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|Quick reference medical handouts used
by Pediatric offices
Why Children Soil Their Pants and What you Can Do About it
By Noel Swanson, MD
NORMAL TOILET TRAINING
Most children learn control of their bowels at about age 2
or 3. If they have NEVER learnt control by the time they
four year old this is known as "primary encopresis" (as
opposed to enuresis which refers to wetting). If your
children are in this position you should seek help from a
Much more common, however, are children who have learnt
bowel control, and then seem to lose it again. Not
surprisingly this is known as "secondary encopresis".
There are, of course, a number of reasons why this might
occur. In older children it may be a sign of severe
emotional disturbance (eg from abuse) and may be accompanied
by smearing the faces on walls, or depositing them in
strange places. Again, this probably requires expert help
from local child mental health and/or protection services.
The most common problem, particularly in younger children
(anything from 2 to, say, 7 or 8) is related to
Here is what typically happens:
Food is eaten, digested, and passed along the intestines.
Eventually they arrive in the large intestines (colon) whose
job it is to dry the stool from liquid to a soft putty
texture. When this is done, the stool is passed on to the
The rectum is normally empty. It has nerve cells in it that
detect when it is full, and it is this that give you the
urge to go to the toilet.
Toilet training is about recognizing those urges and
responding to them appropriately.
But suppose, for some reason, that you don't go to the
toilet. For example, sometimes children get constipated.
When you are constipated, the stool stays in the colon
longer, which means it dries out more, which makes the stool
Such solid stools can be difficult, and even painful to
pass. They may even cause a slight tear in the anus, which
is very painful.
This might put a child off the idea of going to the toilet
next time, since everytime he goes, it is painful.
So, what does he do? Instead of responding to the rectums
signals, he "withholds" his stool, and just tries to avoid
the whole issue.
The problem of course, is that more stool continues to come
down the pipe. Pretty soon you get the whole colon backed
up with stool waiting to be passed. And, of course, the
longer it hangs around the drier and hard it gets and the
harder (and more painful) it is to pass.
A true vicious cycle.
But it gets worse.
First, as I said, new stool is coming down the intestines.
At this point, it is still very liquid. This liquid stools
comes up against a colon full of solid bricks. But, since
it is liquid, it is able to leak past the solid lumps - all
the way to the rectum, and out the anus. The result is
frequent uncontrollably soiling with small amounts of
Second, since the rectum is habitually in a state of being
full, it gradually stretches, just alike a balloon being
blown up. As it does so, it loses its strength (just like a
balloon, which gets easier to inflate the bigger it gets).
It also loses it sensation.
The end result of this is that the child can no longer sense
that the rectum is full and that they need to go to the
And even if they do try to go, the bowel has lost all its
strength, making it difficult to pass the stool.
The net result of this?
1. Child does not know that he needs to "go".
2. Frequent soiling of pants with liquid.
3. Occasional passing of more formed stools (when the
loading becomes too full) - often without warning, since the
child has lost sensation.
Then, in response to all of this, the child may become
embarrassed, and try to hide the evidence by hiding dirty
This then becomes a chronic condition that can, literally,
last for years and years, even forever, if it is not
properly dealt with. The longer it goes on, the weaker the
bowel become, and the hard to correct.
So what do you do?
The big problem is the flabby, insensitive bowel. So the
goal is first to empty it, and then to retrain it back to
To empty the bowel will require positive assistance, ranging
from simple suppositories, to laxatives, to enemas, to
manual clearance in hospital. So your first step is to go
to a doctor - and don't let them brush you off!
Once the bowel has been emptied, it then needs to STAY
empty. But since the child has no sensation telling him
when to go to the toilet AND a weak bowel even when he does,
this stage will also need positive assistance.
You do this by:
a) Developing a clear routing of going to the toilet EVERY
day. Since the child will be nervous about this - because
of previous negative experiences with toileting - you will
have to encourage this by means of various rewards and
It is VERY important that you avoid punitive responses.
That will only make the child even more fearful of the whole
I suggest that you have a set time each day for toileting,
and that this be after a meal. Why? Because the body has
what is called the "post-prandial reflex". Basically this
means that when you put things into your stomach, your body
automatically shunts things along the system, and out the
other end. So let's make use of this reflex by training the
child to pass a motion at the same time.
This avoids the problem of the child waiting for the "need"
to go to the toilet, which won't happen because sensation
has been lost.
2. Because the bowel is overstretched, flabby and weak
(like a deflated balloon), it needs help in moving stuff
along. The best solution for this is to use a mineral oil
type of laxative. This is usually available as a pleasant
flavored liquid or even as a raspberry flavored jelly
This works literally as a lubricant. It makes the stool so
slippery that it CAN'T stay inside, and so gets passed.
Now, the trick is to use this correctly - and very few
physicians will tell you this:
Your goal is to achieve a successful bowel motion EVERY day.
So you adjust the amount of laxative to achieve this.
If you increase the dose, then there will be more, and
easier, bowel motions. It will also leak slightly into the
pants. If you decrease it, then there is a risk of no bowel
motion. My suggestion is that you give enough laxative that
it DOES leak slightly. It is vitally important to get that
regular bowel motion even at the expense of some dirty pants.
You MUST do this every day.
If there is a single day that passes without a bowel motion,
this requires emergency action. You CANNOT afford to allow
the bowel to get backed up again, otherwise you will rapidly
return to the same problem and will have undone all the good
work up to that point. I cannot stress this enough!
So, if a day passes without a bowel motion, go to the
pharmacy, buy some glycerin suppositories, and insert one.
That normally produces action in an hour or two. Then
increase the daily dose of laxative slightly.
If ever more days than two pass without action, then it is
time to go back to the doctor for more intensive help.
Gradually, provided the bowels stay empty, they should
return to their normal strength and sensation. Be warned
however, that this normally takes AT LEAST a year, and often
two years or more, depending on how chronic the condition
was to start with.
Where most people go wrong is to assume, after a few months
of success, that the problem is resolved. They then stop
monitoring it and, before they know it, their child has missed one, then
two, then five bowel actions, and it's all back to square one.
Yes, you can gradually reduce the dose of laxative as you achieve success
over the months. But you must still monitor it. Only when you have had a
good few months, without laxatives and with no further problems can you
begin to relax!
Dr. Noel Swanson, MD is specialist child psychiatrist who has treated many
children with encopresis. His free newsletter is available from
Posted 07-20-06 on kisgrowth.com
As a reminder, this information should not be relied on as
medical advice and is not intended to replace the advice of your childs pediatrician.
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