Behavior Problems, Temperament and Encopresis

In Chapter 5 of the second edition of my book, The Ins and Outs of Poop, I write that though the majority of children who have encopresis do not have unusual behavior problems, many do.  Twenty five to thirty percent of children with encopresis are described by their parents as unusually active, impulsive, inattentive, stubborn and/or disruptive. Most of these behavior problems are manifestations of the child's temperament and rarely rise to the level of a diagnosable condition. Temperament organizes a child's approach to the world. It is the way a child is wired and is a major determinate of how easy or difficult it is for parents to manage their child's behavior.

A child with a stubborn temperament may resist toilet training by refusing to poop in the toilet: choosing instead to withhold stool which can result in functional constipation. Likewise, an unusually stubborn child who becomes constipated following one or more painful bowel movements may refuse key aspects of treatment such as taking laxatives, doing practice sits or "pushing" when sitting on the toilet. Therefore, I often recommend that parents of children with temperament-related stubbornness learn behavior change strategies (that increase compliance and decrease non-compliance) preferably, but not necessarily, before initiating toilet training or treatment for functional constipation (encopresis).

Parents who want to learn these strategies should seek the assistance of a therapist or treatment program that describe their services as "Parent-Child Interaction Training or Therapy." (PCIT) For parents who do not have such a resource available to them, this chapter includes my own detailed PCIT Self Study Course.


Encopresis Treatment and Exercise

Parents of young children being treated for encopresis sometimes think it strange that their child likes to runs around before pooping. One parent said, "My son often needs to run up and down the hallways to make a bowel movement." In fact, there is nothing strange or unusual about this at all. As I say in my book, The Ins and Outs of Poop:

"Exercise is important (especially when treating encopresis!) because it directly affects the movement of stool. Our large intestine works better when we are active. Children (and adults) frequently experience the urge to poop either during exercise or shortly thereafter. Children who are physically active are less likely to become constipated than those who are not." (page 50)

Exercise helps constipation by decreasing the time it takes food to move through the large intestine thereby decreasing the amount of water the large intestine absorbs from stool. Aerobic exercise, like running, is especially helpful because, by speeding up breathing and heart rate, it helps stimulate intestinal peristalsis.

Therefore, provided that your child's laxative and liquid intake is sufficient to make his stool softer than normal ( applesauce or pudding), you might want to encourage your child to run around for a few minutes before sitting to try to poop. 



Teaching constipated children to "push" using games and toys

The treatment of functional constipation often involves teaching and encouraging children to "push" in order to help their poop come out.  As I reported in a previous post, one mother found that teaching her son to push resulted in his first real bowel movement She couldn't believe she hadn't tried that sooner.

So how do you teach and encourage a child to push? In kid-friendly terms, the act of pushing is like trying to blow air through a straw that is blocked on one end so that no air can pass through. Pushing causes the diaphragm to move in a way that puts downward pressure on the rectum and its contents. In the second edition of my book, The Ins and Outs of Poop, I advise parents to teach their preschool or older age child to push by doing the following while sitting on the toilet:

  1. "Breathe in a little and hold it."
  2. "Pull in your belly button a little and hold it in or push out your belly button a little bit and hold it out."
  3. "Try to push your belly button down and out through your poop chute."
  4. "Push for three to five seconds, then let the air out and relax." 

For young preschoolers and older toddlers I advise parents to approach teaching how to push as if it were a game.  Games give a child the opportunity to have fun practicing the components of pushing before they have to deal with the added stress of having to do it while sitting on the toilet to poop. For example:

The Belly Button Game: While either standing or sitting in the bathroom (or in any other room in the house), a parent first demonstrates what it looks like when they move their own belly button in and out and then challenge their child to see how many times they and their child can move their belly buttons in and out together at the same time. Vary it up with how slowly or how quickly the child can move their belly button in and out.

Using toys that encourage partially obstructed exhalation can also be helpful. Partially obstructed exhalation also causes the diaphragm to put downward pressure on the rectum and its contents but less so than breath-holding. To help children recognize the feel of "pushing the belly button down" while sitting on the toilet, toys such as pinwheels or New Year's Eve party favors like "blowouts" or horns are excellent. The objective is to encourage blowing out or exhaling as long as possible without straining. "Blowouts" that make a funny sound when fully extended are ideal.

To maintain interest in "playing" with these toys I recommend that children only be allowed to use them when sitting on the toilet.

Join in and have fun!!

How to determine the correct maintenance dose following a cleanout?

The third step in my Six Step Treatment Program for treating functional constipation is to slowly decrease and then end stool withholding. It requires that you find the maintenance laxative(s) and dosage(s) that keep stools soft enough over a period of months to prevent a reoccurence of dry hard stools. (See Chapter 11). There is no standard laxative maintenance dose for children. The dose must be determined for each child individually starting on the day immediately following the last day of the cleanout. On the last day of a successful cleanout a child's stool should be close to a clear liquid. As stated in an earlier post, a cleanout is usually accomplished be giving higher than usual doses of a water retention laxative such as Miralax.

The procedure for determining the correct maintenance dose is to gradually begin decreasing the cleanout dose until the consistency of the child's stool is like pudding (not formed) or applesauce but not watery or liquid. For example, if the cleanout required 5 teaspoons of Miralax a day, you begin the process of determining the correct maintenance dose by lowering the cleanout dose by 1 teaspoon a day for three days to determine the effect of 4 tsp on stool consistency. If it is still too loose/watery you again lower the dose by 1 teaspoon and wait another three days to determine the effect of 3 tsp on stool consistency and so on until the desired consistency has been achieved.

Some children are especially sensitive to small increases or decreases of water retention laxatives. Therefore, you may have  to "fine tune" the dose by 1/2 a teaspoon up or down in order to achieve the desired pudding or applesauce consistency. For example, a dose of 3  teaspoons may be too high whereas 2 1/2  teaspoons may be just right. (Think "Goldilocks and the Three Bears"!)

(You may have correctly noticed that the pudding consistency I talk about is not one of the 7 stool types on the Bristol Stool Chart in the Appendix of my book. I think of pudding as between a Type 4 and a Type 5 on the Chart or Type 4.5.)


Cleanouts: What Laxative, What Dose, For How Long?

What is a "cleanout"?  A cleanout refers to the process of rapidly removing constipated stool which has backed up in the rectum and, possibly, higher up in the large intestine. This allows new stool to be eliminated when ready.  It is the second of the Six Steps in my book for treating encopresis or functional constipation in children.

Cleanouts are usually done with high doses of a PEG water retention laxative such as Miralax or Restoralax, sometimes in combination with a stimulant laxative.  (If a child's feces are very dry and impacted, a lubricant laxative such as mineral oil may also be necessary.) (See Chapter 11 in my book.) There is no standard cleanout dose for all children just as there is no single standard maintenance dose following the cleanout.  Often, the recommended starting dose of a PEG laxative for a cleanout is "1/2 or more caps". The dose initially recommended by your healthcare provider may be too low and therefore need to be increased.  

The correct cleanout dose produces very loose stool for 1-2 days, followed by a day of mostly liquid or no stool at all, at which time the cleanout is done.

If in doubt about whether a cleanout has been successful, remember that the purpose of a cleanout is to enable your child to move a much larger quantity of poop during the 3-4 days of a cleanout than he/she did in the 3-4 days prior to the cleanout.

PLEASE NOTE: Since your child's poop will be much looser than usual during a cleanout it will be much more difficult for him/her to control. Therefore, for school aged children, I always recommend that cleanouts be done over a weekend or at some other time when your child is not in school.

Wetting Accidents and Encopresis

Wetting accidents ("peeing in one's pants") at night and/or during the day may be a symptom of encopresis (functional constipation). 

Nighttime wetting and daytime dripping or leaking are frequently due to a distended or stretched rectum caused by stool withholding. This is because the rectum and the urinary bladder are physically very close together. (See Chapter 9, page 66)  If one or both of these organs are full they can easily press up against one another, increasing the chance of accidental wetting.  I find that these accidents occur more frequently with children who wait until the last second to urinate.

It is also important to know that pressure on the urinary bladder by a distended rectum can make it difficult for the bladder to empty completely. Over time, especially for girls, incomplete emptying of the bladder can lead to a bacterial infection in the residual urine, commonly known as a urinary tract infection (UTI). 

Since sudden onset daytime wetting accidents can also be caused by a urinary tract infection (UTI) parents would be wise to seek the opinion of their pediatric healthcare provider if the daytime accidents continue.

Milk of Magnesia: Q&A with Dr Tom

Question: My daughter is turning 4 in a month. She is not potty trained, still in diapers and won't even sit on the potty at all. She has tried a few times, mainly in a public restroom but absolutely refuses now. We have been using Milk of Magnesia for a year now, and upped the dose since I have read your book in hopes to clean her out and start potty training more seriously. Her
moods are so much better when she is cleaned out! My question is, do you think Milk of Magnesia is okay as our laxative choice?  Thanks

Answer: Milk of Magnesia works well as a laxative for many children with functional constipation. However, I prefer to use a PEG 3350 laxative such as Miralax. Whether you stay with Milk of Magnesia or not depends on whether it helps your daughter to have a comfortable, very soft, medium-to-large bowel movement at least six days a week. If not, I would try a PEG laxative.
Dr Tom

"Potty Talk" and Toilet Training

Before initiating potty or toilet training it is important that parents be comfortable with "potty talk." Most parents are uncomfortable talking about poop. They are also uncomfortable when their children talk about poop. Unfortunately, when families do not talk about poop, children are more likely to be slow to toilet train and to become constipated. My book, Softy the Poop: Helping Families Talk About Poop, addresses both of these potential problems by facilitating healthy parent-child conversations about poop. Toilet training is easier and constipation can be avoided if parents and children are comfortable talking about poop before toilet training begins

Fiber, Liquid and Encopresis

One of the most common misconceptions about encopresis (functional constipation) even among healthcare specialists, is that it is caused by not eating enough fiber and/or not drinking enough liquid. The truth is that diets low in dietary fiber or liquid do not cause functional constipation. Functional constipation (encopresis) is caused by stool withholding and subsequent rectal distention. However, for prevention, fiber-rich diets are recommended for all children, especially for those who have a history of occasional or functional constipation.

Dietary sources of fiber contain both soluble and and insoluble fiber (see Chapter 17 in my book for the important differences between the two.) For children, the daily amount of fiber recommended is the age of the child plus five grams.  The recommended liquid consumption from all sources for children 1-8 years of age is 4 to 5 cups (32 to 40 fluid ounces) a day.


The Power of Visible Incentives

 Motivating children to do things like daily practice sits or practicing  pushing can be difficult because of the close association with their (conscious or subconscious) fear of pain when pooping.  For some children, special stickers on their “Good Pooping Chart” are enough of an incentive.  But there are others who need a “stronger” incentive like a bite of candy or a small prize.  

Some parents have found that they can actually increase the “power” of these incentives by making them visible (but out of reach) by putting one or more of them in small plastic sandwich bags taped high up on the bathroom wall. Then, when the child finishes  sitting or pushing, they are immediately given the prize they’ve been admiring.