University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In 4 year old girls with encopresis, is behavior management in addition to medical therapy more effective than medical therapy alone in treating encopresis?

Clinical Bottom Lines

1. At 3, 6, and 12 months, more children improved in daily frequency of soiling with behavioral management in addition to intensive medical therapy than with intensive medical therapy alone (NNT ~ 3, Odds Ratio for no improvement at 12 months 0.20, 95% CI 0.06 to 0.65).¹
2. At 12 months, no significant differences were found among the three treatment groups in the number of children experiencing a cure (2 weeks free of soiling). (chisquare = 0.95, p = 0.7).
3. Response to treatment during the first two weeks of therapy was highly predictive of outcome at 3, 6 and 12 months (P < 0.0001).
4. Children receiving behavioral therapy in addition to medical management use significantly less laxative medication (P <0.04).

Summary of Key Evidence

• Randomized, controlled trial, Not blinded.¹ Study limited to children age 5 to 15 with at least weekly soiling for 6 months. Children with chronic medical conditions or developmental disability were excluded.
• Treatment groups defined as:
• IMT = intensive medical therapy alone (Milk of Magnesia and/or senna)
• ETT = behavioral management in addition to intensive medical therapy
• BF  = behavioral therapy in addition to intensive medical management and external anal sphincter electromyographic biofeedback)
• Data collected before treatment, 2 weeks, 3 months, 6 months and 12 months after treatment
• Primary outcomes: improvement in daily frequency of soiling, cure at 12 months
• Secondary outcomes: number of stools passed in the toilet each day, the frequency of self-initiated toileting each day, and the average amount of laxative used each day
• Issues with validity include lack of blinding (although blinding not particularly feasible) and the study was likely not powered to detect differences in many of the outcomes including cure rates.

Additional Comments

• Even when experts in behavioral pediatrics delivered enhanced toilet training, 20% of children did not respond to the enhanced training and approximately 50% were not cured at 12 months
• University of Michigan² and National Guidelines³ support use of behavioral therapy.

Citation

1. Borowitz SM. Cox DJ. Sutphen JL. Kovatchev B. Treatment of childhood encopresis: a randomized trial comparing three treatment protocols. J Pediatr Gastroenterol & Nutr. 2002;34:378-84.
2. University of Michigan Health System. Functional constipation and soiling in children. Ann Arbor (MI): University of Michigan Health System; 2003 Feb. 10 p.
3. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol & Nutr 2006;43:e1-13.

CAT Author: Terry Platchek, MD

CAT Appraisers: Robert Schumacher, MD

Date appraised: February 28, 2007