Fiber, Liquid and Encopresis

One of the most common misconceptions about encopresis (functional constipation) even among healthcare specialists, is that it is caused by not eating enough fiber and/or not drinking enough liquid. The truth is that diets low in dietary fiber or liquid do not cause functional constipation. Functional constipation (encopresis) is caused by stool withholding and subsequent rectal distention. However, for prevention, fiber-rich diets are recommended for all children, especially for those who have a history of occasional or functional constipation.

Dietary sources of fiber contain both soluble and and insoluble fiber (see Chapter 17 in my book for the important differences between the two.) For children, the daily amount of fiber recommended is the age of the child plus five grams.  The recommended liquid consumption from all sources for children 1-8 years of age is 4 to 5 cups (32 to 40 fluid ounces) a day.


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.

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.

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.

Squatty Potty and Functional Constipation or Encopresis

The Squatty Potty is a footstool for children and adults which elevates your feet while sitting on the toilet. The footstool changes your posture so as to more closely approximate squatting than sitting. It comes in both 7" and 9" tall versions.

Squatting is thought by many GI doctors to be the most natural and efficacious position for defecation. I agree. In the squat position, the angle between the rectum and the anal canal is wider/straighter than it is in the sitting position thus allowing stool to pass through with less effort/straining.

How does this relate to functional constipation/encopresis)?

In my book, The Ins and Outs of Poop, I talk about how one or more uncomfortable or painful bowel movements can cause a child to begin to withhold stool whenever she or he feels urgency so as to avoid another uncomfortable or painful bowel movement. Unfortunately, withholding can become a conditioned or habitual response to the feeling of urgency which almost inevitably leads to functional constipation aka encopresis. 

The key to preventing functional constipation is to act quickly with natural remedies when your child has occasional constipation in order to keep his or her stool soft and the need for pushing/straining at a minimum.

In my opinion, the use of a higher than normal footstool such as a Squatty Potty should be thought of as one of the natural remedies for occasional constipation along with more common remedies such as increased fiber and exercise. Footstools like the Squatty Potty may also be of help in the long-term treatment of encopresis.


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.