By Dr. Noel Swanson
NORMAL TOILET TRAINING
Most children learn control of their bowels at about age 2 or 3. If they have NEVER learnt control by the time they four year old this is known as “primary encopresis” (as opposed to enuresis which refers to wetting). If your children are in this position you should seek help from a pediatrician.
Much more common, however, are children who have learnt bowel control, and then seem to lose it again. Not surprisingly this is known as “secondary encopresis”.
There are, of course, a number of reasons why this might occur. In older children it may be a sign of severe emotional disturbance (eg from abuse) and may be accompanied by smearing the faeces on walls, or depositing them in strange places. Again, this probably requires expert help from local child mental health and/or protection services.
The most common problem, particularly in younger children (anything from 2 to, say, 7 or 8) is related to constipation.
Here is what typically happens:
Food is eaten, digested, and passed along the intestines. Eventually they arrive in the large intestines (colon) whose job it is to dry the stool from liquid to a soft putty texture. When this is done, the stool is passed on to the rectum.
The rectum is normally empty. It has nerve cells in it that detect when it is full, and it is this that give you the urge to go to the toilet.
Toilet training is about recognising those urges and responding to them appropriately.
But suppose, for some reason, that you don’t go to the toilet. For example, sometimes children get constipated. When you are constipated, the stool stays in the colon longer, which means it dries out more, which makes the stool more solid.
Such solid stools can be difficult, and even painful to pass. They may even cause a slight tear in the anus, which is very painful.
This might put a child off the idea of going to the toilet next time, since everytime he goes, it is painful.
So, what does he do? Instead of responding to the rectums signals, he “witholds” his stool, and just tries to avoid the whole issue.
The problem of course, is that more stool continues to come down the pipe. Pretty soon you get the whole colon backed up with stool waiting to be passed. And, of course, the longer it hangs around the drier and hard it gets and the harder (and more painful) it is to pass.
A true vicious cycle.
But it gets worse.
First, as I said, new stool is coming down the intestines. At this point, it is still very liquid. This liguid stools comes up against a colon full of solid bricks. But, since it is liquid, it is able to leak past the solid lumps – all the way to the rectum, and out the anus. The result is frequent uncontrollably soiling with small amounts of liquid.
Second, since the rectum is habitually in a state of being full, it gradually stretches, just alike a baloon being blown up. As it does so, it loses its strength (just like a balloon, which gets easier to inflate the bigger it gets). It also loses it sensation.
The end result of this is that the child can no longer sense that the rectum is full and that they need to go to the toilet.
And even if they do try to go, the bowel has lost all its strength, making it difficult to pass the stool.
The net result of this?
1. Child does not know that he needs to “go”. 2. Frequent soiling of pants with liquid. 3. Occasional passing of more formed stools (when the loading becomes too full) – often without warning, since the child has lost sensation.
Then, in response to all of this, the child may become embarrassed, and try to hide the evidence by hiding dirty pants etc.
This then becomes a chronic condition that can, literally, last for years and years, even forever, if it is not properly dealt with. The longer it goes on, the weaker the bowel become, and the hard to correct.
So what do you do?
The big problem is the flabby, insensitive bowel. So the goal is first to empty it, and then to retrain it back to normal functioning.
To empty the bowel will require positive assistance, ranging from simple suppositories, to laxatives, to enemas, to manual clearance in hospital. So your first step is to go to a doctor – and don’t let them brush you off!
Once the bowel has been emptied, it then needs to STAY empty. But since the child has no sensation telling him when to go to the toilet AND a weak bowel even when he does, this stage will also need positive assistance.
You do this by:
a) Developing a clear routing of going to the toilet EVERY day. Since the child will be nervous about this – because of previous negative experiences with toileting – you will have to encourage this by means of various rewards and incentives. My book can help you with this:
It is VERY important that you avoid punitive responses. That will only make the child even more fearful of the whole toileting issue.
I suggest that you have a set time each day for toileting, and that this be after a meal. Why? Because the body has what is called the “post-prandial reflex”. Basically this means that when you put things into your stomach, your body automatically shunts things along the system, and out the other end. So let’s make use of this reflex by training the child to pass a motion at the same time.
This avoids the problem of the child waiting for the “need” to go to the toilet, which won’t happen because sensation has been lost.
2. Because the bowel is overstretched, flabby and weak (like a deflated balloon), it needs help in moving stuff along. The best solution for this is to use a mineral oil type of laxative. This is usually available as a pleasant flavoured liquid (mint flavored liquid parafin – available in UK), or even as a raspberry flavored jelly (Lansoyl – not available in UK).
This works literally as a lubricant. It makes the stool so slippery that it CAN’T stay inside, and so gets passed.
Now, the trick is to use this correctly – and very few physicians will tell you this:
Your goal is to achieve a successful bowel motion EVERY day. So you adjust the amount of laxative to achieve this.
If you increase the dose, then there will be more, and easier, bowel motions. It will also leak slightly into the pants. If you decrease it, then there is a risk of no bowel motion. My suggestion is that you give enough laxative that it DOES leak slightly. It is vitally important to get that regular bowel motion even at the expense of some diry pants.
You MUST do this every day.
If there is a single day that passes without a bowel motion, this requires emergency action. You CANNOT afford to allow the bowel to get backed up again, otherwise you will rapidly return to the same problem and will have undone all the good work up to that point. I cannot stess this enough!
So, if a day passes without a bowel motion, go to the pharmacy, buy some glycerine suppositories, and insert one. That normally produces action in an hour or two. Then increase the daily dose of laxative slightly.
If ever more days than two pass without action, then it is time to go back to the doctor for more intensive help.
Gradually, provided the bowels stay empty, they should return to their normal strength and sensation. Be warned however, that this normally takes AT LEAST a year, and often two years or more, depending on how chronic the condition was to start with.
Where most people go wrong is to assume, after a few months of success, that the problem is resolved. They then stop monitoring it and, before they know it, their child has missed one, then two, then five bowel actions, and it’s all back to square one.
Yes, you can gradually reduce the dose of laxative as you achieve success over the months. But you must still monitor it. Only when you have had a good few months, without laxatives and with no further problems can you begin to relax!
Dr. Noel Swanson, Consultant Child Psychiatrist and author of The GOOD CHILD Guide, specializes in children's behavioural difficulties and writes a free newsletter for parents. He can be contacted through his website on Expert Parenting Advice.