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Quick reference medical handouts used by Pediatric offices


Constipation and Soiling in the Preschooler


see also: The Anguish of Accidental Soiling

Definition

A child who passes bowel movements (BMs) 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 the large mass of hard 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.

There are many reasons why children become constipated--high milk diet, genetic differences, avoiding bowel movements because they cause pain, or holding back BMs (stool holding) as a way of resisting toilet training. The possibility of physical causes requires a complete examination by your child's physician.

Treatment of Soiling with Constipation in Children Who Won't Voluntarily Sit on the Toilet

(For treatment of children who will sit on the toilet, see

  1. First use enemas to remove the impaction.

Start with a Fleet's hyperphosphate enema. The dose is 1 ounce for every 20 pounds of your child's weight. For example, a 30-pound child should receive 1 and 1/2 ounces of hyperphosphate enema. Don't give any child more than 4 ounces of the enema.

Have your child try to hold the enema back for 5 minutes. Then insist that he sit on the toilet for release of the enema.

Give a second hyperphosphate enema 1 or 2 hours after the first one. A third hyperphosphate enema can be given 12 to 24 hours later if you think your child is still impacted. Signs that your child is still impacted include continued soiling or a lump that can be felt in the lower abdomen.

Before giving the enemas, give your child one to two glasses of water to drink because the enemas may cause some dehydration.

If you want to make your own enemas, use normal saline. You can make normal saline by adding 2 teaspoons of table salt to a quart of warm water. Give 2 ounces of normal saline per year of your child's age. Don't give any child more than 16 ounces of saline enema.

If you don't know how to give an enema, ask someone in your physician's office. Once an impaction is cleared, enemas are no longer necessary. Your child's constipation can be treated entirely with oral medicines. Continuous use of enemas irritates the rectum and can cause your child to hold back BMs.

  1. Use stool softeners to keep the bowel movements soft.

    Stool softeners make the stool softer and easier to pass. Unlike laxatives, they do not cause any bowel contractions or pressure. Some commonly prescribed stool softeners are mineral oil, Kondremul, Metamucil, Mitrolan, Citrucel, Maltsupex, Petrogalar, and fiber wafers. 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. Give your child a vitamin pill each day at about noon while he is on the mineral oil.

    Use the stool softener and dosage recommended by your child's physician.

  2. 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 are Senokot, Fletcher's Castoria, milk of magnesia (MOM), Haley's M-O, and Dulcolax. 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.

    Use the laxative and dosage recommended by your child's physician.

  3. Encourage your child to eat a nonconstipating diet.

    Have your child eat plenty of fruits and vegetables every day (raw ones are best). Some examples are figs, dates, raisins, peaches, pears, apricots, celery, cabbage, and corn. 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 new "natural" cereals, bran flakes, bran muffins, or whole-wheat bread in his diet. Popcorn, nuts, shredded wheat, oatmeal, brown rice, lima beans, navy beans, chili beans, and peas are also good sources of fiber. Only milk products (milk, cheese, yogurt, ice cream) and cooked carrots have been proven to be constipating. Your child should limit his intake of milk products to two glasses or the equivalent per day. Encourage lots of fruit juices because they increase BMs. (Exception: Orange juice doesn't help.) However, don't pressure your child about diet; instead, offer choices and include your child in the decisions about which foods to eat.

  4. Transfer all responsibility to your child about using the toilet.

    Your child will decide to use the toilet only after he realizes that he has nothing left to resist. Have one last talk with him about the subject. Tell your child that his body makes "poop" every day and it belongs to him. Explain that his "poop" wants to go in the toilet and his job is to help the "poop" come out. To help him function independently, put him in loose-fitting underwear or training pants (not diapers or pull-ups). Tell your child you're sorry you punished him for not using the toilet, forced him to sit on the toilet, or reminded him so much. Tell him from now on he doesn't need any help from you or other people. Then stop all talk about the subject. When your child stops receiving attention for not using the toilet, he will eventually decide to use it to gain some attention.

  5. Stop all reminders about using the toilet.

    Let your child decide when he needs to go to the bathroom. He should not be reminded to go to the bathroom nor asked if he needs to go. Your child knows what it feels like when he has to "poop" and where the bathroom is. Reminders are a form of pressure, and pressure doesn't work. He should not be made to sit on the toilet against his will because this will give him a negative attitude about the whole process. Don't accompany your child into the bathroom or stand with him by the potty chair. Your child needs to get the feeling of success that comes from doing it on his own and then finding you to tell you what he did.

  6. Give incentives for BMs in the toilet.

    If your child has a BM in the toilet, give him immediate positive feedback, such as praise and a hug. This positive response should occur every time your child uses the toilet. Special incentives, such as favorite sweets or video time, can be invaluable for helping a child change a bad habit. For using the toilet, err on the side of rewarding generously; for example, you might give your child 20 M&Ms. If you want a breakthrough--that is, use of the toilet for the first time--make your child an offer he can't refuse. One of your main jobs is to find the right incentive. The potency of incentives is increased by reducing baseline access to them. Perhaps you'll let him watch a new video he has been talking about. A grab bag containing a variety of treats is also a powerful motivator. On successful days, also consider taking 20 extra minutes to play a special game with your child or take him for a walk to the playground.

  7. Give stars for using the toilet.

    Get a calendar for your child and hang it where he sees it all the time. Place a star on it every time he uses the toilet. Keep this record of progress until your child has gone 1 month without any accidents. Bring the calendar to your visits with your child's physician.

  8. Make the potty chair convenient.

    Be sure to keep the potty chair in the room he usually plays in. This gives your child a convenient visual reminder about his options whenever he feels the need to urinate or defecate. Only give a pleasant verbal reminder if he is clearly having an urge to go and is holding back. You can say, "The poop wants to come out and go in the toilet. The poop needs your help." Tell your child that you want sitting on the potty to be lots of fun. What would he like to do? Ask him to play the "see if you can poop before the timer goes off" game and set the timer for 5 minutes. Then let your child decide how he wishes to respond to the pressure in his rectum. Some children temporarily may need treats for simply sitting on the toilet and trying.

  9. Use diapers and pull-ups as little as possible.

    You want your child to look forward to releasing BMs, rather than holding back. If your child refuses to sit on the toilet, having bowel movements in diapers is better than stool holding. Therefore, permit him access to diapers. However, don't let your child wear diapers all day. Keep your child in loose-fitting underwear or training pants, so that he has to decide each time he has an urge to pass a BM whether to use the toilet or to come to you for a diaper. To help him make the right choice, offer major incentives (for example, a trip to a favorite restaurant or ice cream store) for BMs in the toilet. Offer minor incentives (for example, candy) for BMs in the diaper. (Note: Being in underwear will give him an incentive to maintain bladder control and stay dry.)

  10. If your child is complaining about abdominal pain, clarify how to make it go away.

    Tell her: "The poop wants to come out," "The poop needs your help," "It won't hurt," "Holding back is a bad idea." Offer to help her sit in a basin of warm water to relax the anal sphincter. If she refuses, tell her "I can't help you. You have to help yourself." Then ignore your child or put her in time-out. Tell her to come back after the poop is out. Do not give positive attention for holding-back behavior.

  11. Help your child change his clothes if he soils himself.

    Don't ignore soiling. As soon as you notice that your child has messy pants, clean him up immediately. The main role you have in this new program is to enforce the rule, "We can't walk around with messy pants." Make changing pants a neutral, quick interaction. If your child is soiled, he will probably need your help with cleanup, but keep him involved. If your child refuses to let you change him, ground him until he is ready.

  12. Respond gently to accidents.

    The responses to soiling listed below will only delay successful training and may cause emotional problems:

    • Threatening or lecturing your child
    • Forcing your child to sit on the potty chair
    • Punishing or scolding your child for accidents
    • Keeping your child in soiled pants
    • Giving frequent reminders
    • Allowing siblings to tease your child

  13. Ask the preschool or day care staff to use the same strategy you are using.

    Ask your child's teacher or day care provider to let your child go to the bathroom any time your child wants to. Keep an extra set of clean underwear at the school or with the day care provider. Ask them to read this handout about soiling. Be sure your baby sitter knows how to handle the situation positively and will not punish your child for soiling his pants.

Call Your Child's Physician During Office Hours If:

  • You think your child is blocked up again.
  • Your child's bowel movements continue to hurt.
  • Your child won't take the medicines.
  • You have other questions or concerns.


Written by B.D. Schmitt, M.D., author of "Your Child's Health," Bantam Books.  Copyright 1999 Clinical Reference Systems

 

As a reminder, this information should not be relied on as medical advice and is not intended to replace the advice of your child’s pediatrician. Please read our full disclaimer.

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