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.

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. 

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.

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.

The treatment of encopresis requires parents to keep track of poop accidents so that they can appropriately add or change the laxative or other treatment their child may be on (see the “Weekly Laxative and Stool Record” in my book, The Ins and Outs of Poop).

When I ask parents to describe the size and consistency of their child’s accidents, they will sometimes say, “I’m not sure if it’s an accident or if he/she just didn’t wipe, or wipe completely.” This is an important distinction because changes in laxatives or their doses is often based on the frequency, size and appearance of a child’s accidents.  If a parent doesn't know or is just guessing whether a child had an accident, the data they are using to make this decision is problematic.

Generally, poor or no wiping results in a brown stain or a thin smear. Anything more than a stain or thin smear is defined as an accident.

(One caution, however, about loose or liquid-like stools. These are sometimes mislabeled as accidents caused by constipation when they are not. As described in detail in my book, too much of a laxative (e.g. Miralax) can cause incontinence.)

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.

This post is for parents who use more flushable wipes than toilet paper when cleaning poopy bottoms. You may be unaware that sewer agencies and home owners with private septic systems are sounding an alarm about the rapidly growing use of moistened “personal” wipes because they clog sewer pipes and pumps, causing sewage to overflow into streams and back up into basements. (See related article below)

The problem is not that flushable wipes don’t flush, the problem is the amount of time it takes for the wipes to break apart after they are flushed.  Consumer Reports evaluated how long it takes for toilet paper and wipes to break apart. They found that toilet paper breaks apart in 7 seconds whereas flushable wipes take longer than 30 minutes! It’s clear why clogs occur when you consider the fact that in some utility systems it takes only a couple of minutes for wipes to reach a sewer pump.

To be safe as well as environmentally conscious, flush toilet paper but put wipes in the trash.

Related articles

'Flushable' personal wipes giving sewer utilities a headache

Even though many of the parents I talk to have never had a rectal laxative themselves, they resist giving them to their children because they erroneously believe that they “hurt”. This is unfortunate because there are many children with encopresis who can and do benefit from them.

With PEG oral laxatives, such as Miralax, the time between administration and defecation is slow and unpredictable. Because there is no standard dose, the unpredictable response makes it difficult to determine the most efficacious dose whether it is for conducting a cleanout or for helping a child have a large, soft bowel movement every day without accidents. If we give too little laxative, the child’s stool remains dry and difficult to pass. If we give too much laxative, the child’s stool becomes almost liquid and may “leak” out.

However, the time between the administration of a rectal laxative and defecation is typically very brief, usually within 1-5 minutes, if not immediate. When given correctly (see Chapter 14 of my book), rectal laxatives will empty approximately ¼ of your child’s large intestine thereby reducing the likelihood of accidents.

Another benefit of an enema or suppository is an increase in the efficacy of rewards used to reinforce pooping on the toilet. In other words, the almost immediate bowel movement on the toilet following a rectal laxative allows for an equally immediate reinforcement for pooping on the toilet. As I explain in my book, the immediate and frequent reinforcement of a new behavior leads to faster learning of that behavior than when reinforcement is delayed or infrequent.

The mother of a child with encopresis recently told me that when she asked her pediatrician if Miralax might be the cause of her son’s frequent poop accidents, her pediatrician said, “Absolutely not!  In all my years of practice I have never seen Miralax cause accidents!” 

My first thought was that this doctor must not have treated many children with encopresis.

Any PEG or water retention laxative such as Miralax can cause stool to leak, sometimes uncontrollably, if given in unnecessarily high doses. This is, unfortunately, very common. In my experience, the main reason why children are unintentionally given more (or sometimes less) laxative than they need is because parents and even some healthcare professionals think that “one cap” of the PEG powder is the “standard dose” even for children, so that is how it is typically prescribed. But, often that is far more than the child needs.

The last thing a child (or their parent) wants is to soil or leak MORE than usual! In my experience, the most common reason parents feel that laxatives don't work for their child is that their child has been on an incorrect dose.

The fact is that there is no one dose that is correct for all children. A dose that works for one child may be too much or too little for another child. That’s why I always advise that PEG laxatives be prescribed by the teaspoon and not by the cap, keeping in mind that one cap equals five level teaspoons.  My book describes in detail how to determine the correct dosage for your child.

The messy truth is that many children with encopresis hide their soiled underwear. Generally, they do it to postpone getting in trouble, even if their parents have told them many times that they will not be upset with them for having an accident.  They often believe their parents will also be upset or disappointed with them for having messy underwear -- consider the look on any parent's face (not to mention the "eeew/gross" commentary that often accompanies it) when presented with such underwear!

Typical hiding places include under and behind their bed, in their closet and behind the toilet. Curiously, some children try to hide their soiled underwear at the bottom of the dirty clothes hamper.

One technique I recommend to prevent this behavior is by putting all of your child’s clean underwear “under lock and key” and then telling him that he needs to turn in the underwear he is wearing in order to get another pair of underwear.  This will need to happen on a regular basis (i.e. before PJ's, before baths, in the morning, etc).

Another option is to allow the child his own access, but only provide seven pairs and number the underwear 1-7 (or label by day of week) to ensure you've gotten all of them back at the end of the week.

When your child does bring you his underwear, it is important that you praise him for doing exactly what you asked him to do even if his underwear is soiled. Some children may need a small reward or to have this action featured on a reward chart.  You want him to learn that you mean what you say when you tell him that it’s OK if he has an accident.