What is soiling from constipation?
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 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.
There are many reasons why children become constipated
--high milk diet, genetic differences, sluggish bowel,
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 health care provider.
How can I treat the constipation?
See How to Give an Enema
Warning: If you are using a phosphate 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 commonly prescribed stool
softeners are mineral oil, milk of magnesia (MOM),
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. Give your child a vitamin pill
each day at about noon while he is taking the mineral
oil.
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, ExLax, 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gradually withdrawn from laxatives, even after 6 months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 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 2
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 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
bowel movement 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.
Your health care 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. Tell him you want sitting on the toilet to
be fun and ask what would he like to do (such as looking at
a book). Try to pick good times for gentle reminders and
mention that "your doctor asked me to help you remember."
Other toileting tips for your child that are essential for
success are:
Push while sitting on the toilet. The bowel movement
won't just fall out.
Bend forward so the chest touches the upper legs. This
position opens up the rectum. Bending forward and then
relaxing a little may also help move stool downward.
Use a footstool to provide pushing leverage, if your
child's feet can't easily reach the floor.
Encourage your child to sit on the toilet more often --
even 10 minutes every hour until he has a large bowel
movement 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 staying clean. Some children need more
praise and encouragement than others, and this kind of
support is always helpful. Rewards for releasing poops are
usually unnecessary unless your child is uncooperative or
less than 5 years old. Your child will probably be
overjoyed to be relieved of his constipation and soiling.
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 BM). 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 5-minute 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. This may 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
bowel movement 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 health care 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 health
care 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 health care
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 health care 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
health care 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 health
care provider can be sure that the impaction is completely
cleaned out.
When should I call my child's health care 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.
