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 how to push may at first feel unnecessary because it is not usually something we need to teach our children to do. For most children pushing happens naturally. But children with functional constipation often need to be taught or retrained how to push.

Toilet Training Can Cause Constipation

In the second edition of my book, The Ins and Outs of Poop, I encourage parents to consider whether their child is ready to be trained before beginning training. Typically, when a one to two-year-old develops constipation during toilet training (potty training), it is because his or her parents have not correctly taken into account their child's physical development, temperament or the potential negative impact of stressors inside or outside the home. For example, a child's physical ability to control their bowel and bladder sphincters (muscles) does not occur all at once, it develops over a period of time which varies in length from child to child. Some toddlers are temperamentally anxious and fearful of change. Some toddlers are quite stubborn and defiant and are perfectly happy to walk around in wet or soiled diapers.

Before initiating toilet training, parents are well advised to think about their child's unique temperament and how strongly they think he or she will resist. This is because children who repeatedly resist or refuse to poop on the toilet during toilet training will often withhold their stool which can, fairly quickly, cause them to become constipated. Therefore, if you expect or you see strong resistance, the wise thing for you to do is to postpone toilet training to a later time.


"Does your book apply to children under age 2, like my 18 month old?"

I received a question from the mother of an 18 month old child asking if “The Ins and Outs of Poop” applies to children as young as hers. In fact, Chapter 3 of the second edition of the Ins and Outs of Poop is dedicated to infants and toddlers. Signs of functional constipation in toddlers include hard stools of any size, painful bowel movements, daily withholding and stool incontinence or leakage. For toddlers I recommend that parents initiate treatment right away if they see signs of functional constipation or encopresis. For otherwise healthy toddlers treatment usually starts with dietary changes including giving the child more water or juice such as 100% apple, prune or pear juice.

Because the treatment of encopresis in children is more successful the less time that hard stools and pain persist, I recommend that an oral laxative be strongly considered if a child's stool does not soften within 48 hours. Always consult with your pediatric healthcare provider if you any questions or concerns about the use of oral laxatives.

3 y/o Refuses Laxatives: Sneaky Chef Helps

The mother of a 3 year old girl, whose painful episodes of constipation began when she was 11 months old, recently told me that her daughter was now refusing to ingest any laxative in ANY form, even though laxatives had previously made her bowel movements soft and painless. No matter how we tried to disguise Miralax in countless liquids or Ex-Lax (chocolate form), even in foods like chocolate chip cookies, she refused them.

While working on this problem, we decided to increase the fiber in her diet (obviously she was a picky eater generally, so this, too, was difficult!) and came upon some really wonderful books by Missy Chase Lapine such as The Sneaky Chef: Simple Strategies for Hiding Healthy Foods in Kids' Favorite Meals.

Increasing dietary fiber was helpful for this girl but, as I explain in my book, fiber is much more important and effective for preventing serious constipation than it is for treating it.  Keeping stool soft and bowel movements frequent for extended periods is typically only accomplished via laxatives.

Constipation and encopresis in the first year of life

Parents are often surprised when they learn that their less-than-12-month-old baby is constipated or has encopresis. They did not know that infants become constipated as often as older children and that infants who experience constipation go on to develop functional constipation more frequently than older children. Mothers who breastfed their baby were surprised because they thought breastfeeding prevented constipation, forgetting that the introduction of solid foods can lead to constipation even while breastfeeding.

Parents should contact their pediatrician at the first sign of constipation. Warning signs include: hard pellet-like stools, crying and screaming before or during a bowel movement, arching of the back, stiffening the legs and appearing to be straining to push stool out or hold stool in. A formula fed baby should have at least one bowel movement a day. Less than one bowel movement a day, especially if the baby appears to be straining more than usual, may be a sign of functional constipation. For treatment recommendations see Chapter 3 in the 2nd edition of  The Ins and Outs of Poop: A guide to Treating Childhood Constipation.


Treating Encopresis: PEG Laxative Dose and Stool Consistency

 A water retention laxative such as Miralax is the type of laxative most commonly recommended by pediatric healthcare providers for the treatment of encopresis. When Miralax is prescribed, parents are usually advised to give one or more "caps" or "half caps" of the powder diluted in water. A "cap" is the amount recommended on the container and is therefore assumed to be the "standard" dose. However, the fact is that there is no one dose that is the most efficacious for all children. A cap or half cap may be too much or too little as evidenced by its effect on stool consistency. In my book, The Ins and Outs of Poop, I strongly recommend dosing PEG laxatives like Miralax by the teaspoon (one cap is approximately 5 level teaspoons). Dosing by teaspoons makes it much easier to determine the most efficacious dose for each child.

Why is getting just the right dose so important?

The key to successfully treating encopresis is to find that dose of a laxative that enables a child to have 1 to 2 medium-to-large, very comfortable BMs a day, 5-7 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 need to be raised or lowered in small increments to maintain the desired consistency until withholding has stopped and the rectum has shrunk back to it's normal size.

Travelling and constipation

I was recently asked for advice or "tips" about how to prevent constipation when travelling with children.

It is fairly common for young children to become constipated when their normal eating and sleeping schedules are disrupted.

For example, a number of parents have told me that their child first became constipated while driving between Seattle and California to visit Disneyland, in some cases necessitating an ER visit along the way. Vacation trips are especially difficult for kids because of having to eat at different times and in different surroundings. Kids also become constipated when travelling because of dehydration and insufficient exercise.

To prevent constipation while traveling, I recommend that...

...parents do the best they can to maintain their child's usual eating, nap and bed times and to be sure that their child drinks extra fluids and gets plenty of exercise.

As I say in my book, The Ins and Outs of Poop, our GI tract "likes" exercise: exercise helps us poop. So, if driving a long distance, make frequent stops to let your child walk or run around a bit before sitting on the potty. If you're in an airplane, use the times when the food and beverage carts are not in the way to walk your child up and down the aisle a few times.

PS. All of these recommendations for avoiding constipation apply to adults as well!

No "summer breaks" from encopresis treatment!

It may be tempting to "take a break" from encopresis treatment when traveling, but it's important to remember that even a week off can undo months of hard work.  Traveling with encopresis does require additional planning.  I know it can be complicated but laxatives, sitting times, pushing and incentive programs (e.g. star charts) must be continued to ensure daily bowel movements. And don't forget to keep filling out your Weekly Laxative and Stool Record!

When visiting with friends or relatives, I advise that you explain beforehand, preferably in private, that your child has a potty problem (the term "chronic constipation" is generally easily understood -- most adults can imagine what this feels like) and that what you are doing is necessary in order to make his/her problem go away. You may be embarrassed to talk about your child’s problem with people whom you don’t see very often but just imagine how embarrassed you (and your child!) will feel if he or she has an accident in their home and you have not talked with them about it beforehand.

Take my books, "The Ins and Outs of Poop" and "Softy the Poop" with you just in case you encounter someone who has their own ideas about your child’s problem and how they think you should deal with it. You know the people I’m talking about! 


Don't poop in the swimming pool!

This is a very real concern for parents of children with encopresis, especially on hot summer days at the community pool or when vacationing at a fancy resort.

Parents frequently ask if I think it's okay for their child to swim in a public or private pool provided that she is wearing a swim diaper or that she promises to get out of the pool if she needs to go to the bathroom.

The problem is that swim diapers are not leak proof and children who soil are even less likely to recognize and respond to urgency while swimming than when not swimming. The risk of an accident is further increased by the fact that our large intestine "likes" exercise in the sense that it often triggers peristalsis and a strong urge to poop. The risk of extreme embarrassment if poop is seen in the water and the pool needs to be immediately shut down, is just too high to take the chance.

What I recommend is that a child with encopresis not be allowed to swim in a pool unless he or she has at least one good size bowel movement within an hour or two of going into a pool.

For many children, to be able to go swimming is a powerful incentive to have a bowel movement. For those children who have to sit out because they are unable or unwilling to have a bowel movement, I believe that their disappointment is outweighed by the risk of the embarrassment they (and you!) will experience if they are responsible for everyone having to get out of the water.

Why will he pee in the toilet but not poop in the toilet?

Parents of children with functional constipation often report that their child will urinate in the toilet with no problem but will only defecate if they are wearing underwear or are in a diaper or Pull-up. Why is this? Understandably, parents think that if their child is relaxed enough to pee in the toilet he or she should also be relaxed enough to poop in the toilet. However, as I explain in the 2nd edition my book The Ins and Outs of Poop: A Guide to Treating Childhood Constipation, the fear that underlies functional constipation is related to relaxing the anal sphincter (not the urinary sphincter!) whenever a child consciously or subconsciously feels the need to poop. Most of the children who pee in the toilet but do not poop in the toilet are still actively withholding and frequently have poop "accidents" in their underwear or diapers (See Chapter 9). In my book I explain why withholding must be treated and stopped before the application of "successive approximation" behavioral strategies can enable these children to poop on the toilet without fear ( See Chapter 16).