The treatment of functional constipation often involves teaching and encouraging children to "push" in order to help their poop come out.  As I reported in a previous post, one mother found that teaching her son to push resulted in his first real bowel movement She couldn't believe she hadn't tried that sooner.

So how do you teach and encourage a child to push? In kid-friendly terms, the act of pushing is like trying to blow air through a straw that is blocked on one end so that no air can pass through. Pushing causes the diaphragm to move in a way that puts downward pressure on the rectum and its contents. In the second edition of my book, The Ins and Outs of Poop, I advise parents to teach their preschool or older age child to push by doing the following while sitting on the toilet:

1. "Breathe in a little and hold it."
2. "Pull in your belly button a little and hold it in or push out your belly button a little bit and hold it out."
3. "Try to push your belly button down and out through your poop chute."
4. "Push for three to five seconds, then let the air out and relax." 

For young preschoolers and older toddlers I advise parents to approach teaching how to push as if it were a game.  Games give a child the opportunity to have fun practicing the components of pushing before they have to deal with the added stress of having to do it while sitting on the toilet to poop. For example:

The Belly Button Game: While either standing or sitting in the bathroom (or in any other room in the house), a parent first demonstrates what it looks like when they move their own belly button in and out and then challenge their child to see how many times they and their child can move their belly buttons in and out together at the same time. Vary it up with how slowly or how quickly the child can move their belly button in and out.

Using toys that encourage partially obstructed exhalation can also be helpful. Partially obstructed exhalation also causes the diaphragm to put downward pressure on the rectum and its contents but less so than breath-holding. To help children recognize the feel of "pushing the belly button down" while sitting on the toilet, toys such as pinwheels or New Year's Eve party favors like "blowouts" or horns are excellent. The objective is to encourage blowing out or exhaling as long as possible without straining. "Blowouts" that make a funny sound when fully extended are ideal.

To maintain interest in "playing" with these toys I recommend that children only be allowed to use them when sitting on the toilet.

Join in and have fun!!

"Hello Dr. Tom. I purchased your book "The Ins and Outs of Poop" and I have to say that the simple suggestion of teaching him to push resulted in his first "real" bowel movement in the toilet. Twenty one days later, he is not only pushing out his poop and pee, but he continues to do it in the toilet! After 2 years of struggling with withholding, I thought he would still be in diapers going into kindergarten in the fall. He still does not completely empty but at least he is going. Thank you for writing such a helpful book and for bringing information and attention to a struggle that you don't hear much about."

Parents assume that their child naturally "pushes" when they are sitting on the toilet to poop. However, children with encopresis often think that all they have to do is sit on the toilet long enough and the poop will come out on its own. Not surprisingly, these children frequently end up having either no bowel movement or an incomplete bowel movement both of which keep their rectum stretched and increases the likelihood of poop accidents.

Teaching your child how to push may at first feel unnecessary because it is not usually something we need to teach our children to do. For most children pushing happens naturally. But children with functional constipation often need to be taught or retrained how to push.

Parents frequently ask me, generally in exhasperation: "Why do I always have to remind him to go into the bathroom and try to poop?" 

This question typically occurs sometime during Steps 3 and 4 of my 6 Step Treatment Program (as outlined in detail in my book), when a child is having daily bowel movements but, in many cases, only with parental reminders.

Parents generally think that, by now, their child must feel the urgency to poop, because when he does sit (and push), he almost always gets poop out. They worry that their child will become dependent on them and never learn to go to the bathroom on his own.

I tell them to be patient and not to worry.

I remind them that at this stage in treatment, their child’s rectum has not yet shrunk back to its normal size and, therefore, his ability to sense the need to poop is inconsistent, at best. The main goal at this point in treatment is for a child to have at least one large, very soft bowel movement every day, regardless of whether he does it on his own.

In the meantime, always offer a small reward for going to the bathroom without needing to be reminded. You might also ask him to tell you when is going to go try, and praise him for telling you. But try not to punish, scold, or express frustration when he does not remember.

Though the features and brands are always changing, I have been recommending certain types of products to my patients for years. The ones I feature here are my current favorites. 

Last month I featured the best children's potty chair. For those children who typically sit on the "big potty," it is very important that the child's feet rest flat on a hard surface. This helps the child feel more secure and, together with the handles on a toilet seat insert (next month's featured product), provides leverage when he or she tries to "push".

I am partial to the Little Looster's Looster Booster or the Squatty Potty shown below. Their widths allow a child more ways to climb up and down from the toilet safely and makes it easier to spread their legs apart while keeping their feet firmly planted on the hard surface. I also like the BABYBJÖRN Safe Step because of its solid construction and no-slip rubber base.

Little Looster's Looster Booster

Squatty Potty