Encopresis
Improved, But Still Having Soiling Accidents for a 4-Year Old Girl.
My four year old daughter has always has small soiling accidents since she was potty trained. The accidents became worse when she started school and we moved to a new house at the age of three and a half. Before we understood that withholding pooping was causing the soiling, she was having up to 8 accidents a day. Now she only has 1 or 2, except when she has a different schedule, visiting a friend's house, for example, then there may be more, especially if she had not defecated prior to the play date.
After seeing several pediatricians and a GI, she has been taking two tiny scoops of Miralax (PEG) daily. 1/8th of a teaspoon, just to keep her stools soft. She has a healthy diet including plenty of fruits and vegetables, whole grains, starting her day with a bowl of oatmeal.. She has toilet sits 20 minutes after most meals, a calendar of smiles for daily poops and little dots for accidents. We work hard not to make a big deal of accidents. She often helps with clean up. Shes poops 6 days a week.
None of her doctors have found her to be constipated. However, one GI found in a rectal inspection that my daughter could not squeeze her finger with her anus, so she prescribed biofeedback therapy. My daughter tries to learn to squeeze her anus properly and to push while relaxing her anus.
I do not understand why my daughter continues to soil almost every day even though she has a substantial BM almost every day. Usually the accidents occur before she poops, indicating a reluntance to poop and also a lack of feeling the sensation of needing to poop. Sometimes, she has accidents hours after pooping. This is strange because it would seem that she was already cleaned out. Her GI says she is not pushing long enough. By the way, without the afternoon dose of PEG, she does not poop the following day.
Recently I started to wonder if she had some sort of obstruction in her colon that was preventing her to really get all the feces out when she poops. I increased the dose of PEG two 1/2 teaspoon for one afternoon. She had runny stools and accidents all day. She seemed empty by evening because her stools were very small. I lowered the dose to the small amount again. Today she had two messy accidents and no stool in the toilet.
Perhaps she had runny accidents from the higher dose of PEG two days earlier?
But I still wonder why she continues to have an accident a day, even a tiny one?
I would also like her to be taking something more natural, maybe Fruiteze, rather than PEG. She has been taking PEG for 6 months and the improvement has been slow.
Darlene—Great job on providing background information. You show some excellent insights, but let me see if I can add some new perspectives. You have noted the effects of change on your daughter and she appears to be very sensitive in this regard. My guess is that her gut is a “target” organ most affected by any form of change. Stress (+ or -) slows the gut (Sympathetic Nervous System dominance), but sets her up for a “rebound” reaction of powerful activation of the bowel (Parasympathetic System dominance) in a kind of “let down” or release phenomenon. This places her more at risk for accidents. We know relaxation is very important for having a complete voiding reflex—cats are very easily stressed organisms and they are very subject to holding and megacolons. Stool consistency is an important variable and loose stool, often a result of Miralax, results in frequent accidents because the sub-mucous membrane of the colon cannot discriminate adequately between liquid stool and gas which leads to “oops” moments.
You noted the GI doc who recommended biofeedback because of her not activating the External Anal Sphincter (EAS) which consists of voluntary muscle fibers which engage the “holding reflex”. That surprises me and I wonder if you misunderstood her/his report. I suspect that he reported that she could not “push” the finger back out, which is the “voiding reflex” and which is what you want to be trained. Most of these children are great “holders,” but poor “pusher outers!” Also, this may be more a problem of dysnergia or poor coordination of these two important reflexes in the hold-release sequence which is necessary for adequate colo-rectal control. Also, biofeedback is not usually regarded as effective until the child is 6 or 7 years for cognitive and practice/transfer of training reasons. In fact, this is one of the reasons as an early biofeedback pioneer that I developed the Soiling Solutions (SS) protocol which is a retraining procedure which can be done at home with a carefully stepped and timed sequence of short sits with voiding assured by the use of suppository and/or enema “primers” which enhance and condition urge signals and the proper voiding response in such a way that the child’s own colo-rectal response will take over from these artificial voiding prompts. Unfortunately, for you and me, it does not appear that our culture and physicians are quite ready for my intervention despite my chapter in a medical text and a medical journal article on the SS protocol. Too many people out of total ignorance assume that it is a punishment or threat approach to treatment and not a methodical rational retraining approach.
Today physicians are very reluctant to employ my protocol and prefer what is called “maintenance therapy” and the canard that “your child will grow out of it,” which is what you are doing and which I am fighting. Finally, from what you report with her diet and use of Miralax I would not expect her to have an obstruction. I think the factors I mentioned above could be a sufficient explanation for what is going on with your daughter. Keep reading on down this column, parents should have a choice.
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