Clinical Reference Systems: Pediatric Advisor 10.0
Soiling from Constipation: School-Age Child
A child who passes bowel movements (BMs) into his underwear
has a problem called soiling or encopresis. Many children
who are soiling small amounts several times a day are
severely constipated or blocked up (impacted). The soiling
occurs because pieces of a large mass of hard stool in the
rectum break loose at unexpected times. This is especially
likely to happen when your child is running or jumping.
The soiling is not deliberate. The impaction is usually too
wide to pass spontaneously, and the child can't control the
leakage until the blockage is removed.
There are many reasons why children become constipated--high
milk diet, genetic differences, avoiding bowel movements
because they cause pain, or holding back BMs (stool holding)
as a way of resisting toilet training. The possibility of
physical causes requires a complete examination by your
Treatment of Soiling with Constipation for Children Who Will
Sit on the Toilet
- First use enemas to remove the impaction. Start with a
Fleet's hyperphosphate enema. The dose is 1 ounce for
every 20 pounds of your child's weight. For example, a
50-pound child should receive 2 and 1/2 ounces of
hyperphosphate enema. Don't give any child more than 4
ounces of the enema. Have your child try to hold the
enema back for 5 minutes. Then insist that he sit on
the toilet for release of the enema.
Give a second hyperphosphate enema 1 or 2 hours after
the first one. A third hyperphosphate enema can be
given 12 to 24 hours later if you think your child is
still impacted. Signs that your child is still impacted
include continued soiling or a lump that can be felt in
the lower abdomen.
Before giving the enemas, give your child one to two
glasses of water to drink because the enemas may cause
If you want to make your own enemas, use normal saline.
You can make normal saline by adding 2 teaspoons of
table salt to a quart of warm water. Give 2 ounces of
normal saline per year of your child's age. Don't give
any child more than 16 ounces of saline enema.
If you don't know how to give an enema, ask someone in
your physician's office. Once an impaction is cleared,
enemas are no longer necessary. Your child's
constipation can be treated entirely with oral
medicines. Continuous use of enemas irritates the
rectum and can cause your child to hold back BMs.
- Use stool softeners to keep the bowel movements soft.
Stool softeners make the stool softer and easier to
pass. Unlike laxatives, they do not cause any bowel
contractions or pressure. Some commonly prescribed
stool softeners are mineral oil, Kondremul, Metamucil,
Mitrolan, Citrucel, Maltsupex, Petrogalar, and fiber
wafers. Your child must take stool softeners for at
least 3 months to prevent another impaction. By then,
your child's intestines will be able to contract and
empty normally again.
If you use mineral oil, keep it in the refrigerator
because it tastes best cold. Have your child take it
with fruit juice to disguise the flavor, or follow it
with something tasty. Give your child a vitamin pill
each day at about noon while he is taking the mineral
Give your child a stool softener as directed by your
- Use laxatives to keep the rectum empty if stool
softeners aren't effective. Laxatives (or bowel
stimulants) cause the large intestine to contract,
squeezing the stool toward the rectum. Commonly used
laxatives are Senokot, Fletcher's Castoria, milk of
magnesia (MOM), Haley's M-O, and Dulcolax. Don't worry
that your child will become dependent on the laxatives
(that is, that the bowels won't move well without them).
The most important goal is keeping the rectum empty.
Children can always be gradually withdrawn from
laxatives, even after 6 months of using them.
Give your child a laxative as recommended by the
- Encourage your child to eat a nonconstipating diet.
Have your child eat plenty of fruits and vegetables
every day (raw ones are best). Some examples are figs,
dates, raisins, peaches, pears, apricots, celery,
cabbage and corn.
Bran is an excellent natural laxative because it has a
high fiber content. Have your child eat bran daily by
including such foods as the new "natural" cereals, bran
flakes, bran muffins, or whole-wheat bread in his diet.
Popcorn, nuts, shredded wheat, oatmeal, brown rice, lima
beans, navy beans, chili beans, and peas are also good
sources of fiber.
Only milk products (milk, cheese, yogurt, ice cream) and
cooked carrots have been proven to be constipating. Your
child should limit his intake of milk products to 2
glasses or the equivalent per day. Encourage lots of
fruit juices because they increase BMs. (Exception:
orange juice doesn't help.) However, don't pressure
your child about diet; instead, offer choices and
include your child in the decisions about what foods to
- Encourage your child to sit on the toilet for 10 minutes
after meals. Your child should sit on the toilet until
a bowel movement is passed, or at least 10 minutes.
Unless your child does this, the medicines will not
work. Normally, children and adults know when their
rectum is full because it is uncomfortable and causes
some bowel contractions (the "defecation urge").
Children who have been impacted for a long time lose
this sensation and need 2 to 4 weeks to get it back.
During this time, your child must sit on the toilet even
when he doesn't feel the need to go. The best time
seems to be 20 or 30 minutes after a meal.
Your physician will try to get your child to promise to
do this on his own, but he may need some help from you.
Try a reminder sign. By all means, don't remind him
more than two times a day or in a stern way because this
will foster a negative attitude about the whole process.
Never insist that he sit on the toilet if he is busy
doing something else. Tell him you want sitting on the
toilet to be fun and ask what would he like to do. Try
to pick good times for gentle reminders and mention that
"your doctor asked me to help you remember."
Other toileting tips for your child that are essential
for success are:
- Push while sitting on the toilet. The bowel movement
won't just fall out.
- Bend forward so the chest touches the upper legs.
This position opens up the rectum. Bending forward
and then relaxing a little may also help move stool
- If your child's feet can't easily reach the floor,
use a footstool to provide pushing leverage.
- Encourage your child to sit on the toilet more often:
even 10 minutes out of every hour (on weekends or
after school) until he has a large bowel movement and
- Any soiling occurs (soiling always means the
rectum is very full).
- Your child feels blocked up.
- Your child has a stomachache or cramps.
- Clarify for your child how he can stay clean.
- Go poop every day.
- Take your medicine every day.
- If your poops aren't coming out like they should, sit
on the toilet after every meal.
- Praise your child for staying clean. Some children need
more praise and encouragement than others, and this kind
of support is always helpful. Rewards are usually
unnecessary unless your child is uncooperative or less
than 5 years old. Your child will probably be overjoyed
to be relieved of his constipation and soiling.
- Help your child respond to soiling (leakage). If your
child is on the correct medicines and sitting on the
toilet, there shouldn't be any accidents. However,
finding the correct treatment program may take several
weeks. Also, some children will have recurrences of
soiling (usually after 4 or 5 days without a BM). In
such cases, handle soiling in the following way:
- Recognize soiling. Don't ignore soiling. As soon
as you notice soiling by odor or behavior, remind
your child to immediately clean himself up.
Encourage your child to come to you before anyone
else notices the accident. However, don't expect
your child to confess to being soiled.
- Clean the skin. Before your child sits on the
toilet, suggest a 5-minute soak in the bathtub. At
the least, your child's bottom needs cleaning off
with a wet washcloth. Your child should be able to
do most of this on his own. This may relax the anal
sphincter and give your child the urge to go.
- Have your child sit on the toilet. After soaking in
warm water, have your child sit on the toilet until
a large bowel movement is passed, or at least 10
minutes out of every hour until it does. If stool
is leaking out, the rectum is clearly full and
should be emptied.
- Clean soiled clothes. First, scrape the underwear
partially clean with a butter knife or spatula.
Then rinse it out in the toilet. Finally, store the
soiled underwear until the next washday in a
conveniently located bucket of water with some
bleach in it and a lid. You can encourage your
child to help with this, but you will need to do
most of it until he is 7 or 8 years old.
- Avoid punishment. Do not blame, criticize, or
punish your child. In addition, do not allow
siblings to tease him. Never put your child back
into diapers. If anyone in your family wants to
"crack down" on the child, have that person talk to
your physician because this kind of pressure will
only delay a cure and it could cause secondary
- Ask the school staff for their help. These children
need ready access to the bathroom at school, especially
if they are shy. Encourage your child not to be
embarrassed about leaving the classroom to go to the
bathroom. Your physician will send the school a note
requesting unlimited privileges to go to the school
bathroom any time your child wants to and without having
to raise his hand. Your child should also be allowed to
come in from outside recess. If the problem is
significant, you might also temporarily supply the
school with an extra set of clean underwear.
- Help your child keep a record of progress. Your
physician will give your child a calendar to keep.
Bring this to all visits. This record of soiling
accidents should be kept until your child has stopped
all medicines and gone 1 month without any accidents.
- Keep follow-up appointments. Knowing that he will
return to his physician to report his progress will
often increase your child's motivation. After age 8,
most of the treatment program should be between your
child and his physician. The more involved and
responsible your child feels, the better the results
will be. The first follow-up visit is especially
important so that the physician can be sure that the
impaction is completely cleaned out.
Call Your Child's Physician During Office Hours If:
- Your child soils two or more times and sitting on the
toilet doesn't help.
- You feel your child is blocked up again.
- Bowel movements continue to hurt.
- Your child won't take the medicines.
- Your child won't sit on the toilet.
- You have other questions or concerns.