Encopresis, Exercise and COVID-19

Encopresis could be an unfortunate consequence of community efforts to control the spread of COVID-19 due to decreased opportunities for outdoor exercise. Children who are physically active are less likely to become constipated than those who are not. Unfortunately, school closures and stay-at-home orders combined with the closure of parks and playgrounds in some communities severely limit opportunities for physical activity. Forced to stay inside, children will also be spending more time than usual in front of "screens" which we know causes many children to ignore bowel urgency which can lead to constipation.

Parents need to encourage their children to walk, run and ride bikes and scooters etc as much as possible even if it's just up and down the street in front of their home while making sure that they maintain the "6-foot rule". 

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).


Teacher Punishes Child For Soiling In Preschool

I met this child and her parents in my office two weeks after her preschool teacher had told her parents that she "would quickly stop soiling once she learned that no one was going to help her clean up." The teacher also recommended that the girl be given a backpack to take clean clothes to school and soiled clothes back home. Not surprisingly, this girl was very unhappy  and was having even more trouble with soiling than she did before. 

My first order of business was to speak directly to the teacher to explain encopresis. For children with encopresis, soiling is not a choice.

Parents of children with encopresis (functional constipation) get this kind of advice from all sorts of people: friends, grandparents, daycare and preschool teachers and even healthcare professionals. This “rub her nose in it” advice is based on two erroneous assumptions:

  1. She is able to control when she poops.
  2. Her poop accidents are intentional.

Following this kind of advice inevitably causes shame and embarrassment especially in the classroom. And, as any parent with older children knows, once teasing begins at school it is difficult to stop.

Telling a preschool child with encopresis to clean herself up without help is almost always perceived as punishment, and, as I explain in my book, The Ins and Outs of Poop, punishment is almost always counterproductive. It becomes especially punitive when the accident is large and messy. While I think it’s good to have children HELP with the cleanup as much as they can (e.g. by dumping their poop into the toilet and/or by flushing), they should not be made to do it all by themselves.

Poop accidents can be eliminated through a combination of laxatives and POSITIVE incentives, but most critical is your attitude and willingness to help the child, as well as the attitudes of those other adults she admires and looks up to. 

Encopresis Laxatives: Mineral Oil?

Mineral oil is the most commonly used lubricant laxative in the treatment of encopresis. It is usually given in large quantities (multiple teaspoons) during initial cleanouts to remove very dry, hard stool that is stuck in the colon and cannot be pushed out. This condition is known as an impacted bowel or fecal impaction. Mineral oil facilitates bowel movements by coating the large intestine and the stool with a waterproof film which keeps the stool soft and able to move more easily. Seepage of mineral oil sometimes occurs when mineral oil is used for cleanouts because of the higher than usual doses often required for cleanouts.

During cleanouts mineral oil is often combined with a water retention laxative such as Miralax or Restoralax. However, once the cleanout is finished the mineral is usually discontinued or the dose is significantly reduced so as to avoid seepage or "accidents" during the maintenance phase of treatment when we are relying on the water retention laxative to keep your child's stool softer than normal, e.g. pudding or applesauce consistency.

Contrary to common thought, mineral oil does not cause a vitamin deficiency.



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. 



Will Poop Accidents Keep My Child Out of School

I often get calls from anxious parents in the spring or early summer when they learn that their child cannot attend a particular preschool or start kindergarten if he or she is not “toilet trained.” Parents who had been waiting for their child to “outgrow” his or her poop problem now find themselves with a hard deadline and they want to know if I can make their child's poop problem go away or, at least, stop them from soiling their underwear before school starts. My answer varies with the age of the child and the severity of the encopresis, but it is usually,"No". We then discuss some other possible school options.

Many preschools are staffed and equipped to change messy diapers, so there is less of a problem for preschoolers, especially if teachers know that the parents are working with a healthcare professional to resolve the problem. Some (private) kindergartens (but not all), assume that there will be a few children who are not completely toilet trained on arrival but are likely to be toilet trained within two to three months.

Encopresis with or without soiling does not disqualify a child from enrolling in any public school classroom. Public schools are required by law (ADA) to provide free public education to each qualified student with a disability regardless of the nature or severity of the disability. Encopresis qualifies as a disability. See Chapter 19 of the 2nd edition of my book, The Ins and Outs of Poop, for more information about specific support services.

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 are laxatives almost always necessary?

I read an article that says that laxatives could be bad for kids. Why do you say that "they are always necessary" (on the back of your book)?

Children who have occasional constipation, the kind that we all experience from time to time, rarely need laxatives. Occasional constipation is relieved with natural remedies such as adding more fiber to a child's diet or encouraging exercise. In my book, I devote a whole chapter to the treatment of occasional constipation with natural remedies.

Children with functional or long-term constipation, often referred to as encopresis, almost always do need one or more laxatives as part of their overall treatment. Without laxatives, it is not possible for these children to produce sufficiently soft, large stools every day long enough to end their stool withholding and soiling. With regard to the safety of laxatives, the fact is that research and clinical experience over the past 25 years has clearly shown that, when used properly, laxatives are safe for children.

In my book, I discuss how and when to safely introduce, maintain and then remove laxatives.

But he poops! How can he be constipated?

Our doctor says my 5-year old can't be constipated because he poops every day! But he has frequent "poop accidents."  Any ideas?

This is a very common misconception about constipation even among pediatric healthcare professionals. The fact is that a child can have a fairly large, soft stool every day and still be constipated.

In my book, I talk in more detail about the two types of withholding: complete and incomplete. With incomplete withholding a child may go to the bathroom every day but still not fully evacuate his or her rectum. Over time, this results in a gradual backup of stool which slowly, but surely, stretches the rectum to the point where a child begins to have stool accidents.