Treatment

Children who only poop in diapers or pull-ups

Parents find it difficult to change the behavior of children who have become dependent on, and will only poop and/pee in a diaper or pull-up.  Treatment of these children occurs in three different phases each of which requires the effective use of incentives (pages 120-122)  and star charts (131-133) as shown in my book:

Phase 1. Teach them to poop/pee in the bathroom while wearing a diaper or pull-up.

Phase 2. Teach them to poop/pee sitting on the toilet while wearing a diaper or pull-up.

Phase 3. Teach them to poop/pee sitting on the toilet without a diaper or pull-up.

The time it takes to successfully complete each of these steps varies with the age of the child, their level of anxiety about pooping without a diaper or pull-up and about pooping in the toilet. Parental patience and a willingness use "carrots" rather than "sticks" are essential. 

The email below was sent to me by a real mom following a telephone consultation regarding her 6 year old son who would only poop in a pull-up. 

Hi Dr. Tom,

I wanted to give you a further update on Kyle’s progress.  Just 7 weeks after starting the strategies you and your book helped us design, Kyle is pooping on the potty every day!  This is a child who could barely tolerate a brief sit on the toilet for over three years!  I am AMAZED by how far we have come.  As I reflect on what really made things work for us, four points come to mind.

1) Book and Phone Consultation. I want to tell you that I literally cried when I read your book.  I was ashamed that my six year old could not poop on the toilet. The combination of reading stories from people struggling as we were, and thinking that your strategies might work for us was powerful.  But I had reached a place of exasperation, confusion, and fear of doing the wrong thing.  I still was not sure exactly how to proceed.

When I discovered that I could purchase a phone consultation through your website, I decided to give it a try.  How thankful I am that I did!  It certainly shows that you have been working with kids like Kyle for 30 years.  You knew things about Kyle that even I didn't.  Your understanding, guidance and support were invaluable.  Perhaps most importantly, you gave me the insight and encouragement I needed to be patient.  Luckily for us Kyle has made tremendous progress quickly, but I got off the phone feeling that even if it took many months that would be OK.  We just needed to take baby steps in the right direction.  It is normal for these kids to progress in such a fashion. 

2) Chart Power.  As you mentioned to me, there is a good reason why the chapter on positive motivation is the longest in "The Ins and Outs of Poop".  Finding the right motivation for your child is crucial.  I had tried charts before, but not designed in the way you describe.  Several small steps, most of which I knew he could either do already or that would be easy for him, was key.  He was still resistant, but that is where the abundant stickers and immediate reward came in.  These were more powerful than I could have imagined.  Seeing the beautiful sticker waiting to go on the chart in the moment after his effort meant so much to Kyle.  He got over the hump of his reflexive resistance to all things potty!  Once that happened and he started to focus on the extra video game time he would earn when his chart was filled, he willingly did his push practice every day. 

3) Miralax.  When allowed his pull-up, Kyle would poop every day or two.  He didn't complain of painful BMs even when I asked him directly if discomfort was a problem.  When I asked my pediatrician about a stool softener, she saw no need due to his regularity.  You assured me that kids like Kyle need Miralax.  Were you ever right!  I started at a low dose and slowly increased as you suggested.  It took longer than I had anticipated, but we finally got Kyle's poop to the right place on the "stool chart".  What a difference this made for Kyle.  Even though he could not verbalize his discomfort before he started Miralax, he sure could talk about how much easier it was to push the poop out once we had the Miralax on-board.  I am convinced that he would not be pooping on the potty today without it.

4) Chart Power II.  After about 4 weeks Kyle was much more comfortable sitting and practicing pushing on the toilet.  His poop was much softer, and he reported easier pooping.  He had even gotten a little bit of poop into the potty on a couple of occasions :).  But he did not want to "push practice" when he really had the urge to poop.  In those instances he was still using a pull-up.  I tried to wait, encourage and reason, but to no avail. 

Then it dawned on me - we need another chart!  I designed a “Kyle's Good Pushing When He has to Poop"  chart.  It had to be formatted a bit differently than our "Push Practice" chart, but utilized the same principles.   I made lots of small steps, most of which he was doing already.  We used more beautiful stickers.  And because what I was asking him to do was so tough and important, I made the reward more enticing - cash for toys.  He still resisted at first, but one day, when I had that chart (already primed with a few stickers!) on the bathroom floor waiting for him, he gave in to my suggestion to "just try".  At first he wanted to finish in the pull-up which I said would be no problem.  More quickly than I expected, he didn't need the pull-up at all.  Kyle was pooping on the potty!!! 

Of course, Kyle is still at a tender place.  We still have a lot of Miralax, laxative/stool records, and sticker charts in our future.  But Kyle has achieved so much that eluded us for so long.  You changed our lives Dr. Tom, and we can't say "Thank You" enough!

 

 


No "summer breaks" from encopresis treatment!

It may be tempting to "take a break" from encopresis treatment when traveling, but it's important to remember that even a week off can undo months of hard work.  Traveling with encopresis does require additional planning.  I know it can be complicated but laxatives, sitting times, pushing and incentive programs (e.g. star charts) must be continued to ensure daily bowel movements. And don't forget to keep filling out your Weekly Laxative and Stool Record!

When visiting with friends or relatives, I advise that you explain beforehand, preferably in private, that your child has a potty problem (the term "chronic constipation" is generally easily understood -- most adults can imagine what this feels like) and that what you are doing is necessary in order to make his/her problem go away. You may be embarrassed to talk about your child’s problem with people whom you don’t see very often but just imagine how embarrassed you (and your child!) will feel if he or she has an accident in their home and you have not talked with them about it beforehand.

Take my books, "The Ins and Outs of Poop" and "Softy the Poop" with you just in case you encounter someone who has their own ideas about your child’s problem and how they think you should deal with it. You know the people I’m talking about! 

 


Is drinking more water a treatment for functional constipation (encopresis)?

When parents tell me that they think their child is constipated because he or she does not drink enough water, I remind them  that diets low in water do not cause functional constipation and that drinking more water is not a treatment for functional constipation. Functional constipation is caused by stool withholding and subsequent rectal distention. I tell them there is no good reason to tell their child to drink more water. Constipated children are no different than other children. They will drink more water when their body tells them to drink more water, that is, when they are thirsty.

In an article in the NY Times titled, "No, You Do Not Have to Drink 8 Glasses of Water a Day" pediatrician Aaron Carroll, an expert in this area, says that, "there is no formal recommendation for a daily amount of water that people need. The amount obviously differs by what people eat, where they live, how big they are and what they are doing."

In my book I point out that the "officially" recommended liquid consumption from all sources for children 1 to 8 years of age is 4 to 5 cups (32 t0 40 fluid ounces). I underlined "from all sources" as a reminder that there are many other sources of water that should be included when trying to determine how much water a child drinks in any given day such as milk, soda, soup, fruit and vegetable juices.  

 

 


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.

 


When to Stop Laxatives

The mother of a 5 year old boy with all the symptoms of functional constipation was correctly told by her child's pediatrician to start him on Miralax but incorrectly told to stop the Miralax after only 2 weeks.  As expected, while taking the Miralax his stool softened and he started to have BMs more frequently, but he quickly regressed when the Miralax was stopped. 

Based on the pediatrician's initial recommendation, this mother understandably thought that the laxative should only be given for two weeks then stopped. Not surprisingly when she contacted me she was stuck in a unsuccessful "start-stop-start" Miralax routine.

In an earlier post I explained how stopping laxatives too soon is one of the two most common mistakes made by parents and pediatricians. And as I discuss in my book, laxatives must be continued long enough for a child to stop withholding and for the child's rectum to shrink back to its normal size. This can take anywhere from 6-12 months or longer in some children. The longer a child has had functional constipation, the longer it will take for the rectum to shrink back. 

I know this seems like a long time, but there is, unfortunately, no quick fix for functional constipation or encopresis.


Is it safe to give my child Miralax?

Parents frequently ask me if it is safe to give their child a PEG laxative such as Miralax. Some of these parents have read on the internet or have been told by a friend that these laxatives cause "problems" in children. My answer is the same as that given by most pediatricians or pediatric gastroenterologists. Based on experience, these laxatives are safe.

The vast majority of children taking PEG 3350 experience no behavioral or psychiatric problems. However, for years the FDA has received occasional reports of tremors, tics and obsessive-compulsive behaviors in children taking PEG laxatives but it is not known whether the laxatives are the cause.

As reported early this year in the New York Times, the FDA has asked a group of doctors at the Children’s Hospital of Philadelphia to study the absorption of PEG 3350 in children, especially the very young and chronically constipated. The study is intended to find out whether PEG 3350 is absorbed in the intestines by young children and whether the use of PEG laxatives is linked to the development of behavioral or psychiatric problems. (www.http://nyti.ms/1xy89gQ)

If your child is chronically constipated and your child's healthcare provider has recommended a PEG laxative, you can be reassured that there is currently no scientifically validated evidence that PEG laxatives are unsafe for children.


"One phone conversation turned everything around for good. Thanks Dr Tom!

I was truly at the end of my rope when a Google search finally brought me to Dr. Tom (I had done several in the past, just not the right combo).  I cried myself to sleep some nights wondering how this would ever resolve.  My son was 5.  I had taken him to his Pediatrician, a GI specialist, gotten him custom self-hypnosis CD’s, tried aromatherapy, a chiropractor that did energy work, 2 child psychologists, an occupational therapist to help him “push”, and this was all after trying all of the known methods for potty training.  I was very concerned about Kindergarten and his delicate self-esteem.  One 45-minute PHONE session with Dr. Tom turned everything around for good!  Within 2 days, my son was mostly accident-free.  After a few weeks, we have worked out a regimen that has had him regular, mostly accident-free, & so much more happy & confident.  Dr. Tom has been extremely accessible to all of my questions/concerns which has made a HUGE difference.  The impact Dr. Tom has made in our lives is beyond words.  This has been such a big deal for so long and now we have moved on to other, more interesting things like learning math!  Thanks, Dr. Tom!


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).  


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.


Enemas and Suppositories for Encopresis

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.