Cleanout unnecessary following one poop accident

If a child has just one poop accident during the maintenance phase of encopresis treatment, some parents and pediatricians mistakenly think that the child is constipated again and needs (another) cleanout. Logically, one accident alone, by a child who is on a laxative and has been having regularly large, softer-than-normal bowel movements, is not indicative of a re-occurrence of constipation. Therefore, in this situation, a cleanout is unnecessary.

The correct response in this situation would be to wait and observe what happens in the days that immediately follow the accident. If accidents continue, what is the consistency of the stool? Is it softer or firmer than it has been? If softer, consider decreasing the laxative dose. If firmer, consider increasing the laxative dose. A cleanout should only be considered if the child goes 24-48 hours or more between bowel movements and/or his or her stool turns dark brown in color.

Withholding bowel movements again following a cleanout

Parents often report surprise and disappointment when their child starts to withhold bowel movements again following a cleanout. This is because they and, sometimes, their pediatrician who recommended the cleanout, do not know the difference between functional constipation (encopresis) and occasional or normal constipation.

Children who have encopresis have developed a "habit" of withholding, which is to automatically contract their anal sphincter to avoid a painful bowel movement whenever they feel bowel urgency. So, because withholding is a learned or habitual response to the feeling of having to poop, it will start again after a cleanout. Step#3 of my Six Step Program is the phase of treatment during which your child's association of pain with urgency is gradually extinguished together with the related habit of withholding.

Children with occasional or normal constipation do not have difficulty passing stool because they are withholding but because their stool has become dry and hard and it is very difficult for them to push out. Normal constipation comes and goes fairly quickly and is usually treated by increasing fiber, liquids and exercise but if continues more than a week or so may require the use of a laxative or even an enema to remove the dry stool in order to prevent the child from starting to withhold.

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.

How Long Does a "Clean Out" Take?

When we are doing a "clean out" by increasing the laxative dose as you describe in your book, how do we know the stool has been sufficiently cleaned out to reduce the laxative dosage? 

As part of their initial assessment, some healthcare providers will obtain what is called a lower abdominal x-ray to determine if there is excess stool anywhere in the large intestine. If this was done, a second post-cleanout x-ray can help determine whether the cleanout was successful.

When x-rays have not been done, which is typically the case, the answer to this question is based on the quantity and the consistency of the stool that was moved during the 3-4 day cleanout, compared to the amount and consistency of stool moved in the 3-4 day period prior to the cleanout. Ideally, in about two to four days, the higher dose of a  laxative will enable the child to produce considerably more stool than in the days prior to the cleanout, and the consistency of the stool will become very loose or watery.

At this point we assume that the rectum has been cleaned out and we gradually begin to lower the dose of the laxative until the stool consistency becomes more like apple sauce or pudding. Once this has been accomplished, you then continue on into Step #3 of my Six-Step Program which is to "End Withholding."