Continence

Learning to control the bladder and bowels is a typical part of childhood. Some children and young people may require extra support to reach full independence. Others may need ongoing help to manage their bladder and bowel needs effectively.

Signs and Symptoms of Constipation

Bristol Stool Chart

Diet and exercise wave section

Fluids

Toilet Anxiety

Medicines for Constipation

Disimpaction

Toilet Positioning

Support from schools

Emotional Soiling

Smearing

Signs and Symptoms of Constipation

Children with constipation may show one or more of the following signs:

Fewer than four bowel movements per week. Ideally, children should pass soft stools daily or at least every other day.
Passing stools more than three times a day. This may suggest a full bowel with stool leaking out slowly. This could be hard lumps, soft stools, or liquid stool known as “overflow.” See the Bristol Stool Chart for more information.
Stools that appear as small pellets or resemble rabbit droppings. See the Bristol Stool Chart for more information.
Very large bowel movements or passing a large amount of stool at once.
Straining or experiencing pain when passing stool.
Bleeding when passing stool.
A swollen or painful tummy
Lower appetite, feeling sick, or vomiting.
Foul-smelling stool, excessive wind, or bad breath.
Bladder issues such as frequent small urinations, urgency, bedwetting, or urinary tract infections.
Difficulty with potty training.
Children who refuse to have a bowel movement unless wearing a nappy.
Changes in behaviour related to discomfort or toileting

Bristol Stool Chart

For parents or carers it’s not always easy to know what is normal when it comes to your child’s poo. The Bristol Stool Chart helps by showing what different types of poo look like. It can be really helpful in identifying constipation.

When your child uses the toilet or potty, be sure to look at both the shape and texture of their poo and compare it to the chart.

The ideal type of poo is a Type 3 or a Type 4 – these are soft, formed, and easy to pass.

We advise that your child is seen by their GP if:

They regularly have Type 1 or 2 (hard, pellet-like stools). This may be constipation.
And / or they regularly have Type 6 or 7 (loose or watery stools). This may be overflow caused by constipation.
And / or they experience any signs or symptoms of constipation.

To prepare for a GP appointment we recommend making a poo diary. This will show the GP any patterns in bowel habits: Download the poo diary here.

Diet and Exercise

Healthy Diet

Protein – essential for muscles, bones and digestive health
Fruit and vegetables – packed with essential nutrients and fibre
Carbohydrates – the body’s main source of energy
Dairy – a natural source of calcium and vitamin D
Healthy Fats – important for heart, brain, skin, cell and hair health

Tips for increasing Fibre

Add

Fruit, nuts or seeds to cereal
Vegetables or pulses (such as lentils) to curry, Bolognese or chilli
Peanut butter to apple slices or celery sticks
Linseed to yoghurt

Swap

White bread for whoegrain
Standard pasta for wholemeal
Crackers for carrot or celery sticks with hummus

Try

Keeping a supply of frozen vegetables so you always have them to hand
Leaving skin on vegetables and fruit
Five portions of fruit and vegetables each day
Adding more fluids as your fibre increases

More ideas here: How to get more fibre into your diet – NHS

Daily recommended fibre amount for children –

2 to 5 year-olds: need about 15g of fibre a day
5 to 11 year-olds: need about 20g
11 to 16 year-olds: need about 25g

Further links for diet/exercise:

Physical activity guidelines: children and young people (5 to 18 years) – GOV.UK

The Eatwell Guide – NHS

Physical activity guidelines for children and young people – NHS

Fluids

Drinking the daily recommended amount for children is essential for preventing and treating constipation. This large bowel absorbs this fluid which softens the stool. This makes it easier to pass.

Your child needs to drink enough to for this to happen. They can become constipated if they do not.

The following table shows how much children should be drinking. It also shows how much water they should have each day in total. There is a link to a drinking chart which may be useful. There is a link to a ‘Pooper Highway’ video which helps to explain constipation. There are also some useful website links.

This table shows standard drinking habits. It does not show requirements. Active children will need more to drink. If the weather is hot, children will need more to drink. (National Institute for Health and Care Excellence, 2017).

Download the Drinking Reward Chart here.

Further information:

Watch a video by ERIC called Pooper Highway – how to steer your child through a constipation traffic jam.

Click here for nutrition and hydration tips for children produced by Bladder & Bowel UK

Toilet Anxiety

Bad experiences in the toilet can lead to Toilet Anxiety. This could be a noise or an unpleasant smell. Children may remember this bad experience when they go to the toilet. They may start avoiding using the toilet as a result.

Things to be aware of

Constipation
Soreness and skin inflammation
Fear of falling into the toilet
New toilets
Family changes and stresses
Potty training
Not being able to use the toilet at school
Health issues
Trauma
Not coping with new situations
Being bullied
Developmental conditions e.g. Autism
Concentration difficulties e.g. Attention Deficit Hyperactivity Disorder (ADHD), Autism

Environmental factors

Things in the bathroom sometimes upset children or young people. This may be the bright lights, or smell. It may be the sound of the toilet flushing. It could be the feeling of the toilet seat or toilet paper.

It is important to make the toilet a less scary place for the child. You can make do this by providing distractions and reducing unpleasant sensations.

Try to avoid

Unrealistic targets
Asking too many questions
Getting angry / punishing

Resources for toilet anxiety

Toilet anxiety and toilet phobia in children – ERIC
Potty training children with additional needs – ERIC
Supporting children to feel more comfortable around poo – ERIC
Toileting books – ERIC, The Children’s Bowel & Bladder Charity
Books -‘Poo Go Home’ written by Tamsin Black and ‘Sneaky Poo’ written by Ian Williams and Yvonne Wright.

Only pooing in a nappy

Some children will only poo in a nappy. The reasons for this can often be unclear, it could be a fear of sitting on the toilet, problems such as constipation, fear of the flush or the splash, feeling unsupported while sitting on the toilet or your child finds the nappy a source of comfort.

A child who fears using the toilet can become constipated.

Helping your child to poo on the toilet

Your child needs to understand that the poo wants to go down the toilet. You can download the app ‘Poo goes Home to Pooland’ (free to download).
Make the bathroom a child friendly environment, have wipeable books and toys in the bathroom, bubbles to blow while in the bathroom.
Ensure your child is comfortable when sitting on the toilet – use a soft toilet seat and a step so your child can rest their feet and therefore feel stable while sitting on the toilet.
When your child wants to poo take them to the toilet and let them poo in the nappy in the bathroom.
Let your child help you tip the poo from the nappy into the toilet and let your child flush the toilet and watch poo go to ‘poo land’.
Leave all nappies and cleaning products in the bathroom, change and clean your child in the bathroom and make sure your child is standing up. Do not change/clean your child lying down.
While cleaning your child teach them how to bottom wipe
Wash hands
Always praise your child for the small steps they are taking to using the toilet
Gradually encourage your child to sit on the toilet with nappy on and gradually undo and loosen the nappy.
Once comfortable with a loose nappy start to cut holes in the nappies so the poo goes through the hole and into the toilet, use a toilet paper pillow in the toilet to prevent splash.
Gradually take the nappies away completely.

Resources for pooing in nappy

Children who will only poo in a nappy and other toilet avoiders – ERIC (also some useful real life case studies)
Episode 2 – Children that will only poo in a nappy – ERIC

Medicines for Constipation

Macrogols are a group of medicines commonly used to treat constipation. This group includes products like Laxido, CosmoCol, and Movicol. They all work in the same way but the taste may vary slightly between brands.

The most important ingredient is the water you mix with the powder. This water isn’t absorbed by the bowel. It stays in the digestive system and helps to soften and loosen the stool. This makes it easier for the poo to move through the bowel and be passed more comfortably.

Download a guide for parents and carers – Understanding Macrogol Laxatives

Click here for more information on how to use macrogol laxatives – ERIC.

Disimpaction

If constipation goes untreated for a long time it can lead to a more serious problem. This is called impaction. This means there is a large amount of stool stuck in the rectum or lower colon that your child can’t pass on their own. They will need support with this.

Your GP will support the child if this happens. This treatment is called disimpaction. The goal of disimpaction is to clear out the blockage.

For more information and advice on disimpaction please visit: A parent’s guide to disimpaction – ERIC.

Toilet Positioning

Understanding how to sit correctly on a toilet is very important for health and comfort. Many people overlook this, leading to discomfort or even long-term health issues.

Sitting at the correct angle can make bowel movements easier and reduce strain. It can also prevent conditions like haemorrhoids and constipation.

Sitting in the right position helps the bladder and bowel empty more easily and allows your child to relax. Young boys should be encouraged to sit down when they wee — they may also need to do a poo at the same time.

Tips to help your child sit in the correct position

Knees up: Keep your knees slightly higher than your hips
Squatting: Squatting is often recommended as the best position for effective bowel movements. If needed, use a stool or chair to raise your feet while sitting
Straight back: Sit up straight, avoid slouching, and engage your core muscles slightly to support your spine
Full Contact: Make full contact with the toilet seat
Child-size: Use a child-size toilet seat to make the child feel more secure
Lean Forward: Leaning slightly forward onto your hands or with you forearms on your knees can help

Timing is also important

Poos: The best time for a bowel movement is around 20–30 minutes after meals. This is when the digestive system becomes more active.
Wees: The right time to wee depends on when the bladder is full. A full bladder stretches the muscles and triggers the natural urge to go. Avoid restricting your child’s fluids to keep them dry. Do not to take them to the toilet too often — if the bladder isn’t full, it can’t empty properly.

Support from schools

Discussing your child’s need for extra support with toileting can feel difficult. Please know that you are not alone, and it is fine to ask for help.

Schools in the UK are required to support children with their individual needs, including toilet training, accidents, and continence issues like constipation and soiling. We advise working with the school to set up an Intimate Care Plan. This plan helps parents and school staff work together.

It will help your child receive support which is respectful, dignified, and consistent. The plan provides school staff with clear information on support for your child. This includes specific routines and related needs. You can update and adjust this plan as necessary, in partnership with the school.

Here is an Intimate Care Plan you can download, print and complete with the school:

O:\Executive Management\GHC Communications\Strategy and planning\One off projects\2025 Current\School nursing Continence portal

The file is called Intimate Care Plan v2

Emotional Soiling

There are times when children soil or wet due to an emotional cause. It could be an event like a death of a relative or pet. It could be ongoing anxiety. Bullying can also cause a child to become stressed which then affects the bladder and bowels.

Why?

Anxiety causes the release of stress hormones which affect the body in several ways:-

Increased urine production
Heightened bladder sensitivity
Altered bladder muscle contractions

Anxiety also affects the bowels:

Can alter bowel function, affect the gut, increase muscle spasms and changes in food movement and increased pain perception in the gut
Long term stress can cause issues such as constipation, diarrhea, indigestion or upset stomach
Chronic stress can lead to long-term issues such as Irritable Bowel Syndrome

What Can Help?

Seek advice from a GP in order to have any physical issues investigated. Consider if any emotional issues may be causing or contributing to the wetting or soiling.

Ensure that advice for maintaining healthy bladder and bowels is followed.

Support child with anxiety: Anxiety in children – NHS,
Talk Well (9-25 year olds): Let’s Talk Well in Gloucestershire | Free counselling and support for 9-25 year olds

Children who are in care or have been adopted

Many fostered and adopted children have issues with wetting and soiling. Carers and adopters often receive confusing information as to how to deal with this and this is usually because the most effective way to deal with it varies according to the cause of the problem.

An important distinction to make is whether the wetting or soiling is ‘primary’ or secondary’ – i.e. whether a child has never been ‘dry’ (primary) as opposed to being successfully toilet trained and then problems with wetting or soiling re-emerge- ‘secondary’.

Soiling and smearing tend to be less common problems that wetting and evidence suggests that these issues are more common in children who have experienced early trauma.

Sometimes children have experienced neglect at the point of toilet training and may have missed the chance to develop with support and encouragement.

Many fostered and adopted children have a negative experience of pooing and weeing due to being left in soiled and wet nappies, underwear or bedding. They may have been punished and ridiculed for these normal bodily functions.

Children may avoid using the toilet as it represents being separated from a carer. It can be an unconscious way of wanting the type of care normally given to babies and toddlers. These can be positive signs that the child is willing to allow you to parent. They can also be a way of finding out if you can provide the emotional and physical support that they need.

Smearing

Smearing is the word used to describe when children spread their poo on walls. furniture, themselves – anywhere apart from in the toilet / potty or pants / nappy.

Why?

This is usually a way for the child to communicate something to the parent / carer initially, for instance:

The child may be constipated and can feel the poo in the rectum, therefore putting fingers inside to remove it to relieve the discomfort
Child may be aware of the poo in their pants or nappy and reach inside to see what it is as it may be uncomfortable.

Sometimes this continues to be a habit for several reasons:

Child may actually like the sensation of the poo on their hands / body
Child may like the smell of poo and find this stimulating
Sometimes having a bath or shower after smearing is enjoyable and will want to be repeated.

Advice

Assess the child’s bowels to see if they may be constipated.
If not already toilet trained, consider if the awareness of poo in nappy may be a sign child is ready for this next step,

Think about how you respond to episodes of smearing. Many parents / carers are horrified and will show this to the child, and / or tell them off.

Try to be calm, sometimes children can get excited by angry / distressed adult behaviour and enjoy attention, even though it is negative
Provide other sensory types of stimulation – play dough to occupy hands, other smells such as half a lemon, onion or perfumed hankie the child can keep with them
Avoid showering / bathing the child and instead clean child calmiy and quietly with wipes or a cloth and encourage child to enjoy baths and showers at times when they have not smeared.

Note that it can take a long time to change behaviour but with perseverance change can be positive.

Click here for more information on what is smearing?

Continence

Signs and Symptoms of Constipation

Bristol Stool Chart