When your child doesn’t poop: Solving the constipation death spiral

Michelle wrote in: “We trained my 3-year-old son approximately 3 months ago, and it’s been great. He’s been having virtually no accidents. The problem is that he’s terrified of making ‘dirty’ on the toilet. He does it in his pamper at night when he’s sleeping. He’s very verbal about it, and tells me that he’s scared to let the dirty come out. It’s really difficult to deal with because there are days when he holds it in all day, and misbehaves all day because he’s in pain. All of my friends tell me to give him laxatives to make him go, but my pediatrician recommended against it because he said he doesn’t want to mess with his muscles, and he’ll get over it eventually. I trust my pediatrician completely, but I wanted to hear your thoughts.”

Here are three parenting truisms: You can’t make kids eat, you can’t make kids sleep, and you can’t make kids poop. So issues around eating, sleeping, and the potty are often the biggest parenting challenges, a least for younger children. Parents wish they had a way to “fix” these issues, or “make” their child do what they know their child needs to do. It can be frustrating, but raising children doesn’t always work like that.

Children really do have ultimate control over their own eating, sleeping, and pooping. Why do children sometimes hold their stool? Sigmund Freud felt that stool holding was part of the anal psychosexual stage, and that a children who rebelled against potty training would develop anal-retentive personalities. He also thought that boys in particular had a fear of castration, and that stool looked like a little penis, so boys didn’t want to even symbolically lose their little penises into a toilet. Fascinating stuff, Freud — though it’s worth remembering that his specific analytic theories were just about 100% wrong, even though he deserves credit for figuring out that experiences and subconscious thought affected our outward behavior. In other words, I doubt Michelle’s son is holding his stool because he’s afraid his penis is falling off, but I do believe that his fear could be related to other experiences he’s having a difficult time articulating.

Freud’s theories aside, I think the most common reasons for kids to hold their stool are more ordinary: 1) they like being in control; and 2) stools sometimes hurt. Whatever the initial cause, stool holding inevitably leads to larger, more painful stools, which makes the child try even harder to hold the stool. I’ve called this the “constipation death spiral.” Fixing stool holding means interrupting the cycle of holding leading to pain leading to more holding.

One thing you can try that will not work: talking. I’m not saying you shouldn’t talk about this with your child, but honestly, once your child learns it hurts to poop, you’re not going to be able to talk him out of it. Sure, you’d love to crawl into his little brain and say “Relax, honey. If you let the poop out it will feel better and you’ll be OK.” Good luck with that. Instead, try all of these methods, all at the same time.

Don’t make passing stool any more uncomfortable than it already is. Don’t try to force it, and don’t punish any behavior that’s involved with stool. Don’t belittle the child or insult him. Avoid saying things like “don’t act like a baby” or “you’re making me mad.” Don’t show even with body language that you’re disappointed or upset, even after a stool accident — all of that just feels negative to the child, and will reinforce a holding habit.

Please, please don’t rely on enemas or suppositories. Maybe once every ten years I’ve suggested one of these, and I’ve usually regretted it afterwards. Almost all constipation and holding, no matter how bad, can be managed without sticking things into your child’s bottom. Believe me, once you start wresting with things down there, it will only get worse.

Make stools more comfortable by using an oral, daily stool softener. You can get exact doses and instructions from your pediatrician. The key here is to use a consistent daily dose to keep stools soft and painless, and to not stop using the stool softener until all memories of the painful stools have disappeared. This usually requires months of therapy. That may sound discouraging, but it’s much better than going on and off medications for years. The main medication you’ll use will be a softening agent only, though sometimes we have to add a laxative to get the bowel squeezing. Again, rely on your own child’s pediatrician for specific advice here.

Michelle mentioned a concern that medications might change the muscles of the bowel. While it’s true that with long term use some laxatives (including ex-lax and Senokot) can cause changes in muscle functioning, the stool softeners (like Miralax) are not addictive in any way, and don’t permanently change anything. They just make stool softer. In fact, by relieving the pressure of a big retained mass of stool, softeners allow the muscle wall of the colon to return to normal. No one should be afraid of using these sorts of agents to help their child.

Encourage healthy eating, though don’t harp on it or make it a big deal. More fruits and vegetables, and drinking more water, can help. More dairy can make things worse. But, again, don’t harp on diet or punish your child because of food issues. That will lead to even bigger problems. You will not solve a holding habit by changing diet alone.

Set aside a “potty time” every day for junior to go sit on the pot, to wait to see what happens. A good time for this is right after dinner. Don’t let junior just sit there a few seconds and have a little tiny BM: Encourage him to sit a long time, read a story, or play with your phone (I think some Samsung phones are water resistant). Do whatever keeps him happy. This should not come across as a punishment. The idea here is to stop relying on whether junior says he does or doesn’t have to “go” — just tell him it’s time to go, once a day. And don’t rush.

One final idea: Add some fun with something called “The Poopy Party” (works best for boys over age 3).

By the way, as with many of my posts, all of this applies to ordinary, healthy, neurologically typical children. If your child has GI problems or developmental challenges, other approaches might be more appropriate. Please talk with the doctors who know your child best.

With time and patience, stool holding will stop. The approach needs to be gentle, non-judgmental, and consistent — and even with that, it takes time to develop new habits. Good luck, Michelle, and let us know how it goes!

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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