More Information on Constipation and Encopresis

What is constipation?
Most of the time, when we say a child is constipated, we mean he or she passes bowel movements less than every other or every third day and when he or she does pass a bowel movement, it often is large and hard, and perhaps most important, it hurts.

What are normal bowel habits?
Everybody is different, so what is normal for one person may not be normal for another person. When we talk about normal bowel habits, we are talking about averages. It is important to remember that no matter how often a child passes a bowel movement, it shouldn't hurt!
During the first several months of life, babies generally pass bowel movements between every other day and four times each day. Babies who are breast fed tend to pass bowel movements more often than do babies who are fed formula. It is not unusual for a breast-fed baby to pass a bowel movement with every feeding. By about two years of age, most children pass one bowel movement every day. 95% of children who are two or older pass between one bowel movement every other day and two bowel movements a day.

Many parents have been told their child became constipated because he or she drinks too much milk or eats too much cheese. While what we eat clearly effects our bowel habits, diet alone is usually not the cause of chronic constipation. As a group, children who develop chronic constipation tend not to drink as much fluid as children who do not become constipated, however in most cases, it is not until the child begins to associate pain with passing bowel movements that constipation develops.

While there are certainly other reasons that children may become constipated, they are all quite uncommon.
Hirschsprung's disease
Neurological abnormalities
Hypothyroidism
Most of the time, the pain with bowel movements starts when a child passes a very big or hard bowel movement. There are lots of reasons this might happen:

In young infants, a severe case of diaper rash may cause some small tears or rips to develop at the anus. These are called anal fissures. These rips can be extremely painful - like "paper cuts" on your fingers. 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.
In young infants, when their diet changes from breast milk to formula, or from formula to cow's milk, their bowel movements often become much harder. The same thing often happens in older children when when they begin eating solid foods.
As toddlers go through toilet training, they may hold back too long causing their bowel movements to become large and/or hard. The same thing may occur when children enter pre-school or kindergarten because many children will not go to the bathroom at school (lots of adults won't go to the bathroom at work or in a public place).
Following a bout of diarrhea, some children get a little dehydrated and as the diarrhea goes away, the intestine does what it is supposed to do and absorbs salt and water. This causes the bowel movement to become more harder. This can also happen following surgery or some other traumatic event.
It really doesn't matter why the pain starts. . . what is important is that the child passes a big and/or hard bowel movement and it hurts! Children are smart people, and if something hurts, they at least wonder whether they should do it again.

Once children begin to be afraid of passing bowel movements, the cycle of chronic constipation has begun. While that child may continue to pass bowel movements fairly regularly, if it hurts when they go, they often hold back . . . that is, they don't completely empty themselves when they go to the bathroom. Some people call this "with-holding". Because the child is holding back, they very slowly fill up their large intestine with stool and stretch it out of shape. If you stretch your intestine suddenly, it hurts! Most people call this type of pain "cramps". However, if you stretch your intestine slowly, it doesn't hurt and you don't get cramps. When you stretch the intestine slowly, the walls of the intestine relax by doing something we call "accomodating". As the large intestine slowly stretches, it gets bigger and bigger. Doctors often call this "megacolon" meaning the large intestine is too big. This explains why children with chronic constipation can pass bowel movements that are extremely large . . . often bigger than bowel movements that fully grown adults pass; their large intestine has gotten stretched out of shape.

Since children with chronic constipation chronically "hold-back", they don't regularly empty the lower part of their intestine. This means that their rectum is usually full. Normally, when we pass a bowel movement, we completely empty the bottom of our large intestine (rectum). This means that most of the time, the very bottom part of the large intestine (the rectum) is empty. Once a day, twice a day, or every other day, some stool moves into the empty rectum and stretches it. It is this stretching that gives us the "feeling" or "urge" to go to the bathroom (figure at right). When things are working correctly, the "urge" to go to the bathroom comes on slowly and it doesn't hurt. You respond to the "urge" by going to the bathroom and passing a bowel movement which empties your rectum.

Since children with chronic constipation almost always have stool in the rectum, the nerves that send the signal to the brain are constantly being stimulated; they are constantly getting the signal to go to the bathroom. Over time, they learn to ignore this signal. This is not a conscious decision, but rather something that just happens. It is much like sitting in a room with a buzzing light. For the first several days, you hear the buzzing, but after a while, you learn to ignore the buzzing . . . you just tune it out. After a while, children tune out the signal to pass a bowel movement. Once this happens, the urge to go to the bathroom comes in a very different way. It comes when the large intestine gets critically stretched. It gets stretched so big that basically it says "I can't take it any more!" - this feeling hurts, it is cramps.

In most children, this type of urge comes on quite suddently and it is very uncomfortable. When young children get this feeling, they may become very unhappy, begin sweating or become pale, disappear into a quiet room or closet, or grab hold of 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 a bowel movement, they are holding back. They are not holding back because of spite but rather, out of fear!

Eventually, the child will pass a bowel movement, but it often is very large and very hard, so there will be lots of pain. The pain will just reinforce the child's fear of passing bowel movements so the problem will go on and on and on and on . . . . as the cycle of pain and fear continues, passing bowel movements becomes more and more abnormal.
People who don't have trouble passing bowel movements don't think about it, but passing bowel movements is very complicated. Three things must happen for someone to successfully pass a bowel movement:

We must get the urge to pass a bowel movement.
Once we feel the urge and decide to pass a bowel movement, we increase the pressure in the large intestine to push the bowel movement out. To increase the pressure we must use many different muscles working together. We take in a breath and push down with our diaphragms. We tighten all the different muscles of the abdominal wall and push downward. You contract many internal muscles including the muscles surrounding the intestine as well as a number of muscles in the pelvis.
At the same time we are pushing or straining, we must relax the external anal spincter. This is the muscle at the very bottom of the rectum that keeps stool inside the intestine.
The next time you go to the bathroom, pay attention to what you are doing - you might be surprised!

Not surprisingly, in children suffering from chronic constipation, the coordination of these processes often gets very confused. First, they often do not get the urge to pass a bowel movement in the normal way, but rather, their urge often comes as pain or cramps. Second, when they start straining, rather than using all of their muscles together to push the bowel movement out, they often push with some muscles and pull with others - they grunt and strain and seem to push as hard as they possibly can, but they are usually fighting against themselves. Finally, because they are pushing and straining so hard, rather than relaxing the external sphincter to let the bowel movement out, they often squeeze or tighten the sphincter. As a result, they must generate enough pressure to force the bowel movement through the closed sphincter. This explains why some children with chronic constipation sometimes pass very thin bowel movements.

Most typically, when we think of constipation, we think of hard and painful bowel movements, but there are many other symptoms than can occur:
In many children with chronic constipation, the large intestine gets stretched out of shape ("megacolon"), so that they pass extremely large bowel movements. Sometimes their bowel movements are so large they clog the toilet!.
Because of the pain associated with bowel movements, some young children will refuse to pass bowel movements or even attend the toilet. This can lead to all sorts of conflicts and behavioral difficulties.
When children with chronic constipation pass very large or hard bowel movements they may open up small tears or rips at their anal opening. These tears or rips are called anal fissures. While anal fissures are not dangerous, they can be extremely painful and are often associated with some bleeding with bowel movements. This can be very frightening for parents and children alike. The tears or rips tend to occur in little folds of skin at the anal opening and so they may take a long time to heal much like a paper cut on a knuckle that constantly gets re-opened when you bend your finger.

Many children who suffer from chronic constipation will have changes in their appetite. Parents often notice that their child gets full very easily. They will sit down at the table, eat several bites, and then complain that they are full. These children are often described as nibblers or grazers because they eat little bits throughout the day rather than eating three square meals. Some parents notice that their child's appetite improves dramatically for several days after they pass a large bowel movement, but then it slowly declines again.
Many children with chronic constipation may complain of frequent abdominal pain or cramps and they are often quite irritable and/or diagreeable.

Some children with chronic constipation may have recurrent attacks of nausea and vomiting. It has been clearly shown that the stomach empties much more slowly than usual when someone becomes constipated.
The bladder sits right in front of the rectum so if the rectum becomes enlarged and is chronically filled with stool, there may be less room for the bladder to expand with urine. This may cause a number of urinary problems. Many children with chronic constipation seem to have small bladder capacities and seem to have to urinate more often than usual. In some children, constipation may cause recurrent bladder infections, bedwetting, urinary dribbling, or difficulty starting their stream.

In older children, long-standing constipation can be associated with leakage or smearing of stool in the underwear. As the large intestine gets stretched larger and larger, liquid stool from the small intestine begins to "leak" around more formed stool in the large intestine. In the the beginning, the leakage is usually very small and most parents just assume their child isn't wiping his or herself very well. As the large intestine stretches further, the amount of leakage increases so that eventually children begin having "accidents" - they pass whole bowel movements in their underwear! This is called encopresis. Since these accidents represent "leaking" of soft stool through the colon, children don't usual feel the "accidents" happening - rather, they just happen.
There are many different ways to treat childhood constipaton, but in the end, most treatments revolve around three basic principals:

Empty the large intestine
Once the large intestine has been emptied, establish regular bowel movements
Eliminate the pain associated with passing bowel movements
There are many different ways of accomplishing the three principals above. Early on, constipation can often be treated by changing a child's diet but once the constipation becomes chronic, laxatives are usually needed to re-establish regular bowel movements and eliminate the pain associated with passing bowel movements.

How do we empty the large intestine?
There are three commonly used methods of emptying the large intestine:
Adminstering enemas -
When we administer an enema, we push fluid into the rectum. The fluid softens the stool in the rectum but it also stretches the rectum giving the child a tremendous urge to pass a bowel movement. Almost all enemas consist mostly of water with something else mixed in to keep the water inside the intestine. The most commonly used enemas are:

Fleet's® Phosphosoda enemas contain water and the salt sodium-phosphate. The phosphate is not absorbed in the lower intestine and thus keeps the water from the enema in the intestine with it.
Soap suds enemas contain water with a small amount of soap. The soap is mildly irritating and stimulates the lower intestine to secrete water and salt.
Milk and Molassas enemas contain milk sugars and proteins as well as molassas. None of these are absorbed in the lower intestine and thus keep the water from the enema in the intestine.

Administer suppositories -
By administering a suppository, we irritate the bottom of the intestine, causing it to contract (squeeze) and push out a bowel movement. Some suppositories also stimulate the intestine to secrete salt and water softening the stool in the rectum and making it easier to push out. Commonly used suppositories include:

Administer powerful laxatives to "flush out" the lower intestine -
When we administer very powerful laxatives to "flush out" the lower intestine, we are generally keeping lots and lots of water in the intestine, softening any stool in the lower intestine, and causing diarrhea. Laxatives used to flush out the intestine include:

Once the large intestine has been emptied, laxatives are administered regularly to produce soft bowel movements once or twice each day. Virtually any laxative preparation will be effective if it is given in high enough doses. Most of the commonly employed laxatives work by keeping large amounts of water in the intestinal tract, thus making the bowel movements very soft and keeping the stool moving quickly through the large intestine. Commonly employed laxative preparations include:

Milk of Magnesia® and Haley's M.O.® - these laxatives contain magnesium salts that are very poorly absorbed by the intestinal tract. As a result, the magnesium remains in the intestine and keeps water with it. The end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. In high doses, magnesium salts often produce diarrhea.
Sennokot® and Fletcher's Castoria® - these laxatives contain the natural plant derivative senna. Senna stimulates the intestine to secrete salt and water so that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. Senna also is a mild irritant, causing the lower intestine to contract (squeeze). In some children, high doses of senna cause cramps and diarrhea.
Mineral Oil - many people believe that mineral oil works by "lubricating the intestine". Mineral oil is a non-absorbable oil that is digested by bacteria living in the large intestine. Some of the by-products of this digestion stimulate the intestine to secrete salt and water. This results in there being much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. When taking high doses of mineral oil, many children will experience some orange seepage as well as some itching at their anus.
Metamucil®, Citrucel®, Fibercon®, Fiberall®, and Maltsupex® - these are all fiber-based laxatives. Fiber laxatives contain complex sugars that are not digested or absorbed in the intestine. As a result, the sugars remain in the intestine and keep water with them. The end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. In high doses, fiber laxatives often cause bloating and gas.

In high enough doses, many foods are very effective laxatives however it is often difficult to eat or drink enough of these foods day in and day out to be effective long-term treatments. In high doses most fruits and juices can be very effective laxatives. Many people are familiar with using prunes as laxatives. Much like fiber laxatives, prunes contain complex sugars that are not digested or absorbed in the intestine. As a result, the sugars remain in the intestine and keep water with them. The end result is that there is much more water in the stool, keeping it very soft, and causing it to move through the intestine more quickly. As with fiber laxatives, high doses of prunes often produce bloating and gas.

While many parents and physicians are worried about using laxatives in children, most of their concerns are unfounded. Some common misconceptions include:
Children may become "dependent" on laxatives if they use them too long.
Since nearly all available laxatives work by keeping large amounts of water in the stool, they can be used for very prolonged periods of time without significant risk. There is no evidence that any of the laxatives described above can result in dependency with chronic usage.
Laxatives lose their effectiveness if they are used for prolonged periods.
No studies have ever convincingly demonstrated that any of the laxatives described above lose their effectiveness over time.
Children who use laxatives have an increased risk of developing colon cancer.
While several studies have suggested that adults with untreated constipation may be at increased risk for developing colon cancer, there is no evidence to suggest that laxatives increase this risk.

The length of treatment varies from child to child, but in general, we must treat younger children for longer periods of time than older children.

In children older than age five or six, three or four months of continuous laxative therapy is usually sufficient to reverse many of the problems described above.
In children less than five years of age, we usually recommend continuous treatment with laxatives for at least six months, and sometimes as long as a year.
Younger children need to be treated longer than older children not because the problem is more severe, but rather, because of their developmental stage. Young children are "magical thinkers" . . . they don't associate cause and effect the same way older children or adults do, so we need to treat them long enough that they lose the association between passing bowel movements and pain . . . they need to forget the pain. Toddlers are like elephants, they never forget!

The key to eliminating pain associated with bowel movements is to be sure the bowel movements are soft and not particularly large. In those children who have chronic anal fissures, it may be necessary to administer some form of medicine that is soothing and promotes the healing process.

Are there other things we can do to make treatment easier and more effective?
While almost all treatment regimens revolve around evacuating the intestine and using laxatives to keep the stools soft, a number of behavioral techniques can be quite helpful.

Children who are toilet trained should get in the habit of sitting on the toilet for five to ten minutes after breakfast and again after supper. Many families have very busy schedules and their children are not in the habit of "making time" to pass bowel movements. By establishing regular "bathroom times" after meals, we take advantage of intestinal contractions that occur after we eat. These contractions are often called the "gastro-colic reflex" and they explain why some people pass bowel movements every morning after breakfast or every evening after supper. It is also useful to establish regular bathroom times after breakfast and after supper because many children are completely unwilling to pass bowel movements at school (just as many adults are unwilling to go to pass bowel movements at work).

Some pediatric centers offer biofeedback therapy as a way of improving the muscle coordination associated with passing bowel movements. Remember, many children with chronic constipation have become quite incoordinated and use muscles against one another when they try to pass bowel movements. With biofeedback, several small wires are taped to the skin around the anus and on the abdomen. These wires can measure what the different muscle are doing and display this information on a television screen. By playing a type of video game, a child can learn how to tighten and relax his or her muscles in ways that make passing bowel movements more efficient and less painful.

When somebody suffers from encopresis it means that he or she can't control their bowel movements and so they pass bowel movements in their underwear. Sometimes people use the words "soiling" or "fecal incontinence" to mean the same thing.

In almost all cases, encopresis develops as a result of long-standing constipation. The vast majority of 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 since it was so long ago.

With constipation and painful bowel movements, children do not completely empty themselves when they go to the bathroom. Over a long period of time the large intestine slowly fills with stool and becomes stretched out of shape. As the large intestine stretches larger and larger, liquid stool from the small intestine begins to "leak" around the more formed stool in the colon. In the beginning, this leakage is usually small amounts that streak or stain the underwear and most parents just assume their child isn't wiping him or herself very well.

As the intestine stretches further, the amount of leakage increases so that eventually children begin having "accidents" - they pass whole bowel movements in their underwear! This is called encopresis. Because the accidents consist of stool that is "leaking" through the intestine and not getting completely digested, they are usually very dark and sticky, smell very badly, and they have to scraped off the skin and clothing.

Since these accidents represent "leaking" of soft stool through the colon, children don't usual feel the "accidents" happening - rather, they seem to just happen. The accidents tend to occur more often during the daytime when the child is active and moving around, and only rarely do they occur at night while the child is asleep.

In most cases, encopresis is not primarily a behavioral problem - children with encopresis do not have their accidents out of spite or because they are lazy. Rather, many behavioral problems develop because of the encopresis, and once the encopresis is treated, many of the behavioral problems may resolve.

Northeast Indiana Pediatric Specialists, PC

Dr. Michael Dick & Dr. Todd Dillon
11123 Parkview Plaza Drive Suite 102
Fort Wayne, IN 46845
(260) 483-0688
http://www.med-web.com/nips/

nips@med-web.com