“She’s soiling her pants at school — I think she’s just being lazy or naughty”

Involuntary soiling in a previously toilet-trained child is almost always OVERFLOW INCONTINENCE from chronic constipation with faecal impaction — hard stool builds up, the rectum stretches, and softer stool leaks around it without the child feeling it or being able to control it — so the crucial, therapeutic first step is to REFRAME it as a medical problem, not laziness, naughtiness or deliberate behaviour, removing the blame and shame that worsen it. Take a focused history (Bristol stool form, withholding behaviour, painful/hard or very large stools, palpable abdominal mass, diet/fluids, toileting routine, school-toilet avoidance, onset/triggers) and arrange a face-to-face examination of the abdomen, perianal area, spine and lower limbs with growth plotted (it cannot be done by video, and no digital rectal examination in primary care), while EXCLUDING NICE CG99 red flags for organic disease (symptoms from birth, delayed passage of meconium beyond 48 hours suggesting Hirschsprung’s, gross abdominal distension with vomiting, abnormal lower-limb neurology/spinal signs, ribbon stools) which would prompt referral; faltering growth is an amber flag prompting tests for coeliac disease and hypothyroidism. Manage per NICE CG99 with DISIMPACTION FIRST using an escalating osmotic macrogol (e.g. Movicol Paediatric Plain), titrated up over about 1–2 weeks (dose per BNFC, adding a stimulant if not disimpacted after 2 weeks), and warn the family that soiling and abdominal pain may temporarily worsen as the backlog clears — this is expected and not a reason to stop, since under-dosing or stopping early is the commonest cause of apparent failure. Follow with MAINTENANCE laxatives continued for several months (not stopped abruptly once improved, as relapse is common) plus behavioural measures — regular post-meal toilet sitting using the gastrocolic reflex, a footstool for positioning, a reward chart for sitting rather than results, adequate fluids and fibre, and addressing school-toilet avoidance — with de-shaming throughout. The hidden agenda is parental frustration, exhaustion and a misunderstanding of the mechanism, often with guilt under the anger; reframe compassionately for both child and mother, set realistic month-long expectations, protect the child from shame, and watch for emotional/safeguarding impact.