Clinical Reference Systems: Pediatric Advisor 10.0
Soiling from Constipation: Preschooler
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 the 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 in Children Who Won't
Voluntarily Sit on the Toilet
(For treatment of children who will sit on the toilet, see
Soiling with Constipation: School-Age Child. )
- 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 30-pound child should receive 1 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 on the mineral oil.
Use the stool softener and dosage recommended 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.
Use the laxative and dosage recommended by your child's
- 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
two 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 which foods to
- Transfer all responsibility to your child about using
Your child will decide to use the toilet only after he
realizes that he has nothing left to resist. Have one
last talk with him about the subject. Tell your child
that his body makes "poop" every day and it belongs to
him. Explain that his "poop" wants to go in the toilet
and his job is to help the "poop" come out. To help him
function independently, put him in loose-fitting
underwear or training pants (not diapers or pull-ups).
Tell your child you're sorry you punished him for not
using the toilet, forced him to sit on the toilet, or
reminded him so much. Tell him from now on he doesn't
need any help from you or other people. Then stop all
talk about the subject. When your child stops receiving
attention for not using the toilet, he will eventually
decide to use it to gain some attention.
- Stop all reminders about using the toilet.
Let your child decide when he needs to go to the
bathroom. He should not be reminded to go to the
bathroom nor asked if he needs to go. Your child knows
what it feels like when he has to "poop" and where the
bathroom is. Reminders are a form of pressure, and
pressure doesn't work. He should not be made to sit on
the toilet against his will because this will give him a
negative attitude about the whole process. Don't
accompany your child into the bathroom or stand with him
by the potty chair. Your child needs to get the feeling
of success that comes from doing it on his own and then
finding you to tell you what he did.
- Give incentives for BMs in the toilet.
If your child has a BM in the toilet, give him immediate
positive feedback, such as praise and a hug. This
positive response should occur every time your child
uses the toilet. Special incentives, such as favorite
sweets or video time, can be invaluable for helping a
child change a bad habit. For using the toilet, err on
the side of rewarding generously; for example, you might
give your child 20 M&Ms. If you want a
breakthrough--that is, use of the toilet for the first
time--make your child an offer he can't refuse. One of
your main jobs is to find the right incentive. The
potency of incentives is increased by reducing baseline
access to them. Perhaps you'll let him watch a new
video he has been talking about. A grab bag containing
a variety of treats is also a powerful motivator. On
successful days, also consider taking 20 extra minutes
to play a special game with your child or take him for a
walk to the playground.
- Give stars for using the toilet.
Get a calendar for your child and hang it where he sees
it all the time. Place a star on it every time he uses
the toilet. Keep this record of progress until your
child has gone 1 month without any accidents. Bring the
calendar to your visits with your child's physician.
- Make the potty chair convenient.
Be sure to keep the potty chair in the room he usually
plays in. This gives your child a convenient visual
reminder about his options whenever he feels the need to
urinate or defecate. Only give a pleasant verbal
reminder if he is clearly having an urge to go and is
holding back. You can say, "The poop wants to come out
and go in the toilet. The poop needs your help." Tell
your child that you want sitting on the potty to be lots
of fun. What would he like to do? Ask him to play the
"see if you can poop before the timer goes off" game and
set the timer for 5 minutes. Then let your child decide
how he wishes to respond to the pressure in his rectum.
Some children temporarily may need treats for simply
sitting on the toilet and trying.
- Use diapers and pull-ups as little as possible.
You want your child to look forward to releasing BMs,
rather than holding back. If your child refuses to sit
on the toilet, having bowel movements in diapers is
better than stool holding. Therefore, permit him access
to diapers. However, don't let your child wear diapers
all day. Keep your child in loose-fitting underwear or
training pants, so that he has to decide each time he
has an urge to pass a BM whether to use the toilet or to
come to you for a diaper. To help him make the right
choice, offer major incentives (for example, a trip to a
favorite restaurant or ice cream store) for BMs in the
toilet. Offer minor incentives (for example, candy) for
BMs in the diaper. (Note: Being in underwear will give
him an incentive to maintain bladder control and stay
- If your child is complaining about abdominal pain,
clarify how to make it go away.
Tell her: "The poop wants to come out," "The poop needs
your help," "It won't hurt," "Holding back is a bad
idea." Offer to help her sit in a basin of warm water
to relax the anal sphincter. If she refuses, tell her
"I can't help you. You have to help yourself." Then
ignore your child or put her in time-out. Tell her to
come back after the poop is out. Do not give positive
attention for holding-back behavior.
- Help your child change his clothes if he soils himself.
Don't ignore soiling. As soon as you notice that your
child has messy pants, clean him up immediately. The
main role you have in this new program is to enforce the
rule, "We can't walk around with messy pants." Make
changing pants a neutral, quick interaction. If your
child is soiled, he will probably need your help with
cleanup, but keep him involved. If your child refuses
to let you change him, ground him until he is ready.
- Respond gently to accidents.
The responses to soiling listed below will only delay
successful training and may cause emotional problems:
- Threatening or lecturing your child
- Forcing your child to sit on the potty chair
- Punishing or scolding your child for accidents
- Keeping your child in soiled pants
- Giving frequent reminders
- Allowing siblings to tease your child
- Ask the preschool or day care staff to use the same
strategy you are using.
Ask your child's teacher or day care provider to let
your child go to the bathroom any time your child wants
to. Keep an extra set of clean underwear at the school
or with the day care provider. Ask them to read this
handout about soiling. Be sure your baby sitter knows
how to handle the situation positively and will not
punish your child for soiling his pants.
Call Your Child's Physician During Office Hours If:
- You think your child is blocked up again.
- Your child's bowel movements continue to hurt.
- Your child won't take the medicines.
- You have other questions or concerns.