Encopresis
What is Encopresis?
Encopresis is the involuntary leakage of liquid stool in children with constipation. [5]
Encopresis develops from a vicious cycle of constipation: [5,6]
The child becomes constipated
The child experiences pain when using the bathroom
The child begins to withhold stool
Over time, the child has difficulty identifying bathroom urges.
This cycle repeats until the hard stool becomes impacted, or stuck, in the intestines
The intestines become enlarged and the rectal muscles become tired and relax [5,6]
This relaxation of the rectal muscles causes softer, liquid stool to leak around hard impacted stool soiling the child’s clothing
This leaking of stool can occur numerous times throughout the day without the child’s knowledge.
Leaking caused by encopresis is often mistaken for diarrhea, although the main underlying cause is actually constipation. [5]
Children with encopresis often resist efforts to toilet train due to fear of using the restroom.
Encopresis is diagnosed when all of the following criteria are met: [6]
Repetitive stool accidents in inappropriate places (i.e. clothing, floor)
At least 1 encopresis event for 3 consecutive months
The child must be at least 4 years of age or a developmentally equivalent age
The incidents cannot occur due to medication (most commonly laxatives) use or a medical condition
Treatment may involve the physical removal of the hard impacted stool from the lower colon and medication. [7]
If long-term medication is being used to manage symptoms of encopresis and constipation, see the Constipation note and the nutritional, lifestyle, and supplemental considerations for encopresis below to treat the root cause.
Signs & Symptoms
Fear of using the toilet
Tantrums or aggression when it is time to use the toilet
Soiled clothing
Accidents in inappropriate places (i.e. floor)
Loss of appetite
Disinterested in physical activity
Urinary incontinence
Withholding stool
Long periods of time in between bowel movements
Contributing Factors
Low Fiber Diet
Dehydration
Hypotonia (low muscle tone)
Food Sensitivities
Leaky Gut
Excessive intake of processed and fast foods
May be triggered by:
Pain associated with stool passage
Fear of the toilet
Difficulty using public toilets
Bad experiences with toilet training
Travel
Diaper rashes
Next Steps
Diet
Consider the contributors to the root cause of encopresis, constipation:
Insufficient intake of fiber in the diet
Insufficient fluid intake leading to dehydration
Hypotonia (low muscle tone) of the gastrointestinal tract, which may be due to hard stool impacted in the colon or mitochondrial dysfunction
Intake of food sensitivities, such as dairy and gluten, can lead to poor digestion, absorption, and the development of dysbiosis
Inadequate food intake
Look into both yeast overgrowth and Leaky Gut Syndrome
Next Steps to consider:
Increase intake of fiber from foods such as:
Oatmeal, pears, dates, flax seeds, chia seeds
Consider supplemental fiber if the child is a picky eater
Increase intakes of fluids, such as water and juice.
Ensuring adequate hydration helps to soften stool making it easier to pass.
Remove food sensitivities or foods the child is reactive to, gluten and dairy are the most common culprits
Limit intake of whole milk to 16 oz/day for children over 2 years of age. [7]
Supplements
Prebiotic (fiber) supplements such as inulin and acacia fiber may be beneficial in softening stool and improving movement through the digestive tract.
When adding in a fiber supplement, it is important to increase fluid intake as well.
Magnesium citrate may be beneficial for constipation
Digestive Enzymes can aid in the proper digestion and absorption of nutrients, which may help to prevent constipation
Slippery Elm [9]
*Supplemental iron and calcium can lead to constipation. Evaluate current supplemental intake of these minerals in multivitamins and individual supplements.
Lifestyle
Aim for at least 60 minutes of physical activity each day. Movement can encourage the passage of stool.
Bowel Habit Training [5]
Bowel habit training involves scheduling at least 1-2 visits to the toilet daily
Begin by simply teaching the child to sit on the toilet for 1-2 minutes, gradually work up to 10-12 minutes
Even if the child does not have the urge to use the toilet
Do not force or hold the child on the toilet as this could increase fears associated with using the toilet
Provide activities for the child to do while using the toilet
Ensure the child is comfortable while using the toilet
Small potty or child seat
Use a stool if the child’s feet do not reach the ground
Make sure the environment is quiet
Before the child uses the toilet, stimulate the gastrocolic reflex, and increased movement of the colon caused by eating or drinking
Eat a snack or meal
Drink a warm drink
Try to identify the child’s cues that they may need to use the toilet. These cues can include:
Change in facial expression
Going to a quiet place
Straining
Express positive reinforcement
Praise every small improvement
Reward the child with stickers, high-fives, new activities, or singing a special song every time they sit on the toilet or use it.
Keep a stool diary [6]
A stool diary helps to track the frequency and consistency of stool, pain level, behavior, appetite, sleep, dietary intake, and overall symptoms associated with each bathroom visit
Seek assistance from a trained professional, such as a physical or occupational therapist to assist with toilet training.
Warm, Epsom salt baths may be beneficial in helping to relax rectal muscles and nerves.
Abdominal massage in a clockwise motion may help to encourage bowel movements.
Chiropractic care may be beneficial to help relieve constipation [8]
If the child is taking medications, speak with the child’s primary care provider to identify if any of the medications could cause constipation or kill beneficial bacteria and thus encourage yeast overgrowth and dysbiosis.
DISCLAIMER: Before starting any supplement or medication, always consult with your healthcare provider to ensure it is a good fit for your child. Dosage can vary based on age, weight, gender, and current diet.
Encopresis & Autism in the Research
Rate of Encopresis and Autism
One scientific review included 33 studies on autism and incontinence. Nocturnal bedwetting, daytime urinary incontinence, and fecal incontinence were included. [1]
The review concluded that there is a significantly higher prevalence of incontinence in children with autism as compared to typically developing children. [1]
Encopresis and Mental Health
This study found that children with encopresis were more likely to experience anxiety, depression, poor attention, socialization difficulties, increased disruptive behavior, and poorer school performance as compared to children without encopresis. [2]
Children with encopresis were also more likely to come from family environments that were less expressive and lacked organization. [2]
Toilet Training and Autism
Four elementary-aged children with autism were evaluated in a toilet training study. [3]
The protocol included increased access to fluids, time intervals for toilet sit schedules, programmed positive reinforcement, and dry checks. [3]
At the end of the study, all four participants mastered the toilet training criteria and were able to maintain independent toileting after the study was completed. [3]
Three participants began self-initiating to use the restroom. [3]
This study gives an example of how beneficial bowel habit/toilet training can be in the treatment and prevention of encopresis.
Encopresis and OCD
The Autism Treatment Network was reviewed for children aged 2-17 with autism. [4]
The review found that children with severe constipation, co-occurring diarrhea, and encopresis were significantly more likely to exhibit repetitive and compulsive behavior, practice rituals, and have a clinical diagnosis of Obsessive-Compulsive Disorder (OCD). [4]
This suggests that children with OCD, which is common in those with autism, are more likely to have difficulties with constipation, diarrhea, and encopresis. [4]
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[1] Niemczyk J, Wagner C, von Gontard A. Incontinence in autism spectrum disorder: a systematic review. Eur Child Adolesc Psychiatry. 2018;27(12):1523-1537. doi:10.1007/s00787-017-1062-3
[2] Daniel J. Cox, PhD, James B. Morris, Jr., PhD, Stephen M. Borowitz, MD, James L. Sutphen, MD, PhD, Psychological Differences Between Children With and Without Chronic Encopresis, Journal of Pediatric Psychology, Volume 27, Issue 7, October 2002, Pages 585–591, https://doi.org/10.1093/jpepsy/27.7.585
[3] Cagliani RR, Snyder SK, White EN. Classroom Based Intensive Toilet Training for Children with Autism Spectrum Disorder [published online ahead of print, 2021 Jan 27]. J Autism Dev Disord. 2021;1-11. doi:10.1007/s10803-021-04883-3
[4] Peters B, Williams KC, Gorrindo P, et al. Rigid-compulsive behaviors are associated with mixed bowel symptoms in autism spectrum disorder. J Autism Dev Disord. 2014;44(6):1425-1432. doi:10.1007/s10803-013-2009-2
[5] Cole L, Howell L, Stump J, Schmidt B. Parent's Guide to Managing Constipation in Children with Autism. April 2013.
[6] Constipation & Encopresis. https://nationalautismresources.com/constipation-encopresis/. Accessed May 31, 2021.
[7] Encopresis. Cincinnati Childrens. https://www.cincinnatichildrens.org/health/e/encopresis. Accessed May 31, 2021.
[8] Iyer MM, Skokos E, Piombo D. Chiropractic Management Using Multimodal Therapies on 2 Pediatric Patients With Constipation. J Chiropr Med. 2017;16(4):340-345. doi:10.1016/j.jcm.2017.06.004
[9] Hawrelak JA, Myers SP. Effects of Two Natural Medicine Formulations on Irritable Bowel Syndrome Symptoms: A Pilot Study. The Journal of Alternative and Complementary Medicine. 2010;16(10):1065-1071. doi:10.1089/acm.2009.0090.
Authors
Sinead Adedipe, MS, RDN
Edited & Reviewed by Brittyn Coleman, MS, RDN/LD, CLT
