Elimination Disorders in Children

  • Medical Author:
    John Mersch, MD, FAAP

    Dr. Mersch received his Bachelor of Arts degree from the University of California, San Diego, and prior to entering the University Of Southern California School Of Medicine, was a graduate student (attaining PhD candidate status) in Experimental Pathology at USC. He attended internship and residency at Children's Hospital Los Angeles.

  • Medical Editor: David Perlstein, MD, MBA, FAAP
    David Perlstein, MD, MBA, FAAP

    David Perlstein, MD, MBA, FAAP

    Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx.

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Elimination disorders in children facts

  • Constipation is defined as "a group of disorders associated with persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of a structural or biochemical explanation."
  • Constipation is a relatively common event estimated to be responsible for 3%-5% of all visits to a pediatrician's office.
  • Encopresis has been defined as "the repetitive, voluntary or involuntary, passage of stool in inappropriate places by children 4 years of age and older, at which time a child may be reasonably expected to have completed toilet training and to exercise bowel control."
  • Most studies indicate approximately 4% of all children 4-17 years of age will experience encopresis.

What are elimination disorders in children?

There are two types of disorders of elimination that may affect children. One category reflects problems with stooling, relatively common constipation and less frequently occurring encopresis (also known a fecal incontinence or soiling). The other category of elimination disorders in children reflects problems with urination and is known as enuresis. The article will review only problems associated in children dealing with stooling. Problems with urination in children are reviewed elsewhere.

What are the risk factors and causes of constipation and encopresis?

Most children with encopresis have underlying constipation. Why some children develop encopresis does not seem to reflect differences in either physiology or psychology. Pediatric GI specialists have noted three areas of intestinal maturation that may set the stage (in some children) for the onset of constipation and (in some, ultimately) encopresis. These areas include the following:

  1. Changing from a pure breast milk/formula diet to one that includes and ultimately relies on the majority of calories from solid foods: The increase in solid foods promotes an increase in stool volume and consistency that may require greater effort for stool expulsion.
  2. The process of toilet training: The emotional turmoil for some families in what is generally a natural evolutionary process may engender a myriad of emotional responses in the child who is toilet training. The often conflicting desire to please parents but establish autonomy may "raise the stakes" too high for the toddler to succeed. The fact that many preschools require successfully toilet trained students may engender parental stress since many parents utilize preschool as a safe locale for their child during the adult's workday. One study demonstrated that 35% of children who refused to toilet train developed chronic constipation and were at a substantially higher likelihood of developing encopresis.
  3. School attendance: Pediatricians daily hear stories about children who refuse to use the school toilet for either urinating or bowel movements. The lack of privacy, taunting, and often noisy chaos is just too intimidating when compared with the home environment.

Regardless of the cause, many children with constipation will ultimately pass either an overly large and/or hard stool, resulting in a painful experience. The rational step (from the child's perspective) is to avoid stooling and thus avoid further pain. Consequently, stool accumulates in the rectum and becomes desiccated and thus more difficult and more painful to pass. This recurrent cycle reinforces the child's behavior to avoid stooling at all costs. Children who develop encopresis may develop abnormal stretching and enlargement of the rectal area that reduces the reflex urge to stool. As a consequence, the impacted stool mass may allow "upstream" semisolid stool to leak around the "downstream" stool obstruction, causing soiling in clothes as well as occasional chunks of stool to also be passed without the child's knowledge or desire.

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Causes of Bedwetting

The fundamental problem for children with primary bedwetting is the inability to recognize messages of the nervous system sent by the full bladder to the sleep arousal centers of the brain while asleep. In addition, bladder capacity is often smaller in bedwetting children than in their peers.

What are the symptoms and signs of constipation?

Pediatric gastroenterologists (GI doctors) indicate that symptoms of constipation generally involve six characteristics of abnormal stooling present in infants and toddlers for at least one month and children 4 to 18 years of age for two months. A minimum of two criteria must be present to fulfill the definition of constipation. These stooling patterns/problems include the following:

  1. Two or fewer bowel movements per week
  2. One episode of stool incontinence after mastering toilet-training skills
  3. A history of excessive stool retention which may be accompanied by characteristic retentive posturing ("the poop dance") in older children
  4. A history of passage of painful or hard bowel movements
  5. A history of large stools which may obstruct the toilet
  6. Palpation of a large mass of stool in the rectum during digital rectal exam

What are the symptoms and signs of encopresis?

Specialists who deal with encopretic children note that the above criteria for constipation are also characteristic of encopresis. In one recent study focusing on constipation, many of the children in the study first presented to their physician with a history consistent with encopresis. There are, however, several historical elements that are unique to encopresis. These include the following:

  1. Some children with encopresis may successfully stool every day, however, evacuation of their bowel is incomplete.
  2. Encopretic children commonly "defecate in places inappropriate to the social context at least once a month" (for example, the classroom).
  3. Children with encopresis seem oblivious or nonchalant to either obvious stool staining of their clothes or the heavy stool odor they produce.
  4. There is no underlying organic medical condition that explains the child's encopretic pattern.

How are elimination disorders diagnosed?

A complete evaluation of a child with constipation or encopresis involves a thorough history, a detailed physical examination, and may include laboratory testing. The child's pediatrician may generally handle the analysis of these elements. A pediatric GI specialist consultation may be indicated should a more ominous cause for the elimination disorder be discovered or if the evaluation produces conflicting data and thus obscures the establishment of the exact cause and thus management for the child's problem.

The history to be explored during an evaluation of elimination disorders includes: (1) age and abruptness of onset, (2) frequency and character of the current stool pattern in comparison to that noted prior to the onset of symptoms, (3) relationship to ingestion of meals as well as types of food in the child's diet, (4) unusual weight loss or gain, (5) associated abdominal complaints (for example, abdominal pain), (6) urological issues (many children with elimination disorders may also have enuresis -- involuntary loss of bladder control), (7) psychosocial family dynamics (for example, parental/sibling/peer response to the problem), and (8) gentle exploration for any possibility of sexual abuse -- regression, depression, sexually acting out, etc.

The goal of a complete physical exam is to eliminate the possibility of anatomical or functional causes for the elimination disorder. Children affected by cerebral palsy, global hyponia (low muscle tone), mental retardation, and anatomical malformations (for example, spinal cord abnormalities or displacement of the anus) must be considered and ruled out as a cause for the child's symptoms. Physical examination of the abdomen will often demonstrate a large stool mass. A rectal exam will commonly demonstrate an enlarged rectal volume that is packed with stool. Absence of anal muscular tone should be a "red flag" for a potential neurological disorder. As noted above, appropriate anal location should be documented. Likewise, the physician should perform an evaluation for hidden spinal cord malformations (for example, tuft of hair over the lower spine).

Most children with either constipation or encopresis do not need laboratory or radiographic evaluation unless the history and/or physical examination warrant further analysis (for example, an MRI for spinal cord malformations). Blood studies to evaluate thyroid function may be a consideration on an individualized basis. An abdominal X-ray may be helpful to measure the child's stool burden. For those children with urologic problems, a culture and urinalysis are reasonable studies. A pediatric gastroenterologist may perform a study of anal and rectal muscle tone (anal/rectal manometry) to assess the anal/rectal response to inflation with air in children who do not respond to routine therapy.

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What is the treatment for elimination disorders in children?

Successful treatment of elimination disorders includes reestablishing an appropriate bowel evacuation regimen and development of a program to ensure maintenance of such a stool elimination pattern. A program that may include the use of laxatives, changes in diet, toileting behavior adjustments, and close follow-up has been shown to provide the highest rate of success. The therapeutic approach is often defined by the age of the child. Breastfed infants are less likely to have stooling problems when compared with their formula-fed peers. Diluted prune juice (50:50 with water) will promote a softer and increased volume stool. Rectal stimulation with either a rectal thermometer or glycerin suppository may be an appropriate technique to address a stool-impacted infant. Mineral oil is not recommended for infants due to the possibility of gastroesophageal reflux (GER) and possible lung pathology if aspirated. Careful attention to the child's stooling pattern is worthwhile when solid foods are introduced into the young infant's diet.

Preschoolers, grammar-school-age, and older children with elimination disorders are generally approached in a similar fashion. If the child is chronically impacted, the use of an orally administered cathartic (for example, magnesium citrate) will "clean out" the colon. Colonic enemas have fallen out of favor due to the emotional stress that may be associated with their use. Follow-up daily use of water retaining laxatives (for example, polyethylene glycol without electrolytes marketed as PEG-3350 or Miralax) is common. This approach allows the chronically distended colon to gradually return to a normal volume -- thus allowing redevelopment of stretch receptors to respond to the local rectal/anal enlargement associated with stool arrival to the area. These water-retaining laxatives may be needed for several months before considering a gradual tapering. A thorough review of the child's diet is important. Avoidance of large amounts of constipating items is paramount. Such foods would include excessive milk/dairy products, starches (bread, pasta, etc.), and "fast foods," which are often high in saturated fats. Grandmother's suggestion to "eat your fruits and vegetables" has solid medical credence. An adequate intake of water as well as daily vigorous physical activity will also promote colonic health. Establishment of a daily routine of "toilet time" has been shown to be very helpful. Spending between five to 10 minutes on the toilet is a generally accepted goal. For young children, a reward system is often helpful. The reward should be a response for sitting on the toilet for the allotted time -- not the production of stool. Passage of a daily normal character stool without discomfort is the intended goal of bowel reeducation.

The use of probiotics has received scientific study in the last few years. Pediatric studies are less convincing than those utilizing adult patients and many studies present conflicting results. There has been no documentation of a deleterious effect of probiotic usage in children or adults.

Can elimination disorders in children be prevented?

While there are no guarantees in this world (except death and taxes, as Benjamin Franklin reportedly said), there are several measures that can be taken to lessen the likelihood of constipation and/or encopresis. Breastfed infants have fewer stooling issues than their formula-fed counterparts. Careful monitoring of intestinal changes associated with the introduction of solid foods (between 4 to 6 months of age) is helpful. The process of toilet training should be viewed as the socially coordinated behavior of a purely biologic function. Forceful threats, intimidation, shaming, and extreme pressure should not be part of the toilet-training process. Many a toddler discovers that they, and not their parents, have ultimate control of when and where they will have a bowel movement. Forcing the issue will often only complicate matters. Frustrated parents should remember that very few high school seniors wear Depends to the senior prom. As noted above, a healthy diet emphasizing proper hydration, whole grains, fruits and vegetables, and an active lifestyle will promote normal stool production and elimination.

What is the prognosis for children with elimination disorders?

With parental education regarding risk factors and awareness of techniques maximizing their avoidance, the prognosis for children with elimination disorders is positive. Likewise, effective therapy has been demonstrated to be successful in both the short and long term, allowing reestablishment and maintenance of normal bowel function.

Medically reviewed by Margaret Walsh, MD; American Board of Pediatrics

REFERENCES:

Abi-Hanna, Adel, and Alan Lake. "Constipation and Encopresis in Childhood." Pediatrics in Review 19 (1998): 23-31.

Ferry, George. "Definition, clinical manifestations and evaluation of functional fecal incontinence in infants and children." UpToDate.com. Apr. 29, 2013. <http://www.uptodate.com/contents/definition-clinical-manifestations-and-evaluation-of-functional-fecal-incontinence-in-infants-and-children>.

Ferry, George. "Treatment of chronic functional constipation and fecal incontinence in infants and children." UpToDate.com. July 23, 2013. <http://www.uptodate.com/contents/treatment-of-chronic-functional-constipation-and-fecal-incontinence-in-infants-and-children>.

Har, Aileen, and Joseph Croffie. "Encopresis." Pediatrics in Review 31 (2010): 368-374.

Last Editorial Review: 3/11/2016

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Reviewed on 3/11/2016
References
Medically reviewed by Margaret Walsh, MD; American Board of Pediatrics

REFERENCES:

Abi-Hanna, Adel, and Alan Lake. "Constipation and Encopresis in Childhood." Pediatrics in Review 19 (1998): 23-31.

Ferry, George. "Definition, clinical manifestations and evaluation of functional fecal incontinence in infants and children." UpToDate.com. Apr. 29, 2013. <http://www.uptodate.com/contents/definition-clinical-manifestations-and-evaluation-of-functional-fecal-incontinence-in-infants-and-children>.

Ferry, George. "Treatment of chronic functional constipation and fecal incontinence in infants and children." UpToDate.com. July 23, 2013. <http://www.uptodate.com/contents/treatment-of-chronic-functional-constipation-and-fecal-incontinence-in-infants-and-children>.

Har, Aileen, and Joseph Croffie. "Encopresis." Pediatrics in Review 31 (2010): 368-374.

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