Encopresis Treatment

How do stimulant laxatives (Ex-Lax, Senokot) work?

Stimulant laxatives are used to encourage bowel movements by irritating the inner lining of the intestinal wall. Stimulant laxatives (such as Ex-Lax and Senokot) increase muscle contractions in the large intestine which push stool toward the rectum. These smooth muscle contractions called peristalsis cause the intestine to narrow and then propel the narrow portion forward. Peristalsis looks like an ocean wave travelling slowly through the large intestine.

Unlike water retention laxatives (such as Miralax or Milk of Magnesia) which are used to keep stool consistently moist (soft) and easier to pass, stimulant laxatives are used to increase the feeling of urgency (the need to poop) and to increase the amount of stool produced the following day. It is not uncommon to treat functional constipation/encopresis with a combination of both of these laxatives.





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.

Encopresis treatment: 2 frequent mistakes

Parents and even pediatricians frequently make two mistakes when treating children who have encopresis: stopping laxative treatment too soon and treating encopresis as if was normal constipation.

The treatment of encopresis or functional constipation, as evidenced by stool withholding and soiling, typically requires the use of oral and/or rectal laxatives over a long period of time. Stopping laxatives too soon almost always causes withholding and soiling to reoccur.

Normal or occasional constipation the kind that we all experience from time-to-time, is best treated with natural remedies such as eating more high fiber foods, drinking more liquid and getting more physical exercise. Natural remedies are rarely effective for treating encopresis.

On page 5 of "The Ins and Outs of Poop" I list the signs of normal constipation and encopresis with regard to stool frequency (4-5 BMs vs 3 or fewer BMs per week), stool shape and surface ("sausage" with cracks vs sausage/ball/pellet-shaped stools with lumpy surfaces), stool color (dark-to-very dark brown vs dark-to-almost black), hard to push (occasionally vs frequently), uncomfortable or painful to push (occasionally vs frequently), habitual stool withholding (never vs always), soils underwear (never vs often).


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.

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.

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.

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."