Constipation and soiling (encopresis) in children

What is constipation?

Everyone has a different bowel pattern. A normal frequency of stools (poo) can vary from several times a day to once every few days. Constipation is an abnormal pattern of bowel movements that causes a person to pass less frequent stools that may be large and hard, or small. Constipation can make passing stools uncomfortable.

Constipation is a problem that can develop over days, weeks or months. It often occurs during a change in diet (e.g. starting solid foods as an infant, stopping breast or bottle feeding) or with a change in routine such as toilet learning (toilet training), starting daycare or school, having a new sibling, moving homes, going on holiday or after being sick.

With constipation, stool may build up in the bowels over time. This build-up can cause stomach cramps and pain, but the symptoms of constipation may go unrecognized for a long time. For children who have been constipated for a long time, retraining the bowel and returning it to normal can take many months or sometimes even years.

Remember: Constipation can still happen even if a child is having a bowel movement every day. The type and size of the stool is as important as the frequency. The Modified Bristol Stool Chart is often used as a visual method of describing stool type.

Modified Bristol Stool Chart for children

What is soiling?

Soiling, also called encopresis, occurs when your child is unable to control a bowel movement. The child soils their pants or has an "accident" before reaching the toilet. An occasional accident is common as children master regular use of a toilet. However, regular soiling into underwear in an older child who no longer uses a diaper is most commonly due to chronic constipation

What are the signs of constipation?

You might recognize the signs of constipation if you see your child regularly:

• squatting
• rocking
• walking stiffly on their tiptoes
• crossing their legs
• sitting with their heels pressed against their perineum (the area just in front of their anal opening)

Constipation is a common cause of lower urinary tract symptoms including incontinence, urinary tract infections and bedwetting. Sometimes, constipation is only diagnosed when a child has urinary symptoms.

Constipation is usually diagnosed based on your child’s symptoms and physical examination. There are no specific tests (including bloodwork and X-rays) that are necessary to make the diagnosis. In certain instances, tests are performed to exclude rare causes of constipation.

What causes constipation?

In most children, constipation is caused by issues with bowel routines or diet. Some common causes of constipation are:

• not drinking enough fluids
• not having enough fibre from whole grains or cereals, vegetables and fruits
• eating too much junk food or other foods that promote constipation
• withholding stools to avoid painful bowel movements, sometimes from small tears (fissures) at the bowel opening (anus)
• genetics - some children inherit a tendency toward constipation from their parents
• poor bowel routines, problems with learning to use the toilet and sometimes refusing to spend time on the toilet.

Some children may have a fear of public bathrooms including bathrooms at school. Other children simply prefer to keep playing rather than go to the bathroom when they feel the urge to have a bowel movement. Instead, they 'hold back', causing a build-up of stool.

Other less common causes of constipation are:

• some medications such as morphine
• underactive thyroid gland (hypothyroidism)
• Hirschsprung's disease, a disease of the bowel that is usually diagnosed in the first few weeks of life
• having had surgery of the bowel
• having had a viral infection

What causes soiling?

Constipation is the most common cause of soiling. Constipation leads to soiling by changing the way your child’s body sends messages to their brain. The rectum has two sets of muscles - the internal and external anal sphincters - that allow stool (poo) to pass out of the body. Normally, when stool enters the rectum, the muscles in the internal anal sphincter stretch, telling your brain that you need to pass stool. You are not able to control the muscles of the internal anal sphincter. A person has an urge to pass stool when it reaches the external anal sphincter. You can control the muscles of the external anal sphincter, so if your child relaxes the external sphincter stool can leave their body.

Children withhold their stool by tightening their external sphincter and their buttock muscles (gluteal muscles) pushing stool back into their body, which makes them lose the urge to pass stool. This leads to stool building up in the rectum and stretching the internal anal sphincter, so it is always telling the brain that you need to pass stool. As the internal anal sphincter is always stretched, your brain ignores this message. This is similar to your brain ignoring the feeling of eyeglasses, watches or jewelry that are always touching your face or body. However, as your child is still eating and drinking normally, small amounts of liquid stool pass around constipated stool and leak out without your child sensing the urge to have a bowel movement.

Children with soiling are often unaware they need to have a bowel movement or they have soiled. Most children cannot feel or smell the stool in their underwear as the brain also ignores this message. Most children, especially toddlers, will start to hold their stool because they are avoiding the toilet, or because of painful bowel movements due to constipation. When stool sits in the bowel, the water gets taken out of it, making the stool harder, bigger and more difficult to pass. This can start and then keep a cycle of holding, constipation and soiling ongoing.

How is constipation treated?

In some children, constipation can be relieved by making diet and lifestyle changes. Others need medication for weeks or months. Once constipation starts, it can last a long time. Treatment is long-term and requires patience, co-operation, consistency and commitment from family members and from the school.

Diet in children less than one year old

Babies under two months old generally do not have constipation. Talk to your child's health-care provider before you make any changes to your baby's milk or formula or give any medication to treat constipation.

If your baby is under four months old, you may consider giving 1 ounce (30 mL) of apple, pear or prune juice once or twice a day until they pass stool.

Once your baby is more than four months old, try giving high-fibre, pureed foods. These include apricots, beans, cereals, peaches, pears, peas, plums or prunes.

Diet in children over one year old

Give your child plenty of fluids, especially water.

Make sure your child eats vegetables and fruits every day. Children should have four to six servings of vegetables and fruits a day. Some good examples are apples, apricots, beans, blueberries, broccoli, cabbage, cauliflower, dates, figs, lettuce, peas, pears, prunes and raisins. Avoid any foods that could cause choking in younger children.

Take steps to increase the amount of fibre in your child's diet but it is not necessary to add fibre supplements. There are many sources of fibre to choose from.

Some foods are known to cause constipation. You may wish to limit them in your child's diet. Examples include low-fibre foods such as white rice or bread, white pasta, pizza and junk food such as chips and pop. Filling up on too much dairy may also contribute to constipation. Diet changes are most successful when the entire family follows these healthy choices.

There is no evidence that pre or probiotics are effective in treating constipation.

Toilet routine

Two or three times a day, 20 to 30 minutes after each meal, have your child spend at least five minutes on the toilet or the potty. Even if there is no bowel movement, you are helping to set a pattern. You might find it helpful to use a calendar to reinforce the schedule. Younger children may like stickers they can put on a chart for sitting on the toilet after a meal.

Your child should be comfortable, with the knees up. A footrest can prevent your child's legs from hanging down. It will also keep the knees bent, which helps bowel movements pass more easily.

If you are having problems with toilet learning and your child is holding back stool, you may need to delay it until the constipation is successfully treated.

Regular physical activity

Exercise or physical activity can help keep the bowels moving. Children ages one to four need 180 minutes (3 hours) of regular physical activity each day. Children age five or older need 60 minutes (1 hour) of physical activity.

Medications

Some children with constipation will not respond to diet and toilet routine changes alone and will need medication.

The most effective medications for constipation are stool softeners. These work by keeping water in the bowel to make stool softer so it is easier to pass. The most commonly used medication is polyethylene glycol (PEG 3350). Polyethylene glycol is safe for children and can be used long-term. It is available over the counter, and it is tasteless, odorless and colourless when fully dissolved in a drink. It is most easily dissolved in water but can be dissolved in any drink.

Disimpaction phase

For children who are severely constipated, higher doses of medications are often needed at first to clean out backed-up stool and provide relief from the pain linked to constipation. This is called the disimpaction phase. Another medication that is often used for disimpaction is called Pico-Salax.

Maintenance phase

Once the bowels are cleaned out, the dose of PEG 3350 is adjusted so your child has at least one soft easy to pass stool every day. This is called the maintenance phase.

Avoid using suppositories or enemas when possible. Only use suppositories or enemas if your child's health-care provider has suggested them.

Do not be afraid to give your child long-term medication under your doctor's supervision to help treat their constipation. The bowels do not become dependent on PEG 3350 and will not become lazy. Routine emptying of the bowel is important for overall bowel health.

The goal of this treatment is for your child to have a smooth, easy-to-pass, bowel movement (Bristol stool type 3 or 4) at least once a day without soiling or other symptoms of constipation. Having a bowel movement at least once a day trains your bowels to know what to do, it strengthens the weak muscles that were stretched out and they shrink back to normal.

When can my child stop taking their medications?

Do not consider stopping medications until your child has been doing well for at least six to 12 months. Do not change your child's medication dose before speaking with your child’s health-care provider. Your child's health-care provider will reduce their medication dose slowly, usually by a quarter dose every three to six months. Slow tapering is necessary to ensure that good toileting and dietary habits can be established, and the bowels can shrink back down to normal size.

How can I help my child stop soiling?

• Follow the instructions for disimpaction. Once the bowel is cleaned out, your child will need to establish a new bowel routine while waiting for the rectum and large bowel to return to its normal size. Encourage "toilet time" three times a day for at least five minutes but not for much longer.
• Toilet time is often most successful within 20 to 30 minutes after a meal so schedule these following breakfast, lunch and dinner.
• Depending on your child's age, make toilet time as comfortable as possible by having good foot support (e.g., foot stool) available while your child sits.
• Do not give your child distractions during toilet time such as toys or tablets.
• During toilet sitting time children should be encouraged to focus on actively “bearing down”. Younger children who may not understand the instruction to push while on the toilet can blow up balloons, blow bubbles or blow on a pinwheel to help them bear down.
• Keep a record of how often your child passes stool.
• Do not punish your child if they do not pass stool during toilet time. Instead, set up a reward system for your child when they practice desired behaviours like sitting on the toilet for the entire toilet time, taking medications, drinking fluids and helping to clean their buttocks or diapers. The aim is to reinforce good behaviour and ignore soiling, as it is not their fault.
• Maintain a consistent, positive and supportive attitude right through your child's treatment.

Points to note

Medications

• Medications for constipation are safe as long as your child’s health-care provider monitors your child. They will not make your child's bowel "lazy".
• Follow your health-care provider’s advice and remember that labels on the products are for general use, not for each person's individual needs.
• Most children need the adult dose or even a higher dose of the medication for them to be able to pass stool properly.

Constipation

• You have the best chance of treating constipation by having your child empty their bowel at least once a day without rushing.
• It is common for children to experience constipation again, even after successful treatment. Some children might have difficulty with passing stool into their teen years or as adults.

Soiling

• Soiling is accidental. It is not a sign that your child is deliberately being bad.
• Soiling may get worse when treatment starts and can last for 12 to 24 months.  

When to seek medical assistance

See your child's health-care provider if your child:

• is also having trouble peeing, walking or with balance (this is an emergency)
• is passing stool in places other than the toilet or potty, or hiding soiled underwear
• has blood in the stool
• is urinating (peeing) often or finds urinating painful
• has stools that are very hard and they are straining
• is still soiling routinely after the age of four years

Watch “The Poo in You” from Children’s Hospital Colorado
https://youtu.be/SgBj7Mc_4sc

Add a bowel tracking sheet such as this one from GIKids.org
https://gikids.org/wp-content/uploads/2020/02/Bowel_Management_ToolFINAL.pdf

Find more information about constipation from McMaster Children’s Hospital
https://www.hamiltonhealthsciences.ca/wp-content/uploads/2021/06/MCH-GoPoop-Program.pdf

Find more information about constipation from CHEO (Children’s Hospital of Eastern Ontario)
https://www.cheo.on.ca/en/resources-and-support/resources/P5593E.pdf

NASPGHN (2014). Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations from ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.

Margolis, I. (2010). Treatment of Chronic Constipation and Encopresis.

Rowan-Legg, A. (2011). Managing functional constipation in children. Paediatric Child Health, 16(10):661-665.

Lane, M., Czyzewski, D., Chumpitazi, B., Shulman, R. (2011). Reliability and validity of a modified Bristol Stool Form Scale for children. Journal of Pediatrics, 159:437-441.