Constipation & Encopresis
Understanding stool holding, leakage, and how we treat it

What are constipation and encopresis?

- Constipation means stools are infrequent, hard, or painful to pass, or a child feels they can’t fully empty.
- Encopresis is leakage of stool into underwear after a child is old enough to use the toilet. It usually happens when a large amount of stool is backed up and softer stool leaks around it.

Who is affected?

Constipation is very common in childhood and can happen at any age, especially during times of change (toilet training, starting school). Encopresis is more common in school-age children and occurs more often in boys.

Why does it happen? (The holding cycle)

Most constipation in kids starts with stool withholding—often after a painful bowel movement or when a child is busy or anxious about using the toilet.
- Holding causes the rectum to stretch and lose sensation.
- Stools become larger, drier, and harder, which makes the next bowel movement hurt more.
- Encopresis often follows: the stretched rectum lets thinner stool leak without the child feeling it.
- Behavior plays a big role: encopresis is typically triggered by stool-holding behaviors, not by a child being “lazy” or doing it on purpose.

Normal bowel patterns vary

Bowel frequency ranges widely in healthy kids. Some children naturally go every other day. If stools are soft, painless, and easy to pass, that can be normal. Others tend to be more infrequent and need ongoing softening to stay comfortable.

Symptoms

- Infrequent stools, hard “pellet” stools, or large, painful stools
- Belly pain, decreased appetite that improves after a BM
- Skid marks or soiling (encopresis) in underwear
- Withholding behaviors: crossing legs, tiptoeing, hiding, “dance” to avoid going

Call your care team urgently for: fever, vomiting with swollen/tender belly, weight loss, blood mixed through the stool (not just on the surface), severe cracks/tears, or symptoms in a newborn.

Workup (ruling out other causes)

Constipation is usually diagnosed by history and exam. Testing is targeted:
- Blood work (when indicated): blood count, electrolytes, celiac testing, thyroid testing
- Endoscopy is not recommended for routine assessment of constipation
- Motility testing (anorectal manometry or other studies) is reserved for severe or atypical cases—especially if there is concern for Hirschsprung disease, which is rare

Treatment

We treat in two phases:

Cleanout (empty the backed-up stool)

Your provider will give a cleanout plan (often higher-dose polyethylene glycol [PEG/Miralax], sometimes with a stimulant laxative) to fully empty the rectum and colon.

Maintenance (keep stools soft and regular)

- Miralax (PEG) is the most common daily softener. It is safe and effective for pediatric constipation when used as directed.
- Kids do not get “addicted” to Miralax. It works by preventing the colon from reabsorbing water, which keeps stool soft and easier to pass.
- Dosing is individualized to produce soft, easy-to-pass stools every day (or every other day for some kids).
- Some children need short bursts of stimulant laxatives during setbacks—your provider will guide this.

Behavioral supports

- Scheduled toilet sits: 5–10 minutes after meals and at bedtime
- Proper posture: feet supported on a stool, knees above hips
- Positive reinforcement: praise/reward charts for sitting (not just for “going”)
- Encourage responding promptly to the urge to go; work with school for bathroom access

Everyday habits

- Fluids across the day
- Less processed foods; include fruits/veggies and whole-grain options as tolerated
- Regular physical activity and consistent sleep routines

Follow-up & outlook

Most children improve with a consistent plan. The rectum needs time to shrink back to normal size and sensation, so medicines are usually continued for months, then slowly tapered. Relapses can happen—restart the plan early.

Key points for families

- Constipation and encopresis are common and treatable; encopresis is usually due to stool-holding, not misbehavior.
- Normal bowel patterns vary; some kids need ongoing softening to stay comfortable.
- Testing is limited; celiac and thyroid screening may be checked. Endoscopy isn’t routine. Motility tests are for severe/atypical cases; Hirschsprung is rare.
- Best results come from cleanout → daily softening (Miralax) → behavioral routine.
- Miralax is safe, effective, and not addictive—it simply softens stool by keeping more water in the colon.

References

 NASPGHAN. GI Kids: Patient Education Resources. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. https://www.gikids.org

 American Academy of Pediatrics (AAP). Pediatric Gastroenterology Clinical Reports and Patient Education. https://www.aap.org

 Blaufuss, T. Common Sense Pediatric GI: Practical Guidance for Families. Dakota Pediatric Gastroenterology, Fargo, ND, 2025.

 Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274.

 NASPGHAN. Constipation and Soiling (Encopresis). GI Kids.

 AAP Clinical Report: Constipation in Children and Adolescents. Pediatrics. 2021;148(6):e2021053745.