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Why you must monitor your baby's bowel movements

 Encopresis mostly affects up to four per cent of children aged four years, and it is more prevalent in boys. [iStockphoto]

Is your child already potty-trained but still soils himself and is mostly constipated, has hard stool and avoids using the toilet or goes for long periods without bowel movements?

Well, your child could be suffering from encopresis. Also called functional faecal incontinence or soiling, encopresis is the repeated involuntary passing of stool when not on the toilet, hence soiling clothing. Typically it happens when compacted stool collects and fills up in the colon and rectum, causing leaking of liquid stool around the retained stool, hence staining underwear and might be mistaken for diarrhoea.

Encopresis mostly affects up to four per cent of children aged four years, and it is more prevalent in boys. Its frequency decreases with older age. It is perhaps due to its low prevalence that there is little awareness about the disease. Most often, it is mistaken for just constipation. Parents may also think that a child who does not excrete regularly is merely afraid to use the potty or the toilet.

Your child’s age matters when considering the causes of constipation. In infants and toddlers, we think more of an organic cause as opposed to a functional cause. While it could be caused by emotional issues, constipation is the most common cause of encopresis. This type is called ‘retentive encopresis’. In this case, the child’s stool is hard, dry and may be painful to pass. As a result, the child avoids going to the toilet – making the problem worse.

The longer the stool remains in the colon, the more difficult it becomes to push out. Ultimately, the colon stretches, affecting the nerves that signal when it’s time to go to the toilet. When the colon becomes too full, soft or liquid stool may leak out and loss of control over bowel movements may occur. Stool build-up in the colon may cause it to enlarge, making it hard for the child to feel bowel movements.

Far less frequently, encopresis occurs without constipation and may be the result of emotional issues like stress. A child may experience stress from premature, difficult or conflict-filled toilet training.

Changes in the child’s life, such as dietary changes, starting school, altering schedule, the divorce or separation of parents or the birth of a sibling can cause emotional stressors in your child and trigger encopresis. For school going children, it is important to inform the school of the child’s need to use the toilet regularly. Sometimes teachers perceive requests to use the toilet as naughtiness and turn the students down, which can worsen the problem.

Certain risk factors may also cause encopresis. These may include using medications that may cause constipation such as cough suppressants, attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder, anxiety or depression.

Encopresis could also be a symptom of an underlying medical condition such as colonic inertia, where the child’s colon doesn’t move stool as it should, or digestive tract nerve damage - muscles at the end of the digestive tract (anus) which do not close properly.

It could also be that nerve endings in the bowel are missing, causing blockage of the intestine. Moreover, the child could be suffering from an infection or tear in the rectum.

Treatment of encopresis is unique to each child. It could include removal of any stool ball, taking stool softeners, laxatives or enemas to ensure regular, soft stools. Scheduled toilet sitting, eating a diet high in fibre and drinking plenty of water are other ways to manage it.

Because most children with the condition have retentive encopresis as a consequence of chronic constipation, therapy is initially focused on evacuating the distal colon. This can be done by softening the stool using oral cathartics or a series of enemas. After the colon is evacuated, long-term laxative therapy is started, aiming to produce one to two soft stools daily.

Early treatment can help prevent the social and emotional impact of encopresis.

Dr Kombe is a Consultant Paediatric Gastroenterologist at Aga Khan University Hospital

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