Toilet Training and Soiling—Which Comes First?
Toilet Training and SoilingWhich Comes First?
Source: Taubman B, Buzby M. Overflow encopresis and stool toileting refusal during toilet training: A prospective study on the effect of therapeutic efficacy. J Pediatr 1997; 131:768-771.
Taubman and buzby examined 53 children at least 4 years of age who presented to a pediatric gastroenterology clinic with a history of encopresis at least three times a week and fecal impaction on digital rectal exam. They excluded children with psychomotor retardation, Hirschprung’s disease, or any neurological abnormality. By history, Taubman and Buzby identified which children had problems with toilet training for bowel movements. Most of the children (70%) had been toilet trained successfully prior to age 4 and were defined as having secondary encopresis, while the other 30% had never been successfully toilet trained and were defined as having primary encopresis. All children were treated with the traditional enema clean out, stool softener, high fiber diet, postprandial sitting on the toilet, and positive reinforcement protocol that has proven to be successful over the last 30 years.
About two-thirds of those children who had been successfully toilet trained previously (secondary encopresis) had a therapeutic success at one-year follow-up, and less than 10% of those children who had primary encopresis were successfully treated. Children with secondary encopresis were more likely to respond to treatment if they had been suffering from their encopresis less than a year. Taubman and Buzby further found that children who had some difficulty in becoming toilet trained for bowel movements but ultimately were successfully trained by age 4 were just as likely to have a therapeutic success as those children who were easily toilet trained.
This study reinforces the "therapeutic comfort" that I feel when I see a child in clinic who has developed encopresis after a period of normal bowel habits and the uneasy feeling that develops in the pit of my stomach whenever I come across the infrequent older child who has never been successfully toilet trained. The high degree of success in the treatment of secondary encopresis requires a considerable amount of patient and family education, confidence on the part of the practitioner, and frequent and appropriate follow-up with the patient. It is important to understand that the less frequent problem of primary encopresis in the older child is less likely to respond to therapy. Taubman and Buzby point out that a lack of cooperation with the treatment plan was a common theme in the failure of their treatment. They speculate that this problem is aggravated by a high degree of family dysfunction. Treatment of the patient with primary or secondary encopresis is challenging but is potentially one of the most satisfying problems to help a child and their families resolve. ach
Encopresis:
a. has a different prognosis depending on classification as primary or secondary.
b. prognosis is related to ease of toilet training.
c. successful treatment involves clean out, stool softener, diet and positive reinforcement.
d. treatment failures are not associated with non-compliance by the family.
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