By Patrick J. McGrath, OC, PhD, FRSC
Question:
My four-year-old soils his pants about four times a week. Is this common? I am afraid he will be teased when he starts school next year. What can I do?
Dr. Pat responds:
The medical term for soiling or having a bowel movement where you are not supposed to is encopresis. About 4% of children aged five to six years of age soil their underwear. By the age of 11 to 12 years, about 1.5% of children soil. Boys are more likely to soil than girls.
There are some medical causes of soiling but these are unusual. Children with developmental delays, neurosensory problems, inflammatory disease, or metabolic disease are at more risk for soiling.
Otherwise there are two major types of soiling.
In the most common type of soiling, children are constipated. When they have a bowel movement in the toilet, it is often very large. There may be discomfort or pain. Children often try to hold it back and avoid having bowel movements. A blockage develops in the rectum and may come back unless something is done. The soiling usually occurs when poop seeps around the blockage.
The second type of soiling occurs when children are not constipated. These children soil in their underpants or in other places.
The problem may be because the child:
Once the reason for the soiling is found, treatment can begin. For example, a child might be embarrassed or worried about germs when going to public toilets. Some children might be afraid of the noise of the toilet flushing.
Sometimes young children may have soiled underpants because they just have not learned to wipe themselves properly.
In all cases of soiling, children may be teased or rejected by other kids. Usually, they are embarrassed. Often they try and hide their soiling.
The first step is to talk to the child's family doctor about the problem. It is surprising but many parents of children who soil do not bring this up with their family doctor. In one large study, only a third of parents of children who were soiling had ever spoken to the family doctor about this.
Your child's doctor will do a history of the problem and a physical examination. In some cases, the child will be referred to a specialist.
The first step is to teach your child how pooping works:
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We chew up our food in our mouth.
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Our stomach dissolves all our food.
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The small intestine takes out all of the good stuff.
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The large intestine takes out the water.
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The rectum holds the poop till it is time to empty it.
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We empty the rectum by pushing it out through the anus into the toilet.
Constipation happens when the rectum gets overfilled. Soiling can occur when the overfilled rectum leaks, or when the rectum is emptied in the wrong place (like the underpants instead of the toilet).
Children who have constipation and soiling are first treated for their constipation. The current bout of constipation has to be resolved. Sometimes medical treatment is needed to clean out the child. But prevention of constipation is very important. Diet, including increasing fibre and liquids, is important. Diet and activity are important to keep constipation away.
Children who have been avoiding going to the toilet will need toilet training to help them overcome this avoidance.
Children with the second type of soiling have to learn the proper place to poo. This toilet training requires a combination of scheduling and encouragement.
It is never a good idea to criticize, embarrass, or harass a child for soiling. Severe punishment will not work.
The biggest problem with soiling is being too embarrassed to get help. Soiling is very treatable. Almost all children can overcome soiling.
Patrick J. McGrath OC, PhD, FRSC is a clinical psychologist and a researcher. He is Professor of Psychology, Pediatrics, and Psychiatry at Dalhousie University and Vice President - Research at IWK Health Centre in Halifax. He is also the CEO of the Strongest Families Institute, which provides mental health care to families across Canada.
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Dr. Pat will respond to as many letters as possible with evidence-based answers. We hope that the column will be interesting and helpful for readers; however, Dr. Pat cannot provide health care through the column. Please contact a physician or other registered health care professional to provide health care guidance or advice.