after it has occurred.

In kids who haven’t yet been toilet trained, struggling to hold in excess stool or the constipation that arises from refusing to have a bowel movement (on the toilet) can also lead to encopresis.

Therefore, any child with chronic constipation may develop encopresis. Some situations that may contribute to your child’s constipation include:

• eating a “junk-food” diet that is low in fiber
• painful bowel movements
• lack of exercise
• stress in the family, with friends or at school
• change in bathroom routine, such as when a child starts a new school year and bathroom breaks are less frequent
• being too busy to take time to use the bathroom

For children who have never been toilet trained and who refuse to have a bowel movement on the toilet, additional concerns apply including:

• reluctance to use bathrooms at home or in public
• anxiety about using the toilet

In kids who haven’t yet been toilet trained, struggling to hold in excess stool, or constipation that arises from refusing to have a bowel movement on the toilet, can also lead to encopresis.

Many people mistakenly believe that encopresis is a behavioral issue — a simple lack of self-control. But punishing or humiliating a child with encopresis will only make matters worse. Instead, talk to your doctor, who can help you and your child through this challenging but treatable problem.

Encopresis can cause your child to have both physical and emotional problems.

Physical problems

• Impacted (backed up) stool in her intestine can cause abdominal pain, a loss of appetite and stool accidents.
• Some children, especially girls, develop urinary tract and/or bladder infections.
• The enlarged bowel can push on the bladder causing urine accidents during the day or night.
• Rarely, other health problems may cause the chronic constipation leading to encopresis, including:
  • Hypothyroidism
  • Hirschsprung’s Disease
  • Celiac disease

Emotional problems

Encopresis can be embarrassing, and can prompt teasing from siblings and peers. Watch out for depression and low self-esteem as a result of this condition.

Your child might feel emotionally upset by soiling her clothes, leading to feelings of shame and embarrassment.

You, too, might feel guilt, shame and anger because of your child’s encopresis. It’s very important to try not to communicate this to your child, as this may worsen her emotional state.

Encopresis can be frustrating for parents — and embarrassing for the child. However, with patience and positive reinforcement, treatment for encopresis is usually successful.

Enuresis and encopresis

Enuresis also known as bedwetting or nocturnal enuresis, is when a child of five or older empties their urinary bladder while they are asleep. This can happen every so often, or every night. Soggy sheets and pajamas and an embarrassed child — are a familiar scene in many homes. But don’t despair. Bed-wetting isn’t a sign of toilet training gone bad. It’s often just a normal part of a child’s development.

Enuresis is common. About one in every five children in the US wets their bed. Generally, bed-wetting before age 7 isn’t a concern. At this age, your child may still be developing nighttime bladder control. Enuresis can run in families. It is more common in boys than girls before the age of nine. It can be upsetting for the child and stressful for the whole family.

There are two kinds of enuresis: primary and secondary.

• Someone with primary nocturnal enuresis has wet the bed since he or she was a baby (primary nocturnal enuresis is the most common form).
• Secondary enuresis is a condition that develops at least 6 months — or even several years — after a person has learned to control his or her bladder.

The bladder is a muscular receptacle, or holding container, for pee (urine). It expands (gets bigger) as urine enters and then contracts (gets smaller) to push the urine out.

In a person with normal bladder control, nerves in the bladder wall send a message to the brain when the bladder is full; the brain then sends a message back to the bladder to keep it from automatically emptying until the person is ready to go to the bathroom. But people with nocturnal enuresis have a problem that causes them to pee involuntarily at night.

Some children who wet the bed at night also have problems with how their bladder works during the day.

They may:

• go to the toilet too often
• not go to the toilet often enough need to rush to the toilet in a hurry have damp underwear
• have trouble emptying all of the urine from their bladder have bowel problems, including constipation.

The good news is that it’s likely that bedwetting will go away on its own. In fact, 15 out of 100 kids who wet the bed will stop every year without any treatment at all. If enuresis continues, treat the problem with patience and understanding. Lifestyle changes, bladder training, moisture alarms and sometimes medication may help reduce bed-wetting.

Children don’t wet the bed to irritate their parents. Try to be patient as you and your child work through the problem together. Effective treatment may include several strategies and may take time to be successful.

• Be sensitive to your child’s feelings. If your child is stressed or anxious, encourage him or her to express those feelings. Offer support and encouragement. When your child feels calm and secure, bed-wetting may become less problematic. If needed, talk to your pediatrician about additional strategies for dealing with stress.
• Plan for easy cleanup. Cover your child’s mattress with a plastic cover. Use thick, absorbent underwear at night to help contain the urine. Keep extra bedding and pajamas handy. However, avoid the long-term use of diapers or disposable pull-up underwear.
• Enlist your child’s help. If age-appropriate, consider asking your child to rinse his or her wet underwear and pajamas or place these items in a specific container for washing. Taking responsibility for bed-wetting may help your child feel more control over the situation.
• Celebrate effort. Bed-wetting is involuntary, so it doesn’t make sense to punish or tease your child for wetting the bed. Also, discourage siblings from teasing the child who wets the bed. Instead, praise your child for following the bedtime routine and helping clean up after accidents. Use a sticker reward system if you think this might help motivate your child.

With reassurance, support and understanding, your child can look forward to the dry nights ahead.

When to see a doctor

Most children outgrow bed-wetting on their own — but some need a little help. In other cases, bed-wetting may be a sign of an underlying condition that needs medical attention.

Consult your child’s doctor if:

• Your child still wets the bed after age 7
• Your child starts to wet the bed after a few months of being dry at night
• Bed-wetting is accompanied by painful urination, unusual thirst, pink or red urine, hard stools, or snoring

Any child who is toilet trained and starts new daytime wetting should see a doctor. If the child has daytime symptoms as well as bedwetting, these will be treated before the bedwetting.

Many children do stop wetting in their own time with no help. After age eight or nine, if the child is still wetting often, the problem usually does not get better by itself.

What causes enuresis (bedwetting)?

Doctors don’t always know the exact cause of nocturnal enuresis. They do have some theories, though, on what may contribute to someone developing the condition:

• Hormonal problems. A hormone called antidiuretic hormone, or ADH, causes the body to produce less urine at night. But some people’s bodies don’t make enough ADH, which means their bodies may produce too much urine while they’re sleeping.
• Bladder problems. In some people with enuresis, too many muscle spasms can prevent the bladder from holding a normal amount of urine. Some teens and adults also have relatively small bladders that can’t hold a large volume of urine.
• Inability to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not wake your child — especially if your child is a deep sleeper.
• A small bladder. Your child’s bladder may not be developed enough to hold urine produced during the night.
• Urinary tract infection. This infection can make it difficult for your child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination, red or pink urine, and pain during urination.
• Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child’s breathing is interrupted during sleep — often due to inflamed or enlarged tonsils or adenoids. Other signs and symptoms may include snoring and daytime drowsiness.
• Diabetes. For a child who’s usually dry at night, bed-wetting may be the first sign of diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, fatigue and weight loss in spite of a good appetite.
• Chronic constipation. The same muscles are used to control urine and stool elimination. When constipation is long term, these muscles can become dysfunctional and contribute to bed-wetting at night.
  A structural problem in the urinary tract or nervous system. Rarely, bed-wetting is related to a defect in the child’s neurological system or urinary system.
• Genetics. Teens with enuresis often have a parent who had the same problem at about the same age. Scientists have identified specific genes that cause enuresis.
• Sleep problems. Some teens may sleep so deeply that they don’t wake up when they need to pee.
• Caffeine. Using caffeine causes a person to urinate (pee) more.
• Medical conditions. Medical conditions that can trigger secondary enuresis include diabetes, urinary tract abnormalities (problems with the structure of a person’s urinary tract), constipation, and urinary tract infections (UTIs). Spinal cord trauma, such as severe stretching of the spinal cord resulting from a fall, sports injury, auto accident, or other event may also play a role in enuresis, although this is rare.
• Psychological problems. Some experts believe that stress can be associated with enuresis. It’s not uncommon to feel stressed out during the teenage years, and things such as divorce, the death of a friend or family member, a move to a new town and adapting to a new school and social environment, or family tension can feel overwhelming.

Nocturnal enuresis can be caused by a mix of three things:

• The body making a large amount of urine through the night.
• Having a bladder that can only store a small amount of urine at night.
• Not being able to fully wake up from sleep.

Children who wet the bed are not lazy or being naughty. Some illnesses are linked with bedwetting. But most children who wet the bed do not have major health problems.

Daytime control of the bladder comes before night-time dryness. Most children are dry through the day by three years and dry at night by school age. Any child may still wet every now and then, day or night, up until they are seven or eight years.

Doctors don’t know exactly why, but more than twice as many boys as girls have enuresis. It is often seen in combination with attention-deficit/ hyperactivity disorder (ADHD) ¹⁾.

Risk factors for enuresis

Bed-wetting can affect anyone, but it’s twice as common in boys as in girls. Several factors have been associated with an increased risk of bed-wetting, including:

• Stress and anxiety. Stressful events — such as becoming a big brother or sister, starting a new school, or sleeping away from home — may trigger bed-wetting.
• Family history. If one or both of a child’s parents wet the bed as children, their child has a significant chance of wetting the bed, too.
• Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.

Enuresis complications

Although frustrating, bed-wetting without a physical cause doesn’t pose any health risks. However, bed-wetting can create some issues for your child, including:

• Guilt and embarrassment, which can lead to low self-esteem
• Loss of opportunities for social activities, such as sleepovers and camp
• Rashes on the child’s bottom and genital area — especially if your child sleeps in wet underwear

Enuresis diagnosis

If your child is having trouble controlling his/her urine at night, talk to your doctor to learn more about nocturnal enuresis and to rule out the possibility of a medical problem.

Depending on the circumstances, your doctor may recommend the following to identify any underlying cause of bed-wetting and help determine treatment:

• Physical exam
• Discussion of symptoms, fluid intake, family history, bowel and bladder habits, and problems associated with bed-wetting
• Urine tests to check for signs of an infection or diabetes
• X-rays or other imaging tests of the kidneys or bladder to look at the structure of the urinary tract
• Other types of urinary tract tests or assessments, as needed

Enuresis treatment

Most children outgrow bed-wetting on their own. If treatment is needed, it can be based on a discussion of options with your doctor and identifying what will work best for your situation.

If your child isn’t especially bothered or embarrassed by an occasional wet night, lifestyle changes — such as avoiding caffeine entirely and limiting fluid intake in the evening — may work well. However, if lifestyle changes aren’t successful or if your grade schooler is terrified about wetting the bed, he or she may be helped by additional treatments.

If found, underlying causes of bed-wetting, such as constipation or sleep apnea, should be addressed before other treatment.

Options for treating bed-wetting may include moisture alarms and medication.

Moisture alarms

These small, battery-operated devices — available without a prescription at most pharmacies — connect to a moisture-sensitive pad on your child’s pajamas or bedding. When the pad senses wetness, the alarm goes off.

Ideally, the moisture alarm sounds just as your child begins to urinate — in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm and wake the child.

If you try a moisture alarm, give it plenty of time. It often takes one to three months to see any type of response and up to 16 weeks to achieve dry nights. Moisture alarms are effective for many children, carry a low risk of relapse or side effects, and may provide a better long-term solution than medication does. These devices are not typically covered by insurance.

Medication

As a last resort, your child’s doctor may prescribe medication for a short period of time to stop bed-wetting. Certain types of medication can:

• Slow nighttime urine production. The drug desmopressin (DDAVP) reduces urine production at night. But drinking too much liquid with the medication can cause problems, and desmopressin should be avoided if your child has symptoms such as a fever, diarrhea or nausea. Be sure to carefully follow instructions for using this drug. Desmopressin is given orally as a tablet and is only for children over 5 years old. According to the Food and Drug Administration, nasal spray formulations of desmopressin (Noctiva, others) are no longer recommended for treatment of bed-wetting due to the risk of serious side effects.
• Calm the bladder. If your child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan XL) may help reduce bladder contractions and increase bladder capacity, especially if daytime wetting also occurs. This drug is usually used along with other medications and is generally recommended when other treatments have failed.

Sometimes a combination of medications is most effective. There are no guarantees, however, and medication doesn’t cure the problem. Bed-wetting typically resumes when medication is stopped, until it resolves on its own at an age that varies from child to child.

Home remedies

Here are changes you can make at home that may help:

• Limit fluids in the evening. It’s important to get enough fluids, so there’s no need to limit how much your child drinks in a day. However, encourage drinking liquids in the morning and early afternoon, which may reduce thirst in the evening. But don’t limit evening fluids if your child participates in sports practice or games in the evenings.
• Avoid beverages and foods with caffeine. Beverages with caffeine are discouraged for children at any time of day. Because caffeine may stimulate the bladder, it’s especially discouraged in the evening.
• Encourage double voiding before bed. Double voiding is urinating at the beginning of the bedtime routine and then again just before falling asleep. Remind your child that it’s OK to use the toilet during the night if needed. Use small night lights, so your child can easily find the way between the bedroom and bathroom.
• Encourage regular toilet use throughout the day. During the day and evening, suggest that your child urinate every two hours or so, or at least often enough to avoid a feeling of urgency.
• Prevent rashes. To prevent a rash caused by wet underwear, help your child rinse his or her bottom and genital area every morning. It also may help to cover the affected area with a protective moisture barrier ointment or cream at bedtime. Ask your pediatrician for product recommendations.

What can parents do

• Seek help from a health professional with special training in children’s bladder problems, such as a doctor, continence physiotherapist or continence nurse advisor.
• Make sure there is enough light at night. This makes it easy to get to the toilet.
• Watch for constipation as this can make bladder problems worse. Seek medical help if constipation is an ongoing problem.
• If your child is using a bedwetting alarm, you can help by:
  • getting up when it goes off
  • waking them up
  • helping them change their clothes or sheets.
• Attend review appointments with your child’s continence professional

There are some things which DO NOT help:

• Do not punish the child for wet beds.
• Do not shame the child in front of friends or family.
• Do not lift the child at night to toilet them. This may cut down on some wet beds but it does not help the child learn to be dry.
• Do not try to fix bedwetting at a stressful time.

Encopresis complications

A child who has encopresis may experience a range of emotions, including embarrassment, frustration, shame and anger. If your child is teased by friends or criticized or punished by adults, he or she may feel depressed or have low self-esteem.

Encopresis causes

There are several causes of encopresis, including constipation and emotional issues. Some kids may develop chronic constipation after stressful life events such as a divorce or the death of a close relative.

Although rectal surgery or birth defects such as Hirschsprung disease and spina bifida can cause constipation or encopresis without constipation, this is uncommon.

Constipation

Most cases of encopresis are the result of chronic constipation. In constipation, the child’s stool is hard, dry and may be painful to pass. As a result, the child avoids going to the toilet — making the problem worse.

The longer the stool remains in the colon, the more difficult it is for the child to push stool out. This is because the colon’s job is to remove water from the stool before it’s passed. The longer the poop is stuck there, the more water is removed — and the harder it is to push the large, dry poop out. The large poop also stretches out the colon, weakening the muscles there and affecting the nerves signal that tell a child when it’s time to go to the bathroom.

Then, the colon can’t easily push the hard poop out, and it’s painful to pass. So the child continues to avoid having a bowel movement, often by dancing, crossing the legs, making faces, or walking on tiptoes.

Eventually, the rectum and lower part of the colon becomes so full that it’s hard for the sphincter (the muscular valve that controls the passage of feces out of the anus) to hold the poop in. Partial bowel movements may pass through, causing the child to soil his or her pants. Softer stool may also leak out around the large mass of feces and stain the child’s underwear when the sphincter relaxes. Kids can’t prevent this soiling — nor do they have any idea it’s happening — because the nerves aren’t sending the signals that regulate pooping.

Some causes of constipation include:

• Withholding stool due to fear of using the toilet (especially when away from home) or because stools are painful
• Not wanting to interrupt play or other activities
• Eating too little fiber
• Not drinking enough fluids
• Drinking too much cow’s milk or, rarely, an intolerance to cow’s milk — though research results conflict on these issues

Emotional issues

Emotional stress may trigger encopresis. A child may experience stress from:

• Premature, difficult or conflict-filled toilet training
• Changes in the child’s life, such as dietary changes, toilet training, starting school or schedule changes
• Emotional stressors, for example, the divorce of a parent or the birth of a sibling

Encopresis can also be associated with emotional and developmental difficulties that express themselves in an unwillingness or inability to have regular bowel movements. Some children experience particularly negative reactions to toilet training, aggravated by a variety of parental responses. Others develop encopresis in reaction to changes in social circomstances, such as when shifting from private to shared bathrooms at the beginning of preschool or kindergarten. Stress resulting from a move, parents divorcing and other major changes to a child’s environment can all trigger constipation that may eventually result in the cycle that leads to encopresis.

Children with encopresis associated with developmental disorders may have never been fully toilet trained, whereas children with other types of encopresis may have been toilet trained but developed the disorder in response to apparent environmental stressors.

Risk factors for encopresis

Encopresis is more common in boys. These risk factors may increase the chances of having encopresis:

• Using medications that may cause constipation, such as cough suppressants
• Attention-deficit/hyperactivity disorder (ADHD)
• Autism spectrum disorder
• Anxiety or depression

Encopresis prevention

Below are some strategies that can help prevent encopresis and its complications.

Avoid constipation

Help your child avoid constipation by providing a balanced diet that’s high in fiber and encouraging your child to drink enough water.

Learn about effective toilet training techniques

Educate yourself on effective toilet training techniques. Avoid starting too early or being too forceful in your methods. Wait until your child is ready, and then use positive reinforcement and encouragement to help make progress. Ask your doctor about resources on toilet training.

Get early treatment for encopresis

Early treatment, including guidance from your child’s doctor or mental health professional, can help prevent the social and emotional impact of encopresis. Regular follow-up visits with your doctor can help identify ongoing or recurring problems so that adjustments in treatment can be made as needed.

Long-Term outlook for children with encopresis

Though it may seem as though your child will suffer from encopresis forever, this isn’t the case. The vast majority of kids (the possible exceptions being those who have an underlying medical issue) will stop having stool accidents and have regular bowel movements on the toilet.

The end result of treatment is the same for both causes of encopresis, but the way you get there is different.

• Long-term constipation— Your doctor will help your child pass the impacted stool and then help keep stool soft so that it passes easily and doesn’t get backed up again. After about six months, your child’s intestine and rectum will shrink to their normal size and your child should be able to have normal bowel movements on her own without any medication or prompting.
• Toilet refusal— These children will get a combination of medical (laxatives, stool softeners) and behavioral treatments to help them become more comfortable using the toilet for bowel movements.

Encopresis symptoms

At first, parents may think their child has a simple case of diarrhea. But after repeated episodes, it becomes clear that there’s another problem — especially because the soiling happens when the child isn’t sick.

As the colon is stretched by the buildup of stool, the nerves’ have trouble telling the brain that it’s time for a bowel movement. If untreated, the soiling will get worse and kids may lose their appetites or complain of stomach pain.

A large, hard poop may also cause a tear in the skin around the anus that will leave blood on the stools, the toilet paper, or in the toilet.

Parents are often frustrated by the fact that their child seems unfazed by the poop accidents, which happen mostly during waking hours. Denial may be one reason for a child seeming calm — kids just can’t face the shame and guilt associated with the condition (some even try to hide their soiled underpants from their parents).

Another reason may be more scientific: Because the brain eventually gets used to the smell of poop, the child may no longer notice the odor.

Signs and symptoms of encopresis may include:

• Leakage of stool or liquid stool on underwear, which can be mistaken for diarrhea
• Constipation with dry, hard stool
• Passage of large stool that clogs or almost clogs the toilet
• Avoidance of bowel movements
• Long periods of time between bowel movements
• Lack of appetite
• Abdominal pain
• Problems with daytime wetting or bedwetting (enuresis)
• Repeated bladder infections, typically in girls

Encopresis diagnosis

To be diagnosed with encopresis, a child must be at least the age of 4 and experience the repeated leakage or passage of feces into inappropriate places, such as the floor or her underwear, at least once a month for at least three months. Before making a diagnosis of encopresis, a doctor will rule out possible physiological factors such as food allergies or medicines that act as laxatives.

To diagnose encopresis, your child’s doctor may:

• Conduct a physical exam and discuss symptoms, bowel movements and eating habits to rule out physical causes for constipation or soiling
• Do a digital rectal exam to check for impacted stool by inserting a lubricated, gloved finger into your child’s rectum while pressing on his or her abdomen with the other hand
• Recommend an abdominal X-ray to confirm the presence of impacted stool
• Suggest that a psychological evaluation be done if emotional issues are contributing to your child’s symptoms.

Encopresis treatment

How to help a child with encopresis

Generally, the earlier that treatment begins for encopresis, the better.

The first step involves clearing the colon of retained, impacted stool. After that, treatment focuses on encouraging healthy bowel movements. In some cases, psychotherapy may be a helpful addition to treatment.

Step 1. Clearing the colon of impacted stool

There are several methods for clearing the colon and relieving constipation. Your child’s doctor will likely recommend one or more of the following:

• Certain laxatives
• Rectal suppositories
• Enemas

Your child’s doctor may recommend close follow-up to check the progress of the colon clearing.

• Laxatives and enemas should be given only under the supervision of a doctor; never give these treatments at home without first checking with your doctor.

After your child passes the hard stool, it’s important to develop a good routine to ensure that stool does not get backed up again. Because your child’s intestine and rectum will remain stretched (they go back to normal after about six months), your child may still have problems with leakage.

To reduce the number of accidental bowel movements, or fecal soilings, have your child sit on the toilet two to three times a day for five to ten minutes, preferably shortly after a meal.

Step 2. Encouraging healthy bowel movements

Once the colon is cleared, it’s important to encourage your child to have regular bowel movements. Your child’s doctor may recommend:

• Dietary changes that include more fiber and drinking adequate fluids
• Laxatives, gradually discontinuing them once the bowel returns to normal function. It’s important to continue using the stool softener to give the bowels a chance to shrink back to normal size (the muscles of the intestines have been stretched out, so they need time to recover).
• Training your child to go to the toilet as soon as possible when the urge to have a bowel movement occurs
• A short trial of going off cow’s milk or checking for cow’s milk intolerance, if indicated
• Parents also will be asked to schedule potty times twice daily after meals (when the bowels are naturally stimulated). The child will sit on the toilet for about 5 to 10 minutes. This helps kids learn to pay attention to the urges to go.

Keep in mind that relapses are normal, so don’t get discouraged. Your child might get constipated again or soil his or her pants during treatment, especially when being weaned off of the stool softeners.

A good way to track your child’s progress is by keeping a daily poop calendar. Make sure to note the frequency, consistency (hard, soft, dry), and size (large, small) of the bowel movements.

Patience is the key to treating encopresis. It may take anywhere from several months to a year for the stretched-out colon to return to its normal size and for the nerves in the colon to become effective again.

Some parents find that positive reinforcement helps to encourage the child throughout treatment. For instance, put a star or sticker on the poop calendar for having a bowel movement (or even just for trying to), sitting on the toilet, or taking medicines.

Whatever you do, don’t blame or yell — it will only make your child feel bad and it won’t help manage the condition. With lots of love, support, and reassurance that he or she isn’t the only one in the world with this problem, your child can overcome encopresis.

Step 3. Behavior modification

Your child’s doctor or mental health professional can discuss techniques for teaching your child to have regular bowel movements. This is sometimes called behavior modification or bowel retraining.

Your child’s doctor may recommend psychotherapy with a mental health professional if the encopresis may be related to emotional issues. Psychotherapy may also be helpful if your child feels shame, guilt, depression or low self-esteem related to encopresis.

Encopresis treatment at home

• 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. These tips can help:

• Focus on fiber. Feed your child a healthy balanced diet that includes plenty of fruits, vegetables, whole grains and other foods high in fiber and avoid constipation-causing foods, which can help form soft stools.
• Encourage your child to drink water. Drinking enough water helps keep stool from hardening. Other fluids may help, but watch the calories.
• Limit cow’s milk if that’s what the doctor recommends. In some cases, cow’s milk may contribute to constipation, but dairy products also contain important nutrients, so ask the doctor how much dairy your child needs each day.
• Arrange toilet time. Have your child sit on the toilet for five to 10 minutes at a regularly scheduled time every day. This is best done after meals because the bowel becomes more active after eating. Praise your child for sitting on the toilet as requested and trying.
• Put a footstool near the toilet. This may make your child more comfortable, and changing the position of his or her legs can put more pressure on the abdomen, making a bowel movement easier.
• Stick with the program. It may take months to resume normal bowel sensation and function and develop new habits. Sticking with the program can also reduce relapses.
• Be encouraging and positive. As you help your child overcome encopresis, be patient and use positive reinforcement. Don’t blame, criticize or punish your child if he or she has an accident. Instead, offer your unconditional love and support.

Over time, with the proper guidance, children can redevelop a positive association with regular, healthy bowel movements.

Encopresis can be embarrassing, and can prompt teasing from siblings and peers. Watch out for depression and low self-esteem as a result of this condition.

If a child has experienced feelings of shame, guilt or depression as a result of having encopresis, a knowledgeable psychotherapist can help her both understand those feelings and develop techniques for having regular healthy bowel movements.

Diet and Exercise

Diet and exercise are extremely important in keeping stools soft and bowel movements regular. Also, make sure your child gets plenty of fiber-rich foods such as fresh fruits, dried fruits like prunes and raisins, dried beans, vegetables, and high-fiber bread and cereal.

Try these creative ways to add it to your child’s diet:

• Bake cookies or muffins using whole-wheat flour instead of regular flour. Add raisins, chopped or pureed apples, or prunes to the mix.
• Add bran to baking items such as cookies and muffins, or to meatloaf or burgers, or sprinkled on cereal. (The trick is not to add too much bran or the food will taste like sawdust.)
• Serve apples topped with peanut butter.
• Create tasty treats with peanut butter and whole-wheat crackers.
• Top ice cream, frozen yogurt, or regular yogurt with high-fiber cereal for some added crunch.
• Serve bran waffles topped with fruit.
• Make pancakes with whole-grain pancake mix and top with peaches, apricots, or grapes.
• Top high-fiber cereal with fruit.
• Sneak some raisins or pureed prunes or zucchini into whole-wheat pancakes.
• Add shredded carrots or pureed zucchini to spaghetti sauce or macaroni and cheese.
• Add lentils to soup.
• Make bean burritos with whole-grain soft-taco shells.

And don’t forget to have your child drink plenty of fluids each day, especially water. Diluted 100% fruit juice (like pear, peach, or prune) is an option if your child is not drinking enough water. Also, limiting your child’s daily dairy intake (including milk, cheese, and yogurt) may help.