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Encopresis: Stool Incontinence in Children

Updated: Apr 16

Not having a huge pediatric practice, I must admit how surprised I am by the number of pediatric clients I care for who suffer with stool incontinence. This is said to occur in about 3 to 4 percent of 4-year-old children and then decreases with age. My clinical experience has only identified boys with this struggle, one in college, a few younger, but most are elementary or middle schoolers, even high school.

More often this is caused by constipation or a sort of retention, so the incontinence is more a leaking of stool around this mass or a leaking of a sort of hoarding of stool. Hirschsprung disease may be to cause, which typically presents pretty early in life, or Celiac disease. Many times this is psychological though and one must consider a history of trauma. Another potential is gravitational insecurity which is a presentation of sensory integration disorder.

Stool retention and constipation result in dilation of the rectum and sigmoid colon, which leads to changes in the reactivity of muscles and sensitivity of nerves of the bowel wall. They bulge and get a bit too relaxed essentially. These changes decrease the efficacy of bowel excretory function and lead to further retention. This becomes worse and worse over time, so when children don't present early, it can be really difficult to resolve this issue.

As stool remains in the bowel, water is absorbed, which hardens the stool, making passage more difficult and painful. Softer, more loose stools may then lead around the hardened stool bolus, resulting in overflow. Both leakage and ineffective bowel control result in stool accidents.

One of the more common reasons for constipation is food, chemical and dye sensitivity which I hate to admit, most conventional practitioners completely skip over or they recommend extensive #eliminationdiets which may or may not eliminate some of the child's triggers, but will also miss others and will certainly eliminate many which aren't triggers, unnecessarily restricting their diet. My preference is MRT testing with LEAP therapy. This is very specific to the individual and helps me create a diet with absolutely no inflammatory reactions, allowing the gut to heal and then we can start reintroducing foods to identify additional triggers.

Another important intervention that I don't feel gets enough appreciation in conventional medicine is the recommendation of a Squatty Potty. This video is really pretty perfect with explaining this phenomenon of needing to get our knees up to stool optimally, but trust me, once your body gets accustomed to this, there is no going back. If you're a human being, and you poop from your butt, you need a squatty potty. This will also help give grounding to those with gravitational insecurity.

Genetic testing to identify gluten sensitivity or even Celiac disease can be super helpful. We have our clients utilize an ancestry company and then have this raw data interpreted. Again, I don't want to give everyone blanket recommendations. I want to know with objective data what the trigger is, because as much as I like to think I can figure it out based on my own clinical expertise, this is one area I have found myself wrong far too many times. Paprika, goat cheese, apples, bananas, and turmeric are some of the highest inflammatory foods found in some of my client's testing results. Never would I have identified those and guessing is super disruptive their their life when we are modifying and eliminating major food groups.

Movement is yet another significant oversight. Sadly, none of us move as much as we think we do. We are a society who lives in our brains. We are logical, always thinking and learning, curious and seeking visual stimulation, but this makes us feel more active than we really are and even exhausted, but that exhaustion is mental not physical. When we are stagnant, our gut doesn't get near the blood flow it does while moving. My clients have shared that walking helps their constipation so much that they've learned they can't walk far from home.

One recommendation that is quite often given though, is supplementation with Miralax, and I'll share that I am not a fan. My clients are privy to an educational forum in which we offer a number of treatment regimens, recommendations for wellness and such, and within here I write about what I believe to be the dangers of Miralax for these individuals. If you haven't access, a little google searching may be enlightening. This post though is full of useful information, so if you are a client, and this topic of relevance to you or a loved one, check it out too.

Treatment of Stool Incontinence in Children

Education is important, as is demystification of this disorder for family members, and I wish school teachers who are often cruel to those requesting excuse to the restroom during class. Our first approach is to eliminate any impaction which is why the Miralax is recommended, but again, there are other options. Behavioral therapies and diet interventions, such as the MRT mentioned above or potentially elimination of gluten can be exceedingly helpful. Some practitioners will recommend laxative therapy (Bisacodyl or senna) although not yet have I had a case where I felt this was optimal. Enemas have also not been something I've had to recommend more recently. Certainly I've had a few more severe cases that did require #laxatives and #enemas, but those are complex scenarios for which I can't really discuss here. Once the bowel is confirmed empty though, creating a stool routine is important, especially having them sit on the toilet for a few minutes after each meal.

Identifying the underlying disorder really is key. Maintaining a lifelong habit of Miralax or laxatives is not ideal. That's just another bag of worms and the longer this underlying cause is ignored, the worse the case and the more difficult the healing process. Either way, don't blame the child. This isn't an issue of disobedience.

Somatic Therapy

I am a fan of therapy for even the healthy folks in my practice, but this particular individual often has trauma that may even be repressed. This doesn't mean they've had some catastrophic event because everyone responds different to various situations so what one person will resonate as trauma may not to another. The event in itself really isn't the point; it's how our bodies respond. Somatic therapy addresses that trauma repressed in our body which can cause children especially to hoard their stool. We see that when little ones are stressed, even after working through eliminating impactions and creating healthy stool habits, that stress will cause this to reoccur. Changes in their life can also cause this to happen. It's funny that not many of us stool at work or school, for example, or on vacation. We need to feel safe to perform this activity.

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