Medical College of Georgia
 Department of Pediatrics   A-Z Index   MCG Home    

Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI
--Colic: A Parent’s (and Pediatrician’s) Nightmare
--Milk Intolerance vs. Milk Allergy
--Spitting vs. GE Reflux: What is the Difference?
--H. Pylori Infections in Children
--Diarrhea and Dehydration - Dx and Rx 

  

Constipation and Encopresis

Definition: The deposition of stools in the underwear in children over 4 years of age. 

Mechanism: Constipation leads to fecal retention, which leads to impaction, which leads to loss of rectal tone and megacolon which reduces sensations and leads to overflow.

Incidence: 3% of the population with Males > females 6:1.

Classification of Encopresis:

  1. Primary: never toilet trained (36 mos of age); much harder to treat than secondary
  2. Secondary: occurs later due to emotional issues, pain on defecation, etc.

Typical History of Child with Encopresis: 4-year-old male with encopresis. He is unaware he is soiling.  His diet consists mostly of milk, cheese, and bread.  He has always been a difficult child, but is particularly so now.  Physical examination shows a distended, boggy abdomen with stool seen on underpants; rectal exam shows a huge vault and large rectum filled with stool.  If rectum empty: X-Ray shows a lot of stool.

Associated Enuresis: 29% have daytime enuresis; 34% nighttime; UTI in 11%.  Treatment of encopresis gets rid of urinary incontinence in 89% (day) and 63% (night). (Peds 97;100:228-32).  Urinary tract infections much more common in girls.

Treatment of Encopresis:

1. Dietary: Must increase fiber and water, decrease starch, milk and breads: fiber needs vary with age: 10-20 gms for 2-6 years, 20-30 grams for 6-12 years, and 30-45 gms/day for > 12 yrs. 

Types of Food Examples of High Fiber Examples of Low Fiber
Breads and crackers Fiberich bread, seven grain bread, bran bread, cornbread white bread, rye bread
Cereals Fiber one, bran, granola, shredded wheat and bran cheerios, wheaties, wheat chex, shredded wheat without bran
Flours bran, cornmeal all purpose white flour
Fruits figs, dried apricots, dates, raisins, dried prunes, orange, banana regular apricots, plums, cantaloupe, pear
Nuts and seed Brazil nuts, peanuts, almonds sesame seeds, poppy seeds, peanut butter
Vegetables Baked beans, peas, corn Celery, lettuce, cabbage
Miscellaneous Kidney beans and chili Popcorn, coconut

2. Psychological Support: Many children either as a cause of or as a result of encopresis need Rx

3. Bowel habit training: Use positive reward system (charts, etc)

4. Medications: Daily enemas x 3 or until clear; oral cathartics: Mineral oil up to several tablespoons 3x/day.  Give for at least 3-4 weeks.  Warn parents of recurrences Cisapride used occasionally (J of Ped Gastro 96;22:38-44)

5. Biofeedback: Early results of this treatment were hopeful, but recent literature suggests that not helpful. (Peds 96:105:1995) (Arch Dis Child 96;75:367-74)

Long-term Prognosis: 8 year: 58% remission; 29% improved; 13% not improved.

Have children return for regular follow-up appointments!  This is often a chronic disease.

Next Page

© Medical College of Georgia
All rights reserved.

Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004