Increasing Daily Water Intake and Fluid Adherence in Children Receiving Treatment for Retentive Encopresis

Previously, we found that children participating in an empirically supported group behavioral intervention for the treatment of retentive encopresis (Opipari, Miller, Streisand, & Stark, 1999) demonstrated poor adherence (<50%) to prescribed fluid goals and relied heavily on juice in efforts to meet these targets (Kuhl, Felt, & Patton, 2009). Children receiving this treatment may be at risk for ongoing or worsening symptoms of constipation if they fail to meet fluid targets but are adherent to recommendations to increase their daily fiber intake, especially as stool softening medications are weaned (Felt, Brown, Van Harrison, Kochhar, Patten, 2008; North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, 2006). In addition, 46% of our sample exceeded the American Academy of Pediatrics’ (AAP) age-based guidelines for daily juice intake (AAP, 2001) during the last week of treatment. Juice consumption in excess of these guidelines places children at heightened risk for developing dental carries or becoming overweight. Collectively, these two findings indicated that modifications to the preexisting protocol should be made to improve fluid goal adherence and children’s consumption of healthier fluid choices as they increased their fluid intake. The purpose of this study was to examine the efficacy of an educational and behavioral enhancement (enhanced intervention, EI) in increasing fluid intake for children participating in the group behavioral intervention for the treatment of retentive encopresis (Opipari et al., 1999). Fluid intake is an understudied area within the pediatric literature, despite the commonality of fluid recommendations in the management of pediatric illnesses such as chronic constipation, migraine headache, sickle cell disease, and obesity. Families participating in our program anecdotally reported that children had difficulty meeting their prescribed fluid targets because they often denied thirst and refused to drink unless provided with preferred beverages such as juice. Identified barriers to food-based recommendations for young children with chronic health conditions, such as satiation and parental use of ineffective behavior management strategies (Patton, Dolan, & Powers, 2006; Stark & Powers, 2005), are likely applicable to understanding why children have difficulty increasing and modifying their fluid intake. Interventions combining educational and behavior modification strategies have been highly effective in addressing these barriers and improving adherence to nutrition-based recommendations for young children (Stark, 2003), so a similar treatment package might be effective in improving adherence to fluid-based recommendations. This study reports on the efficacy of a fluid-specific educational and behavioral enhancement (EI) to the 7-week, empirically supported group behavioral intervention protocol designed by Stark and colleagues (Opipari et al., 1999) in a sample of treatment-seeking children with retentive encopresis. The fluid intervention targeted increasing clear fluid goal adherence and children’s daily intake of water. We tested the following hypotheses: (a) children receiving the EI would demonstrate a significantly greater increase in their daily water intake from baseline (Weeks 1 and 2) to the conclusion of the first fluid phase (Week 4), and from the baseline phase to the conclusion of the second fluid phase (Week 6) compared to children who received the original group behavioral intervention (standard care; SC); (b) participation in the EI would significantly increase the odds of children meeting prescribed daily clear fluid goals in fluid Phase 1 and in fluid Phase 2 compared to participation in the SC; and (c) participation in the EI would significantly decrease the odds of children exceeding the AAP age-based guidelines for daily juice intake (AAP, 2001) during the active phases of fluid intervention (Weeks 3–6).