Encopresis from Constipation (Toilet-Trained Child)

What is encopresis?

A child who passes stools into his underwear has a problem called soiling or encopresis. Many children who are soiling small amounts several times a day are severely constipated or blocked up (impacted). The soiling occurs because pieces of a large mass of stool in the rectum break loose at unexpected times. This is especially likely to happen when your child is running or jumping.

The soiling is not deliberate. The impaction is usually too wide to pass spontaneously, and the child can't control the leakage until the blockage is removed.

What is the cause?

There are many reasons why children become constipated —high milk diet, genetic differences, sluggish bowel, avoiding stool release because they cause pain, or holding back stools as a way of resisting toilet training. The possibility of physical causes requires a complete examination by your child's healthcare provider.

How can I treat the constipation?

• Enemas (bowel cleanout)

  If your child is blocked up (impacted) with stool, he may need an enema to unblock him so that oral medicines can work. Enemas are generally not used under 2 years of age. Follow your healthcare provider's advice.

  Warning: If you are using a phosphate enema (such as Fleet’s enema) it can have serious side effects if given in too high a dosage or given more than once per day. Follow the enema directions carefully.

• Stool softeners

  Stool softeners make the stool softer and easier to pass. Unlike laxatives, they do not cause any bowel contractions or pressure. Some common nonprescription stool softeners are mineral oil, milk of magnesia, MiraLax, and high-fiber products. Your child must take stool softeners for at least 3 months to prevent another impaction. By then, your child's intestines will be able to contract and empty normally again.

  If you use mineral oil, keep it in the refrigerator because it tastes best cold. Have your child take it with fruit juice to disguise the flavor, or follow it with something tasty. While your child is using mineral oil, give him a vitamin pill each day. Do not give the vitamin at the same time that he takes the mineral oil.

  Increase the dose of stool softener gradually until your child is having 2 or 3 soft stools each day.

• Laxatives

  Use laxatives to keep the rectum empty if stool softeners aren't effective. Laxatives (or bowel stimulants) cause the large intestine to contract, squeezing the stool toward the rectum. Commonly used laxatives contain a natural plant extract called senna. Examples are Senokot, Ex-Lax, and Fletcher's Castoria. Dulcolax is another helpful laxative. Don't worry that your child will become dependent on the laxatives (that is, that the bowels won't move well without them). The most important goal is keeping the rectum empty. Children can always be gradually withdrawn from laxatives, even after 6 months of using them.

• High Fiber Diet

  Encourage your child to eat a nonconstipating diet. Have your child eat plenty of fruits and vegetables every day (raw ones are better.

  Bran is an excellent natural laxative because it has a high fiber content. Have your child eat bran daily by including such foods as the whole grain cereals, bran flakes, bran muffins, or whole-wheat bread in his diet. Popcorn, nuts, oatmeal, brown rice, lima beans, navy beans, chili beans, and peas are also good sources of fiber.

  Milk products (milk, cheese, yogurt, ice cream) can be constipating in large amounts. Your child should limit his intake of dairy products to 2 servings per day. Encourage lots of fruit juices because they increase stools. (Exception: orange juice doesn't help.) However, don't pressure your child about food. Instead, offer choices and include your child in the decisions about what foods to eat.

How can I help my child stay clean?

Clarify for your child how he can stay clean.

• Go poop every day.
• Take your medicine every day.
• If your poops aren't coming out like they should, sit on the toilet more often.

Encourage your child to sit on the toilet for 10 minutes after meals. Your child should sit on the toilet until a stool is passed, or at least 10 minutes. Unless your child does this, the medicines will not work. Normally, children and adults know when their rectum is full because it is uncomfortable and causes some bowel contractions. Children who have been blocked up for a long time lose this sensation and need 2 to 4 weeks to get it back. During this time, scheduled toilet sitting time is crucial. Your child must sit on the toilet even when he doesn't feel the need to go. The best time seems to be 20 or 30 minutes after a meal. Once he passes a normal sized stool, he doesn’t need to sit any more times that day.

Your healthcare provider will try to get your child to promise to do this on his own, but he may need some help from you. Try a reminder sign. By all means, don't remind him more than 2 times a day or in a stern way because this will foster a negative attitude about the whole process. Never insist that he sit on the toilet if he is busy doing something else. Try to pick good times for gentle reminders and mention that "your doctor asked me to help you remember."

How to sit on the toilet: Other toileting tips for your child that are essential for success are:

• Push while sitting on the toilet. The stool won't just fall out.
• Bend forward so the chest touches the upper legs (like squatting). This position opens up the rectum. Bending forward and then relaxing a little may also help move stool downward.
• Encourage your child to try different positions.
• Use a footstool to provide pushing leverage, if your child's feet can't easily reach the floor.
• Don’t allow your child to read books or play games while sitting on the toilet. He needs to concentrate on how to make his body work.
• Encourage your child to sit on the toilet more often — even 10 minutes every hour until he has a large stool if:
  • Any soiling occurs (soiling always means the rectum is very full).
  • Your child feels blocked up.
  • Your child has a stomachache or cramps.

Praise your child for releasing stools. Some children need more praise and encouragement than others, and this kind of support is always helpful. Rewards for releasing poops are usually unnecessary in children who are already toilet trained. Your child will probably be overjoyed to be relieved of his constipation and soiling. Children may need treats if they are uncooperative about sitting on the toilet or less than 5 years old.

Help your child respond to soiling (leakage). If your child is taking the right medicines and sitting on the toilet, there shouldn't be any accidents. However, finding the right treatment program may take several weeks. Also, some children will have recurrences of soiling (usually after 4 or 5 days without a stool). In such cases, handle soiling in the following way:

• Recognize soiling. Don't ignore soiling. As soon as you notice soiling by odor or behavior, remind your child to immediately clean himself up. Encourage your child to come to you before anyone else notices the accident. However, don't expect your child to confess to being soiled.
• Clean the skin. Before your child sits on the toilet, suggest a quick soak in the bathtub. At the least, your child's bottom needs cleaning off with a wet washcloth or wet wipes. Your child should be able to do most of this on his own. Warm water may also relax the muscles around the anus and give your child the urge to go.
• Have your child sit on the toilet. After soaking in warm water, have your child sit on the toilet until a large stool is passed, or at least 10 minutes out of every hour until it does. If stool is leaking out, the rectum is always full and should be emptied.
• Clean soiled clothes. First, scrape the underwear partially clean with a butter knife or spatula. Then rinse it out in the toilet. Finally, store the soiled underwear until the next washday in a conveniently located bucket of water with some bleach in it and a lid. You can encourage your child to help with this, but you will need to do most of it until he is 7 or 8 years old.
• Avoid punishment. Do not blame, criticize, or punish your child. In addition, do not allow siblings to tease him. Never put your child back into diapers. If anyone in your family wants to "crack down" on the child, have that person talk to your healthcare provider because this kind of pressure will only delay a cure and it could cause secondary emotional problems.

Ask the school staff for their help. These children need ready access to the bathroom at school, especially if they are shy. Encourage your child not to be embarrassed about leaving the classroom to go to the bathroom. Your healthcare provider will send the school a note requesting unlimited privileges to go to the school bathroom any time your child wants to and without having to raise his hand. Your child should also be allowed to come in from outside recess. If the problem is significant, you might also temporarily supply the school with an extra set of clean underwear.

Help your child keep a record of progress. Your healthcare provider will give your child a calendar to keep. Bring this to all visits. This record of soiling accidents should be kept until your child has stopped all medicines and gone 1 month without any accidents.

Keep follow-up appointments. Knowing that he will return to his healthcare provider to report his progress will often increase your child's motivation. After age 8, most of the treatment program should be between your child and his healthcare provider. The more involved and responsible your child feels, the better the results will be. The first follow-up visit is especially important so that the healthcare provider can be sure that the impaction is completely cleaned out.

When should I call my child's healthcare provider?

Call during office hours if:

• Your child soils two or more times and sitting on the toilet doesn't help.
• You feel your child is blocked up again.
• Bowel movements continue to hurt.
• Your child won't take the medicines.
• Your child won't sit on the toilet.
• You have other questions or concerns.