Fecal Retention, Encopresis in 5 Year Old

I hear how frustrated and worried you are. It does sound like your five year old was somehow traumatized in relation to having bowel movements. I don't think your holding his cheeks apart to help him go when he was three caused this, btw. It is very common for kids to have painful BMs and then to develop a habit of "fecal retention" (which means holding in their stools; often the term encopresis is used because that describes the soiling of the underwear which usually results). Sometimes, other stresses cause the fecal retention. Unfortunately, fecal retention soon becomes a habit, and it causes bigger stools, which makes them more painful, so this sets up a vicious cycle of avoiding having BMs.

The bad news is that your son needs Miralax to move his bowels, and that is a physical addiction that should not be necessary for a child. Worse, Miralax can lead to bowel accidents. Even worse, he resists going enough that even with the Miralax, he ends up going in his clothes. Miralax does work for some kids, but it doesn't work for many kids, and it can keep you stuck in a bad situation that only gets worse as your child gets older.

I know this seems like a psychological issue, and it may have begun that way, but I urge you to reframe this as physiological. Kids desperately want to solve this issue but it is not in their control because their bodies are not working properly. His stools may still hurt, or he may have lost the ability to recognize his own rectal urges, or his colon may be distended, which makes his BMs larger and more uncomfortable. So this is not just about what goes on in his head. His colon is not working as yours or mine does.

I assume that since you took your son to John Hopkins, a doctor is following his case. That would be important, since the colon can become impacted. I am a psychologist, not an MD, so I want to be sure you are consulting with an MD.

Your goal--as you obviously already know--is to help your son overcome his fear of having a BM. But it may well be that he has to also restore his colon to normal function. I would suggest that you give yourself no more than one month to see some change, using the following suggestions:

1. Make sure that it does not ever hurt him to move his bowels. That means you do need to keep him on the Miralax--probably for a year--to make his stools soft. You want his BMs to be about the consistency of oatmeal. Of course, you also want to be sure that his diet is healthy, with plenty of water, fiber, good oils, etc.

2. Make sure your son is in control of his own body. In other words, avoid enemas, as long as he can move his bowels with Miralax. It does not cause cramps and it leaves your son in charge of when he will move his bowels, so it is a good solution if it works.

3. Have regular bathroom times when you sit with your son while he is on the toilet, at least twice a day. Your goal is to keep him company to allay any fears he has about it hurting, and to help him relax so that he is more likely to move his bowels. A warm bath before his "sits" helps move the bowels. Then have special books, games, etc that he can only play with you when he is in the bathroom. Make these times with you really fun. You are his partner, assistant, and cheerleader. If he does have a BM, celebrate. Stay in the bathroom with him for half an hour each time, and encourage him to move his bowels. If he doesn't, after half an hour, say "Ok, let's take a break, but please tell me when you're ready to come back and try again, ok?"

4. Schedule your bathroom times at the same time every day to establish a habit, preferably right after meals. After eating, the intestines move the food through by squeezing, so it is easier to have a BM.

5. Teach your son the Valsalva maneuver to help him move his bowels. He needs to:

• Hold his breath.
  
  
• Squeeze in his abdominal muscles.
  
  
• Push hard to push out the stool.

6. Offer your son the choice between a potty chair and the toilet. I know potties will mostly be too small for him, but he might be more comfortable with one. Many kids are frightened of falling in the toilet. Many other kids just can't get the leverage they need to push, because their feet dangle. Dangling legs tighten rectal muscles and make defecation difficult. You might want to consider a stool like this:

http://www.thepottystool.com/index.html

I know it might seem excessive to buy a special stool, but it gives kids the support and security they need, as well as the leverage. What is important now is that your son become comfortable moving his bowels on a regular basis. Once he accomplishes that, you can help him transition to the regular toilet.

7. If your son soils his pants in spite of your efforts to get him to use the potty, don't punish him. That will only make him hide his soiled pants and begin lying to you. This is not a habit you want him to develop. Instead, take a deep breath, stay as calm as you can, and say "I guess you couldn't make it to the bathroom this time. Soon you will be able to use the bathroom every time. What can I do to help you use the potty instead of your pants?" He may not know, of course. Most kids with encopresis don't feel their urge to go until they're in the middle of it.

It is important to resolve this issue now, because when kids reach school age this becomes much more difficult to solve, which can lead to all kinds of problems, not the least of which is an enlarged colon and reduced sensitivity to their own urges. School-age kids often begin to hide their problem, have accidents at school, and have their self-esteem eroded. For this reason, I would only suggest the above protocol for one month. If you see improvement, then great -- keep at it. Within six months your son should have normalized and you can wean him very gradually off the Miralax.

However, if you do not see positive progress within a month, I would strongly recommend that you take more drastic action and consult with a gastroenterologist to see if your son is blocked. He may need a complete clean-out before he can normalize with the program I have outlined.

I will add, though, that doctors often seem stymied by this issue, and it drags on without solution. The usual medical approach is basically like mine, although they do medical tests to insure there is nothing medically wrong. But they just continue to keep the stool soft and hope the child will get used to having stools. Unfortunately, this seems to work in only about half of cases.

There is a different approach now, pioneered by Dr. Robert Collins. Basically, he recommends the time in the bathroom that I recommend, only if the child does not go after the first two sits, you use a suppository to help them, and if the child does not go after that, you use an enema to make sure the child moves his bowels.

Most doctors have been nervous about the suppository/enema approach for fear of traumatizing the child. I have to say that is my instinct, also. I think giving kids enemas is very invasive. However, encopresis is a severe problem that can traumatize a child for life, and the longer it goes on the more traumatic it is. So even though I would not subject a child to enemas lightly, if my child had this problem and the approach I have outlined above did not work within a month, I personally would try the Collins approach. I have come to this conclusion after several months of following the Collins discussion group that uses his approach.

Watching new parents begin this approach is interesting, because they feel just as nervous as I would. But then a miracle seems to happen. It may take a few weeks, but the kids begin being able to move their bowels on their own without resorting to the enemas and suppositories as often, and within a few months, most of them are off them. So this approach does seem to retrain the bowel reflexes.

As I follow the discussion on Collin's list, I see relieved parents and kids who are thrilled as they regain control of their own bodies. However, he doesn't just give them enemas, he has a specific protocol that allows the enemas to be diminished and eliminated, and it certainly sounds right to me that the child would be relieved and happy to regain control of his own bowels.

As I say, enemas are invasive and traumatic, so I would not take this path lightly, but since this is such a challenging problem to solve, his approach is good to know about if your son does not respond to my more gentle recommendations. I want to add that when you buy Collins' book (which costs a hefty $75), you get access to the forum of parents using his approach that I have been reading. That seems invaluable to read BEFORE trying his approach, to make sure you really want to do it. You can even just pay a lesser amount and get access to the forum, which has archives. Collins' website is http://www.encopresis.com/. Just so you know, I have nothing to do with Collins and am recommending his approach as a last resort, not a starting place, once you do your own research. I am also a psychologist, not a physician, so I am giving you my opinion as an informed mental health professional only.

I wish you luck in solving this very challenging problem. Please remember to be patient with your son, and to love him as much as you can, unconditionally, through this. Your love is what will help him get through this with his self-esteem intact. Whether he responds to my mild approach, or you end up using the Collins approach, he will eventually be able to use the toilet normally. Your goal is for his self esteem and your relationship to come out stronger for this experience.

Please let me know how this works out.

All blessings,
Dr. Laura

p.s. Please note that I have revised the above advice now that I have had the opportunity to follow the Collins forum for a few months. I am impressed with all the success stories from parents, and want to be sure that folks who read my response hear my opinion. Some of the comments below were in response to my original advice, which was not informed by any direct knowledge of the Collins approach.