II. Types
- Failed initial bowel training
- Toilet Phobia
- Manipulative soiling
- Irritable Bowel Syndrome
III. Epidemiology
- Ages 4 to 18 years old
IV. Signs
- Fecal Incontinence without stool impaction or Constipation
- Normal stool number and normal colonic transit
V. Evaluation
- See Encopresis
VI. Associated Conditions
- Psychosocial disorders
- Neurologic Disorders
VII. Management: Address Toilet refusal behavior
- Positive toilet sits
- Start with short sits on toilet
- Sit 3-5 times per day for 30 seconds
- Increase to 5 minutes each (timer signals end)
- Leave on diapers and pants
- Provide relaxing, enjoyable activity
- Start with short sits on toilet
- Gradual shaping procedure (if above fails)
- Parent models toileting behavior for 2 weeks
- Male caretakers should sit while urinating
- Play games and read books in or near bathroom
- Gradually progress to positive toilet sits above
- Parent models toileting behavior for 2 weeks
VIII. Management: Ensure soft, well-formed stools
- Adjust diet to ensure frequent well-formed stool
- Short-term supplements (flavored fiber drink, bran)
- Consider short-term daily Laxative
- Milk of Magnesia 1-3 ml/kg/day
- Mineral Oil 1-5 ml/kg/day (avoid if aspiration risk)
- Sorbitol 1-3 ml/kg/day
- Soiling may be more frequent with these regimens
- Prepare a matter-of-fact neutral clean-up procedure
IX. Management: Schedule prompt toilet sits
- Establish toilet sits when child most likely to stool
- Schedule up to 5 per day for 3-5 minutes each
- Consider sit 5-20 minutes after each meal
- Use daily toileting diary to set up other sit times
- Use a timer to signal end of toilet sit
- Once achieved, hold a graduation ceremony
- Declare the child a "big" girl or boy
- Completely switch from diapers to pants
X. Management: Provide incentives for stools in toilet
- Reward child when stools in toilet
- Avoid rewarding clean pants (Stool Withholding)
- Incentives might vary
- Candy
- Star chart
- Dot-to-dot
- Special activities
- Gradually reduce verbal prompts to toilet
- Allow child to recognize urge to urinate and defecate
- Reward child for requests to use bathroom
XI. Management: Physician Contact for Stool Withholding
- See also Pediatric Constipation Management
- No stool for 4 days
- Try one of stool softening regimens above
- Impaction (may require inpatient management)
- Hypertonic phosphate enemas 1-2/day x1-3 days OR
- Mineral Oil
- Daily Dose: 15-30 ml per year of age
- Maximum: 8 ounces