Unfortunately, many pediatricians and/or their staff are not trained or experienced in treating complicated poop problems like encopresis and chronic constipation.

Here is an email I recently received, reprinted with the parent's permission:

Hi Dr. Tom,

I'm currently pretty livid, and a little bit defeated. My 3.5 year old son's pediatrician referred us to a pediatric GI clinic to rule out any other underlying causes for his constipation. He's on a very large daily dose of Miralax and his poops are extremely soft.

We saw the nurse practitioner at the clinic. The good news is that she doesn't think there is anything else going on in addition to what we already know: his rectum is stretched out, so things do not work exactly the way they should.

We were in a pretty good place before the appointment. He was having a large poop daily and, with a few recent exceptions, he was going in the potty. It took us months to get there. But she did a rectal exam and not in a way that I liked. At all.

She didn't actually tell him she was going to do it. She made him cry trying to get him on his side, until I stepped in and got him to roll over without tears. Then she just told him, "This is going to feel like pooping backwards," and stuck a finger in. Given that he has fear issues regarding pooping, that does not seem like a wise thing to say to comfort him.

Some children find it extremely difficult to poop or pee without a diaper or pull-up on. As mentioned in the previous posts on this topic (see list at the end of this post), wearing a diaper or pull-up helps them relax their poop and pee muscles, in part by assuring them that their poop and pee will not drop into the toilet.

Eliminating diaper or pull-up dependency is a two-step process which is described in further detail in my book:

The first step, counterintuitive but necessary, is to get your child to poop and/or pee while sitting comfortably on the toilet with his diaper on.

The second step involves cutting progressively larger holes in the diaper or pull-up, starting with slits so small that neither poop nor pee will drop into the toilet.  This process may sound strange and/or tedious, but I have used this technique for over 20 years and it really works!

The key to success is to proceed very, very slowly because most diaper dependent children will refuse to pee or poop if they perceive the hole in the diaper to be too big.  This can be avoided by asking your child at each step of the way if he or she is comfortable trying the larger hole. If not, stick with the smaller hole until your child is ready to try a slightly bigger one.

While for some children this process only lasts one or two weeks, it is also completely normal for this hole-cutting process to take months before the child is comfortable enough to let the poop drop into the toilet through the hole, and subsequently to allow the diaper or pull-up to be removed completely. Parents have found Chart #6 in Chapter 16 in my book to be helpful in guiding their children through this process successfully. And don't forget the use of incentives and visual sticker charts to reward each small shift in behavior!

Previous posts on this topic are located in the "Only Poops in a Diaper" category, see far right column or below:

Poops Only in a Diaper? Your Child Is Not Alone

Older Kids Who Still Wear Pull-Ups

Real Poop Story: A 6 Yr-Old Who Will Only Poop in Pull-Ups

Real Poop Story Cont'd: A 6 Yr-Old Who Will Only Poop in Pull-Ups

Even though many of the parents I talk to have never had a rectal laxative themselves, they resist giving them to their children because they erroneously believe that they “hurt”. This is unfortunate because there are many children with encopresis who can and do benefit from them.

With PEG oral laxatives, such as Miralax, the time between administration and defecation is slow and unpredictable. Because there is no standard dose, the unpredictable response makes it difficult to determine the most efficacious dose whether it is for conducting a cleanout or for helping a child have a large, soft bowel movement every day without accidents. If we give too little laxative, the child’s stool remains dry and difficult to pass. If we give too much laxative, the child’s stool becomes almost liquid and may “leak” out.

However, the time between the administration of a rectal laxative and defecation is typically very brief, usually within 1-5 minutes, if not immediate. When given correctly (see Chapter 14 of my book), rectal laxatives will empty approximately ¼ of your child’s large intestine thereby reducing the likelihood of accidents.

Another benefit of an enema or suppository is an increase in the efficacy of rewards used to reinforce pooping on the toilet. In other words, the almost immediate bowel movement on the toilet following a rectal laxative allows for an equally immediate reinforcement for pooping on the toilet. As I explain in my book, the immediate and frequent reinforcement of a new behavior leads to faster learning of that behavior than when reinforcement is delayed or infrequent.