The Ins and Outs of Poop

Why are laxatives almost always necessary?

I read an article that says that laxatives could be bad for kids. Why do you say that "they are always necessary" (on the back of your book)?

Children who have occasional constipation, the kind that we all experience from time to time, rarely need laxatives. Occasional constipation is relieved with natural remedies such as adding more fiber to a child's diet or encouraging exercise. In my book, I devote a whole chapter to the treatment of occasional constipation with natural remedies.

Children with functional or long-term constipation, often referred to as encopresis, almost always do need one or more laxatives as part of their overall treatment. Without laxatives, it is not possible for these children to produce sufficiently soft, large stools every day long enough to end their stool withholding and soiling. With regard to the safety of laxatives, the fact is that research and clinical experience over the past 25 years has clearly shown that, when used properly, laxatives are safe for children.

In my book, I discuss how and when to safely introduce, maintain and then remove laxatives.

But he poops! How can he be constipated?

Our doctor says my 5-year old can't be constipated because he poops every day! But he has frequent "poop accidents."  Any ideas?

This is a very common misconception about constipation even among pediatric healthcare professionals. The fact is that a child can have a fairly large, soft stool every day and still be constipated.

In my book, I talk in more detail about the two types of withholding: complete and incomplete. With incomplete withholding a child may go to the bathroom every day but still not fully evacuate his or her rectum. Over time, this results in a gradual backup of stool which slowly, but surely, stretches the rectum to the point where a child begins to have stool accidents.

Encopresis and Diet

Parents frequently ask if their child's encopresis (functional constipation) was caused by their diet . They also want to know if there is a particular diet that will cure their child's encopresis.

The answer to both questions is that diet alone does not cause encopresis nor is there a particular diet that will cure encopresis. However, there are certain foods that if consumed regularly can help to prevent encopresis and, in combination with laxatives and certain behavioral interventions, can help to cure encopresis.

Food which are high in both soluble and insoluble fiber are the most helpful. Dietary fiber, which includes both soluble and insoluble, is defined as indigestible carbohydrates found in plant cell walls. Some foods are higher in soluble fiber (such as oats and peas) while other foods are higher in insoluble fiber (such as vegetables and whole grain bread).

More detailed information about the amount fiber in specific foods, the daily fiber requirements for children and about different fiber supplements can be found in chapter 17 (Food and Drink for Good Poops) of my book.

3 y/o Will Only Poop While Standing in a Pull-Up

Many children with encopresis will only poop in a diaper or a pull-up. The longer this continues the more their parents worry that it will become a habit.

Here is what one mom recently said to me:

"My daughter is 3 years old and has been standing to poop with a pull-up on for 3 months now. She is fully potty trained for urine. Would you recommend that I keep trying to get her to poop while sitting on the toilet for a few minutes every day (even if she doesn't push) and only then let her stand to poop in her pull-up? Or, should I wait if she doesn't seem ready? I am concerned that the longer the habit goes on the harder it may be to break?"

 

Here is my response:

"No need to worry about her developing a habit of standing to poop. She will sit to poop when she is ready. She must first unlearn the habit of withholding. This requires many, many experiences of having a medium to large bowel movement every day, that is softer than normal (e.g. applesauce or pudding consistency) and that does not hurt or cause her discomfort. Unlearning the habit of withholding is a very slow process. The length of time is different for each child, especially for 2 or 3 year olds. You cannot and should not rush her.

While she is unlearning the habit of withholding (in order to avoid an uncomfortable or painful stool even if she has not had such a stool in a very long time!), I suggest that you help her begin to relax on the toilet by making a game of having her sit bare-bottom on the toilet for a minute or two once or twice a day just "for practice" with no expectation of pooping.  This would be in addition to when she sits to urinate.

 

It helps if she is being reinforced for her bare-bottom practice and urination sits with stars or stickers, etc. Don't force her to practice if she resists now and then. Make it a fun game and encourage her with prizes, e.g. stars and stickers and perhaps an occasional treat for good measure.  Be patient! This is going to take quite a while."

Extra Soft Poop: The Key to Treating Encopresis

In an earlier post I said that there was no single dose of a water retention laxative (for example, 1 "cap" of Miralax) that is right for all children. One cap may be too much, making a child's poop too loose. Or it may be too little thus not softening a child's poop enough, if at all. In my book, The Ins and Outs of Poop, I go into detail on how to find the right laxative dose for your child.

Why is getting just the right dose so important?

The key to successfully treating encopresis, (and by this I mean stool withholding and the rectal distention caused by withholding - read my book for more kid-friendly explanations) is to find the dose of laxative - usually a water retention laxative - that enables a child to have 1 to 2 medium-to-large, very comfortable BMs a day, 6-7 days a week that are softer than the "normal" toothpaste consistency.

The desired consistency is like that of pudding or applesauce but not watery.

Over the many months required to effectively treat encopresis, the laxative dose may also need to be raised or lowered in small increments (see my book The Ins and Outs of Poop)  to maintain the desired consistency until withholding has stopped and the rectum has shrunk back to it's normal size.

                                                

 

 

 

Teacher punishes and shames my son. What should I do?

Please, please tell me what to do. My son has encopresis and went five months with no soiling on only 1 tsp. of laxative per day. He was doing great, he was happy, going to the bathroom on his own, all was well. When he started school I told them about his medical condition.

Everything was fine until his teacher began to control and punish him for needing to go to the bathroom. The teacher will not let him go unless SHE excuses him. Then she uses shame and humiliation when he doesn’t follow HER bathroom rules. He is withholding again and poops in his pants at school. He comes home every day saying he is bad. My five year old just wants to please his teacher but he is filled with anxiety.

I have asked the school multiple times for help, for a different teacher, for assessments, etc. but they will not do anything.

Dr Tom’s reply:

Your son's teacher needs to be educated about functional constipation, including the need for children with encopresis to have immediate access to the bathroom. They also need to know that punishment can make his problem worse. In situations like this, I frequently advise parents to ask the teacher to read my book and/or to visit my website (TheInsandOutsofPoop.com).  

You might also ask your pediatrician to send a letter or an email to the teacher explaining your son's medical condition.

If doing these things does not help, you should consider filing a complaint with your school district or finding another school.

Mother’s reply:

Thank you so much for your advice.  I complained to the school district and they finally allowed him to switch classrooms. Thank goodness.  He is slowing getting back on track.

My Son's (4yrs) First "Real" Poop in the Toilet!

"Hello Dr. Tom. I purchased your book "The Ins and Outs of Poop" and I have to say that the simple suggestion of teaching him to push resulted in his first "real" bowel movement in the toilet. Twenty one days later, he is not only pushing out his poop and pee, but he continues to do it in the toilet! After 2 years of struggling with withholding, I thought he would still be in diapers going into kindergarten in the fall. He still does not completely empty but at least he is going. Thank you for writing such a helpful book and for bringing information and attention to a struggle that you don't hear much about."

Parents assume that their child naturally "pushes" when they are sitting on the toilet to poop. However, children with encopresis often think that all they have to do is sit on the toilet long enough and the poop will come out on its own. Not surprisingly, these children frequently end up having either no bowel movement or an incomplete bowel movement both of which keep their rectum stretched and increases the likelihood of poop accidents.

Teaching your child about pushing to poop may at first feel odd (it is certainly not a common conversation between adults!) but using your own experiences, tips and advice or using the directions I outline in my Ins & Outs book can help! Remember that while it can sometimes hurt a little when pushing out a stool, if your child has to strain excessively or is in severe pain while trying to push, please see your pediatrician.

"Softy the Poop" Can Help Treat A Child's Encopresis

My new book for young kids, Softy the Poop: Helping Families Talk About Poop, makes it fun and healthy for families to talk and learn about poop!

As outlined in The Ins and Outs of Poop, the first of the six steps in treating chronic constipation, or encopresis, is to Educate the Family.  In this book, kids (and parents) will learn about the visual differences between normal poop and constipated poop. Softy provides families with new child-friendly terms to describe the differences in poops, such as “round like a ball” or “long and smooth like a snake.”  

Poop Notes for Parents at the end add even more detail and explanation for parents.

For those children struggling with constipation or encopresis, one thing parents must do every day (critical to making any necessary laxative adjustments) is to look at their child’s stool to determine whether it's too moist or too dry. Softy the Poop provides common definitions for the differences in poops; this becomes even more important as children get older and want privacy in the bathroom.

Counselor Says Child's Encopresis Is Caused By Poor Parenting

A mother recently told me that when she sought advice from a counselor about her 5 year old son’s encopresis, the counselor told her that his accidents and his seeming indifference to having poop in his underwear was due to her poor parenting. Needless to say, this mother was very relieved to hear from me that her son’s soiling behavior was not her fault. 

Unfortunately, there are still many medical and nonmedical healthcare providers who know very little, if anything, about encopresis.  Encopresis is not a topic that is typically covered in detail in medical school (general or pediatric).

When the parent of a child with bowel problems is looking for a healthcare provider for advice or guidance, their first question should always be, “How familiar are you with functional constipation or chronic constipation or encopresis in children?”

If the provider says that they do know about this condition, the second question to ask is, “How many children with this condition have you seen in your practice?” Ideally, what you want is a provider with both knowledge and clinical experience.

(If you cannot find a provider who has either or both of these traits, but you do have a provider you like and trust, I am always available to speak with the provider regarding your child's specific situation. Please visit Consultations and sign up for a free 15-minute telephone consultation.)

When Should A Child Take Responsibility for Treatment?

A mother I know recently became so exasperated with her 6 y/o daughter’s off and on cooperation with treatment that she told her, “I’m done! You know what you have to do to stop having poop accidents so you take care of it yourself!”

Up until then, this smart, usually compliant but shy first grader always needed to be told to take her laxative, sit on the toilet after meals, listen to her body and not hide her soiled underwear. When she complied she had daily bowel movements and no accidents, sometimes for as long as a month or more. However, when her parents tried to reduce their own involvement, these “good” months would always be followed by a period of two or more days between poops, having accidents and hiding her soiled underwear.

What happened after her mother said, “I’m done!” is amazing. On her own initiative, her daughter now takes her laxative every morning, goes into the bathroom to poop when she feels the urge, and has no accidents. In my experience, this strategy generally does not work with most children (see my post here about the inefficacy of negative approaches) but it’s worth a try with older, independently minded children who generally want to please their parents.

Parents who try this approach cannot use these kinds of statements lightly or often, or their effect is lost. Parents will need to remain committed to what they have said, at least for a period of time that is long enough for the child to recognize the parent's seriousness.  This may mean the child will have accidents again. Remember, it is always okay to change your approach, especially as extended stool withholding can cause real physical harm.  It's also okay to change if your child requests your help again (for example, they have an accident at school and are embarassed).