Definition

• A child who refuses to be toilet trained and passes stools into his underwear. The medical term is encopresis.
• Some children have encopresis because they deliberately try to hold back stools.
• Stool-holding can lead to constipation, painful stools and even complete blockage (stool impaction).
• Most children who have a stool impaction constantly leak or ooze stool in small amounts.
• If the impaction becomes chronic, the colon becomes stretched out of shape. Then the bowel muscles don’t work. The rectum is no longer able to squeeze out stool.
• Unblocking the child may require enemas. Keeping the child unblocked also requires 3 to 6 months of laxatives or stool softeners.
• Stool holding is an important problem to recognize early and treat vigorously.

Health Information

Causes

• Some children refuse to be toilet trained for stools (called bowel training resistance).
• They get into a tug of war with their parents around using the toilet.
• Some of these children hold back stools so they won’t have to go.
• The stool holding becomes worse if they pass a painful stool (pain avoidance).
• Some decide to never pass a stool again and don’t understand that is impossible.
• Stool-holding is the hardest type of toilet training resistance to treat.

Care Advice

How to Treat the Constipation

1. Clarify the Goal with Your Child:
   • Your job is to "go poop every day." Tell them, "Your body makes a poop every day. The poop wants to come out every day."
   • Older children who don’t like stool leakage can be told, "If you poop every day and keep your body empty, than nothing will leak out."
2. Bowel Cleanout:
   • If your child is blocked up (impacted) with stool, contact your doctor.
   • Your doctor may order a bowel cleanout.
   • After the cleanout, all children with stool-holding need to be on maintenance medicines.
   • They need to be on these medicines until they give up stool-holding.
3. Give Stool Softeners for Hard Stools:
   • Stool softeners make the stools softer and easier to pass.
   • Unlike laxatives, they do not cause any bowel contractions or pressure.
   • Common nonprescription stool softeners are Miralax, mineral oil or milk of magnesia.
   • Increase the dose gradually until your child is passing 1 or 2 soft stools each day.
   • Sometimes, a high fiber diet alone will keep the stools soft.
4. Give Laxatives to keep the Rectum Empty:
   • Most stool holders also need a laxative to keep them empty.
   • Laxatives (bowel stimulants) cause the large intestine to contract. This pushes the stool toward the rectum. It’s usually given if you child goes 2 days without a normal size poop.
   • Most laxatives contain senna, a natural plant extract.
   • Don’t worry that your child might become dependent on laxatives. This means the bowels won’t move well without them. Laxative dependency doesn’t happen in children.
   • Children can be gradually withdrawn from laxatives, even after many months of using them.
   • The most important goal is keeping the rectum empty. This is the goal until your child gives up stool holding.

How to Treat the Stool Holding

1. Transfer All Responsibility to Your Child:
   • Your child will decide to use the toilet only after giving up the "power struggle game".
   • Have one last talk about the subject.
   • Tell your child that the body makes "poop" every day. It’s your child’s poop.
   • Explain that "poop" wants to come out. Your child’s job is to help the "poop" come out.
   • Tell your child from now on they don’t need any help.
2. Stop All Talk About This Subject:
   • When your child is around, stop talking about toilet training.
   • Pretend you’re no longer worried about this subject.
   • When your child stops receiving attention about not going, they’ll eventually decide to go.
3. Stop Most Reminders About Using the Toilet:
   • Let your child decide when they need to use the toilet.
   • They know what it feels like when they have to "poop".
   • Reminders are a form of pressure, and pressure keeps the power struggle going.
   • Stop all practice runs.
   • Never make your child sit on the toilet because this always greatly increases resistance.
   • Your child needs to gain the feeling of success that comes from doing it their way.
   • There are a few exceptions to reminders discussed in #4 and #5.
4. Remind to use the Toilet if Your Child has Abdominal Pain:
   • Holding back stool hurts the body. So, there are some exceptions to reminding.
   • If your child says their stomach hurts, explain how to make it go away.
   • Tell them: "The poop wants to come out. Holding back makes your tummy hurt."
   • If your child refuses, tell them, "I can’t help you. You have to help yourself."
   • Then ignore your child.
   • Tell them to come back after the poop is out. Do not give positive attention for holding-back behavior.
5. Remind if Deliberately Holding Back Stool:
   • If you see your child holding back a stool, initially say nothing. This approach is in hopes your child will do the right thing.
   • If your child holds back for more than 5 minutes, give a pleasant reminder.
   • First say, "Your body is talking to you. What does it want you to doƒ" If necessary, add "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 fun. What would they like to do?
   • If your child declines the offer to provide a special potty activity, say nothing more.
   • Let your child decide how they wish to respond to the pressure in their bottom.
6. For Stool Leakage, Ground your Child until Passes a Stool (4 and older):
   • If your child is over 4 and leaking stool, ground him until he passes a stool.
   • State "When poop leaks out, it always means there’s a big poop inside. It’s trying to get out. You need time to think about how to help your body get it out."
   • Tell your child he’s grounded until he passes a big poop.
   • He can only go to essential events. Examples are meals, preschool or school, church. Also, he can go to scheduled classes such as music lessons or team events. Otherwise, he’s grounded in his bedroom. This means no TV, games, friends over or playing outside. This goes on until he completes his assignment.
   • Using the term "poop jail" usually makes this funny and more acceptable for kids.
7. If Grounding is Necessary, Protect Your Role as the Child’s Ally:
   • You can tell your child that this is what the doctor said to do.
   • If your child complains, give him a hug.
   • If this approach doesn’t work, consider restricting your child to the bathroom.
   • Inform him he can’t come out until he produces a big poop.
8. Ground Your Child for No Stool in 3 Days:
   • If your child reaches day 3 without passing stool, ground your child.
   • Grounding should be in place until he passes a big poop.
   • "Big" means at least the size of a banana.
   • Remember that holding it back causes it to become larger and wider. After 5 to 7 days, it will become too wide to pass. The medical term for this is stool impaction.
   • For children younger than 4, put them in a pull-up at these times. Encourage them to let go of their poop.
9. Give Incentives for Releasing Stools:
   • Our main goal is to help your child give up stool-holding.
   • Your main job is to find the right incentive.
   • Special rewards, such as favorite sweets or video time, can be invaluable. For using the toilet for stools, initially use big rewards. For example, special games or going somewhere special can be used.
   • Remember that an incentive works even better if it is special. That means a treat that your child doesn’t otherwise get.
   • If you want a breakthrough, make your child an offer they can’t refuse.
   • For children under 4, give incentives for pooping into diapers (pull-ups) if they won’t use the toilet.
   • For details, see the handout: Incentives for Motivating Your Child.
10. Keep Sticker Chart for Using the Toilet:
    • Get a calendar for your child. Post it in a very obvious area. Call it the Good Pooper chart.
    • Have them place a star on it every time they poop in the toilet. You can also use stickers that your child picks out.
    • Keep this record of progress until your child has gone 1 month without any soiling.
11. Allow Diapers or Pull-ups for Poops if Needed:
    • We want your child to look forward to releasing stools, rather than holding back.
    • If your child refuses to sit on the toilet, having stools in diapers is better than stool holding. Therefore, permit access to diapers.
    • Another option is to keep pull-ups next to the potty chair or toilet.
    • Keep your child in loose-fitting underwear during the day.
    • Wearing underwear also gives your child an incentive to maintain bladder control (urine).
12. Help Your Child Change Clothes for Soiling:
    • Don’t ignore soiling.
    • Your main role is to enforce the rule "people can’t walk around with messy pants."
    • Your child will need your help with poop cleanup until at least age 6.
    • Make changing a neutral, quick interaction. Always dump the stool in the toilet. Have your child watch you do it.
    • If your child refuses to let you change them, ground your child. Put them in time-out until they are ready.
    • Caution: Never wait for over 30 minutes to change a poopy diaper. Reason: Stools can cause skin irritation.
13. Keep Your Child’s Follow-up Appointments:
    • All children with stool-holding need regular visits with their primary care doctor.
    • All children with stool-holding need to be on medicines for a long time. Their doctor needs to help you monitor the dosage of the medicines.
    • This is the only way to prevent getting blocked up.

Call Your Doctor If

• You think your child is blocked up
• Passing stools is painful
• You have other questions or concerns

Author: Barton Schmitt MD, FAAP

Copyright 2000-2020 Schmitt Pediatric Guidelines LLC

Disclaimer: This health information is for educational purposes only. You the reader assume full responsibility for how you choose to use it. The information contained in this handout should not be used as a substitute for the medical care and advice of your pediatrician. Listing of any resources does not imply an endorsement.

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