Encopresis and Diet

Parents frequently ask if their child's encopresis (functional constipation) was caused by their diet . They also want to know if there is a particular diet that will cure their child's encopresis.

The answer to both questions is that diet alone does not cause encopresis nor is there a particular diet that will cure encopresis. However, there are certain foods that if consumed regularly can help to prevent encopresis and, in combination with laxatives and certain behavioral interventions, can help to cure encopresis.

Food which are high in both soluble and insoluble fiber are the most helpful. Dietary fiber, which includes both soluble and insoluble, is defined as indigestible carbohydrates found in plant cell walls. Some foods are higher in soluble fiber (such as oats and peas) while other foods are higher in insoluble fiber (such as vegetables and whole grain bread).

More detailed information about the amount fiber in specific foods, the daily fiber requirements for children and about different fiber supplements can be found in chapter 17 (Food and Drink for Good Poops) of my book.

3 y/o Will Only Poop While Standing in a Pull-Up

Many children with encopresis will only poop in a diaper or a pull-up. The longer this continues the more their parents worry that it will become a habit.

Here is what one mom recently said to me:

"My daughter is 3 years old and has been standing to poop with a pull-up on for 3 months now. She is fully potty trained for urine. Would you recommend that I keep trying to get her to poop while sitting on the toilet for a few minutes every day (even if she doesn't push) and only then let her stand to poop in her pull-up? Or, should I wait if she doesn't seem ready? I am concerned that the longer the habit goes on the harder it may be to break?"
Here is my response:

"No need to worry about her developing a habit of standing to poop. She will sit to poop when she is ready. She must first unlearn the habit of withholding. This requires many, many experiences of having a medium to large bowel movement every day, that is softer than normal (e.g. applesauce or pudding consistency) and that does not hurt or cause her discomfort. Unlearning the habit of withholding is a very slow process. The length of time is different for each child, especially for 2 or 3 year olds. You cannot and should not rush her.

While she is unlearning the habit of withholding (in order to avoid an uncomfortable or painful stool even if she has not had such a stool in a very long time!), I suggest that you help her begin to relax on the toilet by making a game of having her sit bare-bottom on the toilet for a minute or two once or twice a day just "for practice" with no expectation of pooping.  This would be in addition to when she sits to urinate.
It helps if she is being reinforced for her bare-bottom practice and urination sits with stars or stickers, etc. Don't force her to practice if she resists now and then. Make it a fun game and encourage her with prizes, e.g. stars and stickers and perhaps an occasional treat for good measure.  Be patient! This is going to take quite a while."

Counselor Says Child's Encopresis Is Caused By Poor Parenting

A mother recently told me that when she sought advice from a counselor about her 5 year old son’s encopresis, the counselor told her that his accidents and his seeming indifference to having poop in his underwear was due to her poor parenting. Needless to say, this mother was very relieved to hear from me that her son’s soiling behavior was not her fault. 

Unfortunately, there are still many medical and nonmedical healthcare providers who know very little, if anything, about encopresis.  Encopresis is not a topic that is typically covered in detail in medical school (general or pediatric).

When the parent of a child with bowel problems is looking for a healthcare provider for advice or guidance, their first question should always be, “How familiar are you with functional constipation or chronic constipation or encopresis in children?”

If the provider says that they do know about this condition, the second question to ask is, “How many children with this condition have you seen in your practice?” Ideally, what you want is a provider with both knowledge and clinical experience.

(If you cannot find a provider who has either or both of these traits, but you do have a provider you like and trust, I am always available to speak with the provider regarding your child's specific situation. Please visit Consultations and sign up for a free 15-minute telephone consultation.)

When Should A Child Take Responsibility for Treatment?

A mother I know recently became so exasperated with her 6 y/o daughter’s off and on cooperation with treatment that she told her, “I’m done! You know what you have to do to stop having poop accidents so you take care of it yourself!”

Up until then, this smart, usually compliant but shy first grader always needed to be told to take her laxative, sit on the toilet after meals, listen to her body and not hide her soiled underwear. When she complied she had daily bowel movements and no accidents, sometimes for as long as a month or more. However, when her parents tried to reduce their own involvement, these “good” months would always be followed by a period of two or more days between poops, having accidents and hiding her soiled underwear.

What happened after her mother said, “I’m done!” is amazing. On her own initiative, her daughter now takes her laxative every morning, goes into the bathroom to poop when she feels the urge, and has no accidents. In my experience, this strategy generally does not work with most children (see my post here about the inefficacy of negative approaches) but it’s worth a try with older, independently minded children who generally want to please their parents.

Parents who try this approach cannot use these kinds of statements lightly or often, or their effect is lost. Parents will need to remain committed to what they have said, at least for a period of time that is long enough for the child to recognize the parent's seriousness.  This may mean the child will have accidents again. Remember, it is always okay to change your approach, especially as extended stool withholding can cause real physical harm.  It's also okay to change if your child requests your help again (for example, they have an accident at school and are embarassed).  

Painful constipation, soiling and daytime wetting: Q&A with Dr Tom

A parent recently asked me if soiling at home but not at school and frequent daytime wetting might be related to "painful constipation":

Question: My daughter had some painful constipation several months back which seemed to be the beginning of her soiling issues. After that time she started soiling frequently, as many as 4 or 5 times a day. She is soiling less now but there are two questions I have about the soiling. The first is that she rarely soils at daycare, she typically only soils at home. The second is that she is now wetting her pants frequently, something she didn't do when she started soiling. I think that all of her soiling issues point back to those constipation issues but I don't know if these two behaviors are in line with that idea.

Answer: Painful bowel movements will often lead to withholding followed by soiling (encopresis). Since your daughter continues to soil, albeit less than at first, she is still constipated.That she tends not to soil at school is also typical in the early stages of functional constipation. Ongoing withholding and soiling are often associated with day and night wetting. This is because a distended or stretched rectum will press on the bladder causing occasional leaking during the day and/or bedwetting at night. This is all covered in my book.



He Only Poops After He Falls Asleep

A mother recently reported to me that: “When we were first training our 4 year old son, he had a difficult bowel movement on the toilet. He cried and became very upset. That was when our worst problems began. After that, he didn’t want to poop at all. He became constipated and would only poop at night in his pull-up, after he went to sleep.

Having bowel movements in bed, while falling asleep or while sleeping, is not uncommon for children who are functionally constipated.  It usually occurs at the onset of functional constipation when a child is intentionally withholding poop in order to avoid another painful bowel movement. Intentional withholding requires a child to pay close attention for any bodily signals of urgency. However, once the child falls asleep, conscious withholding stops and stool passes.

Compared to other symptoms of functional constipation, nighttime bowel movements are relatively easy to eliminate once a child begins to withhold less (or not at all) during the day. Detailed instructions for decreasing and stopping withholding can be found in The Ins and Outs of Poop.

Beware of Laxative Scare Mongers!

The mother of a child with chronic constipation recently wrote to me in a panic after reading an internet article (though as I note below, it is actually a well-disguised advertisement for the author's product) titled   “Is MiraLAX the Next Vioxx? No, It's Much Worse!” She said that, on Miralax, her daughter is “now pooping every day” and “has made major progress towards pooping on the toilet”. However, having read the article, she decided to stop giving her daughter Miralax. In its place, she said that she was going to try some “natural alternatives”.

In other words, the article scared this mother into not giving her child a laxative that is safe and effective and replacing it with natural remedies which are helpful for occasional constipation but which are largely ineffective for treating chronic constipation (encopresis).

The author of this article very cleverly uses half-truths to deceive readers into believing that Miralax causes a host of neurologic disorders such as autism, dementia, depression, schizophrenia, multiple sclerosis, Alzheimer’s disease and even encopresis!

The active ingredient in Miralax is polyethylene glycol 3350 (PEG 3350), NOT ethylene glycol. However, the author leads people to believe that PEG 3350 is exactly the same as ethylene glycol which, when used in products such as “automotive antifreeze and brake fluid“, can cause neurologic problems.  There is no scientific evidence that laxatives containing PEG 3350 cause neurologic or neuropsychiatric disorders.

When read carefully, this article is no more than a well-disguised advertisement for a scientifically untested and non-FDA approved combination of supplements and probiotics developed by the author for a veritable shopping list of conditions:  “chronic constipation, bloating, diarrhea, irritable bowel disease, diverticulosis, depressed immunity, chronic fatigue, anemia, infertility, amenorrhea, acne, hair loss, graying hair, premature aging, pre-diabetes, diabetes, respiratory and urogenital infections" and on and on.

And, as if this wasn’t enough to scare parents into discontinuing a safe and effective treatment for childhood constipation, the author recommends stopping giving your child FIBER because he says it makes stools so big that they hurt. As any medical professional will tell you, fiber, just like PEG laxatives, may make stools bigger but it also makes them softer so they do not hurt

Do not believe everything people tell you about laxatives, especially on the internet. My advice? When in doubt, ask your pediatric healthcare provider.

Childhood Autism and Constipation

In my last post I talked about how children with ADHD are more likely to have functional constipation/encopresis than children without ADHD. Today’s post focusses on a higher than usual incidence of autism among children diagnosed with functional constipation. A little known fact outside of the autism community is that GI disorders, most notably, chronic diarrhea and constipation, are among the most common medical conditions associated with autism. A recent study published last year in “The Journal of Pediatrics” confirmed this association.

The researchers found that in a group of 242 children diagnosed with functional constipation, a “strikingly high” number (29%) of these children had concomitant symptoms of childhood autism.  These findings do not mean that autism causes functional constipation. As in the case of ADHD, these findings simply mean that there is a relationship of some kind between autism and encopresis.

The researchers speculate that their findings might be related to genetic factors or sensory processing difficulties. As with ADHD, they also speculate that autistic children get so absorbed in what they are doing or thinking that they simply ignore the urge to poop thus causing them to become constipated.  The importance of this study for you and for your healthcare professional is to be “alert” for symptoms of autism when diagnosing or treating functional constipation.

ADHD and Constipation/Encopresis

Over the years many parents have asked me if their child’s encopresis might be due to ADHD.  They assume that perhaps their child is not able to pay attention to their need to poop or pee. Up until now, in the absence of any good scientific evidence, all I could say was that children who do have ADHD are no more likely to be constipated and soil their underwear than children who do not have ADHD.  

However, a study published in October of last year in “Pediatrics”, the official journal of the American Academy of Pediatrics, sheds new light on the relationship between encopresis and ADHD.

In a retrospective study of almost 743,000 children between the ages of 4 and 12 years of age, 33,000 of whom had ADHD, the researchers found that children with ADHD are significantly more likely to have constipation and soiling. It was also found that medication for ADHD neither increased nor decreased the incidence of soiling.

These findings do not tell us that ADHD is the cause of encopresis. Most children with ADHD do not have encopresis.

What these findings do tell us is that there is a relationship of some kind between ADHD and encopresis. The researchers speculate that there may be an “altered communication between the central nervous system and the enteric nervous system” or  that ADHD children may be less attentive to or slower to respond to bodily cues of poop or pee urgency.

One implication of these findings is that screening for ADHD may be helpful in determining the best treatment plan for some children with encopresis.

Why Do I Always Have to Remind Him to Go and Try to Poop?

Parents frequently ask me, generally in exhasperation: "Why do I always have to remind him to go into the bathroom and try to poop?" 

This question typically occurs sometime during Steps 3 and 4 of my 6 Step Treatment Program (as outlined in detail in my book), when a child is having daily bowel movements but, in many cases, only with parental reminders.

Parents generally think that, by now, their child must feel the urgency to poop, because when he does sit (and push), he almost always gets poop out. They worry that their child will become dependent on them and never learn to go to the bathroom on his own.

I tell them to be patient and not to worry.

I remind them that at this stage in treatment, their child’s rectum has not yet shrunk back to its normal size and, therefore, his ability to sense the need to poop is inconsistent, at best. The main goal at this point in treatment is for a child to have at least one large, very soft bowel movement every day, regardless of whether he does it on his own.

In the meantime, always offer a small reward for going to the bathroom without needing to be reminded. You might also ask him to tell you when is going to go try, and praise him for telling you. But try not to punish, scold, or express frustration when he does not remember.