The Ins and Outs of Poop

Painful constipation, soiling and daytime wetting: Q&A with Dr Tom

A parent recently asked me if soiling at home but not at school and frequent daytime wetting might be related to "painful constipation":

Question: My daughter had some painful constipation several months back which seemed to be the beginning of her soiling issues. After that time she started soiling frequently, as many as 4 or 5 times a day. She is soiling less now but there are two questions I have about the soiling. The first is that she rarely soils at daycare, she typically only soils at home. The second is that she is now wetting her pants frequently, something she didn't do when she started soiling. I think that all of her soiling issues point back to those constipation issues but I don't know if these two behaviors are in line with that idea.

Answer: Painful bowel movements will often lead to withholding followed by soiling (encopresis). Since your daughter continues to soil, albeit less than at first, she is still constipated.That she tends not to soil at school is also typical in the early stages of functional constipation. Ongoing withholding and soiling are often associated with day and night wetting. This is because a distended or stretched rectum will press on the bladder causing occasional leaking during the day and/or bedwetting at night. This is all covered in my book.

 

 

He Only Poops After He Falls Asleep

A mother recently reported to me that: “When we were first training our 4 year old son, he had a difficult bowel movement on the toilet. He cried and became very upset. That was when our worst problems began. After that, he didn’t want to poop at all. He became constipated and would only poop at night in his pull-up, after he went to sleep.”

Having bowel movements in bed, while falling asleep or while sleeping, is not uncommon for children who are functionally constipated.  It usually occurs at the onset of functional constipation when a child is intentionally withholding poop in order to avoid another painful bowel movement. Intentional withholding requires a child to pay close attention for any bodily signals of urgency. However, once the child falls asleep, conscious withholding stops and stool passes.

Compared to other symptoms of functional constipation, nighttime bowel movements are relatively easy to eliminate once a child begins to withhold less (or not at all) during the day. Detailed instructions for decreasing and stopping withholding can be found in The Ins and Outs of Poop.

Fear of Pooping in the Toilet: What About Talk Therapy or Hypnosis?

The mother of a 3 ½ year old girl with encopresis recently asked me if I thought talk therapy or hypnosis would help her daughter get over her fear of pooping in the toilet.

In my experience, talk therapy (or play therapy for a 3 1/2 year old child) and hypnosis are not effective treatments for children who are afraid to poop in the toilet.  Not pooping in the toilet, like stool withholding, is often due to the subconscious anticipation of a painful bowel movement caused by an actual painful bowel movement that occured sometime in the past.

This kind of fear is best treated with "exposure therapy," which I explain in detail in Chapter 11 of my book. The key to effective treatment is to determine which behavioral incentives and which laxative or combination of laxatives is required for a child to have at least one very soft, but not watery, pain free bowel movement every day without accidents for a minimum of six months.

Six months or more may seem long but, as any adult knows from their own life experiences, habits can be very hard to break and pain can be very hard to forget. My book is written to help you and your child understand and then get through this process with as many smiles and as little frustration as possible.

Once the subconscious fear of having a painful bowel movement has been extinguished and withholding has stopped, it’s time to move on to step four of my six-step program for treating encopresis, shrinking the rectum.

Recommended Products: Children's Potty

I have received requests to post useful poop-related products. Though the marketplace and brands are always changing,  I have been recommending certain types of products to my patients for years. The ones I will post are my current favorites.  Most are available on Amazon.com and in major stores such as Walmart, Target, Babysrus or Toysrus. 

Dr. Tom's Recommendation: Children's Potty
BABYBJÖRN Potty Chair

 

For children new to the potty or during potty training, I like the BABYBJÖRN Potty Chair shown above.  This version has a high back which provides a sense of security when teaching children to sit back and relax.  The high back and arms allow children to easily, slowly and carefully seat themselves. The high "splash" guard at the front of the interior bucket protects the floor and is especially useful with boys.  This seat comes in many different colors.

Don't Forget To Push!

Children being treated for encopresis are usually instructed to sit on the toilet at least two to three times a day in order to try to poop even if they do not feel the urge to poop. The goal is for them to have one or more medium to large soft bowel movements every day.

It is important that whenever you remind your child to sit on the toilet, that you also remind her that she needs to push in order to help her poop come out.  Some children think that all they have to do is sit on the toilet and their poop will come out on its own.  Children who have learned to withhold in order to avoid pain when pooping frequently need to be retrained to push when sitting on the toilet.

However, unless you actually see your child push, you have no way of knowing if she really does push or if she even knows how to push. That is one of the reasons I always advise parents to be in the bathroom when their child is trying to poop. 

In Chapter 15 of “The Ins and Outsof Poop” I talk about how sitting and pushing correctly increases the likelihood of a successful bowel movement and I describe in detail how to teach your child to push. Check it out! You and your child will be glad you did.

Real Poop Story, Cont'd - A 6-Yr Old Who Will Only Poop in Pull-Ups

The email below, written by a real mom with her permission (names changed for privacy), is a follow-up to the Real Poop Story in last month's email newsletter (sign up at left) which featured her original email to me regarding her 6 year old son who would only poop in a pull-up, read it here.  I am very impressed with this mom: her willingness to try incremental steps regardless of how long they take and how she quickly learned to "read" her son and customize the steps and materials to suit him.

Hi Dr. Tom,

I wanted to give you a further update on Kyle’s progress.  Just 7 weeks after starting the strategies you and your book helped us design, Kyle is pooping on the potty every day!  This is a child who could barely tolerate a brief sit on the toilet for over three years!  I am AMAZED by how far we have come.  As I reflect on what really made things work for us, four points come to mind.

1) Book and Phone Consultation. I want to tell you that I literally cried when I read your book.  I was ashamed that my six year old could not poop on the toilet. The combination of reading stories from people struggling as we were, and thinking that your strategies might work for us was powerful.  But I had reached a place of exasperation, confusion, and fear of doing the wrong thing.  I still was not sure exactly how to proceed.

When I discovered that I could purchase a phone consultation through your website, I decided to give it a try.  How thankful I am that I did!  It certainly shows that you have been working with kids like Kyle for 30 years.  You knew things about Kyle that even I didn't.  Your understanding, guidance and support were invaluable.  Perhaps most importantly, you gave me the insight and encouragement I needed to be patient.  Luckily for us Kyle has made tremendous progress quickly, but I got off the phone feeling that even if it took many months that would be OK.  We just needed to take baby steps in the right direction.  It is normal for these kids to progress in such a fashion. 

2) Chart Power.  As you mentioned to me, there is a good reason why the chapter on positive motivation is the longest in "The Ins and Outs of Poop".  Finding the right motivation for your child is crucial.  I had tried charts before, but not designed in the way you describe.  Several small steps, most of which I knew he could either do already or that would be easy for him, was key.  He was still resistant, but that is where the abundant stickers and immediate reward came in.  These were more powerful than I could have imagined.  Seeing the beautiful sticker waiting to go on the chart in the moment after his effort meant so much to Kyle.  He got over the hump of his reflexive resistance to all things potty!  Once that happened and he started to focus on the extra video game time he would earn when his chart was filled, he willingly did his push practice every day. 

3) Miralax.  When allowed his pull-up, Kyle would poop every day or two.  He didn't complain of painful BMs even when I asked him directly if discomfort was a problem.  When I asked my pediatrician about a stool softener, she saw no need due to his regularity.  You assured me that kids like Kyle need Miralax.  Were you ever right!  I started at a low dose and slowly increased as you suggested.  It took longer than I had anticipated, but we finally got Kyle's poop to the right place on the "stool chart".  What a difference this made for Kyle.  Even though he could not verbalize his discomfort before he started Miralax, he sure could talk about how much easier it was to push the poop out once we had the Miralax on-board.  I am convinced that he would not be pooping on the potty today without it.

4) Chart Power II.  After about 4 weeks Kyle was much more comfortable sitting and practicing pushing on the toilet.  His poop was much softer, and he reported easier pooping.  He had even gotten a little bit of poop into the potty on a couple of occasions :).  But he did not want to "push practice" when he really had the urge to poop.  In those instances he was still using a pull-up.  I tried to wait, encourage and reason, but to no avail. 

Then it dawned on me - we need another chart!  I designed a “Kyle's Good Pushing When He has to Poop"  chart.  It had to be formatted a bit differently than our "Push Practice" chart, but utilized the same principles.   I made lots of small steps, most of which he was doing already.  We used more beautiful stickers.  And because what I was asking him to do was so tough and important, I made the reward more enticing - cash for toys.  He still resisted at first, but one day, when I had that chart (already primed with a few stickers!) on the bathroom floor waiting for him, he gave in to my suggestion to "just try".  At first he wanted to finish in the pull-up which I said would be no problem.  More quickly than I expected, he didn't need the pull-up at all.  Kyle was pooping on the potty!!! 

Of course, Kyle is still at a tender place.  We still have a lot of Miralax, laxative/stool records, and sticker charts in our future.  But Kyle has achieved so much that eluded us for so long.  You changed our lives Dr. Tom, and we can't say "Thank You" enough!

Real Poop Story - A 6 Yr-Old Who Will Only Poop in Pull-Ups

This month's Real Poop Story comes from a parent who requested a phone consultation with Dr. Tom.  Dr. Tom requests that parents email him a brief summary of their child's poop problem prior to their initial phone consultation. He also answers post-phone consultation questions by email and encourages parents to update him periodically about their child's progress. Here is one mother's initial email reprinted with her permission and with names changed for privacy.

Hi Dr. Tom,

Here is a brief potty history for my six year old son Kyle. He was toilet trained for pee shortly after his third birthday. He successfully pooped on the potty early on in toilet training but seemed alarmed by the experience. After one success he wanted to go back to his pull-up. Around his 4th birthday I began to more actively try to get Kyle to poop in the toilet. We tried all sorts of things he could do while sitting. He got to where he would sit for a good while but no poop would ever come out. He would always “lose the feeling”. If I got angry about his use of the pull-ups he just wouldn’t poop for days.

Around Kyle’s 5th birthday I tried outright bribery. He could earn small Legos if he sat on his potty chair and a large one if he pooped. It was during this time that it began to dawn on me that it wasn’t just unwillingness on his part. He could barely squeeze out the tiniest bit of poop and asked me desperately if what he produced would be enough.

After some online research I decided to try a step-wise approach. During this period I once tried to encourage him by saying that he should “just hop on the toilet and push, it’s no big deal.” He looked at me with tears in his eyes and said, “It is a big deal for me, I just can’t do it”. I was heart-broken and decided to consult my pediatrician. I thought perhaps a stool softener would help.

Our pediatrician felt a stool softener wasn’t warranted because Kyle does poop at least every other day when allowed the pull-up. She assured me that he would likely outgrow his habit as social pressure mounted with increasing age. She also suggested making him clean himself up but I thought that was unreasonable and never pursued it. It is almost a year since that visit and my confidence that Kyle’s pull-up problem will resolve on its own has declined. So here is where we are right now.

I am looking forward to talking with you.

 

Click here for the next installment of this story.

The Power of VISIBLE Incentives

 Motivating children to do things like daily practice sits or practicing  pushing can be difficult because of the close association with their (conscious or subconscious) fear of pain when pooping.  For some children, special stickers on their “Good Pooping Chart” are enough of an incentive.  But there are others who need a “stronger” incentive like a bite of candy or a small prize.  

Some parents have found that they can actually increase the “power” of these incentives by making them visible (but out of reach) by putting one or more of them in small plastic sandwich bags taped high up on the bathroom wall. Then, when the child finishes  sitting or pushing, they are immediately given the prize they’ve been admiring.