Clinical Reference Systems: Pediatric Advisor 10.0
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Definition

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 child's physician.

Treatment of Soiling with Constipation for Children Who Will Sit on the Toilet

1. 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 some dehydration.

   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.

2. 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 oil.

   Give your child a stool softener as directed by your doctor.

3. 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 doctor.

4. 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 eat.

5. 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 downward.
   • 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 if:
     • Any soiling occurs (soiling always means the rectum is very full).
     • Your child feels blocked up.
     • Your child has a stomachache or cramps.

6. 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.

7. 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.

8. 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 emotional problems.

9. 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.

10. 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.

11. 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.