Does your child obviously need to use the toilet, only to resist? This is a common problem, especially among late (3 years old and up) toilet trainers.
Basically, your child feels the need to defecate, but resists (or withholds) passing stool. Your child may cross his or her legs, sit on the back of their heels, fidget, or lay in seemingly uncomfortable positions to help reduce the urge to defecate. Your child may even reflexively clench his or her buttocks to stop the stool from coming out. The underwear or pants may have smears of stool because the child can only resist the urge for so long. The problem of pain and withholding becomes a difficult-to-break vicious cycle.
The longer this cycle continues, the larger the stool will become within the child’s rectum. Passing larger stools becomes more and more painful. Your child will likely do everything possible to avoid the unpleasant stooling experience. Constipation can lead to an anal fissure or rectal tear, causing even more pain upon stooling.
Large stools can stretch the walls of the colon and rectum so much that the sphincter muscles controlling the bowels become ineffective and floppy. The normal signals sent to the brain whenever the rectum is full (also called the gastrocolic reflex) are not correctly sent because of the stretch, so children may not even feel the urge to defecate.
While constipation is usually the main player in stool withholding, true anxiety related to the act of using a toilet can also exist. This may be related to flushing the toilet, sitting on a toilet seat, or being alone in the bathroom. Some children choose to withhold stool in order to avoid the anxiety-provoking situation. Still others simply have a strong will against toilet training. Bowel and bladder control are one of the final battles toddlers will have to win over their parents’ attention.
If the problem is purely secondary to constipation (and not another medical condition), starting a medication can often relieve the symptoms. Most pediatricians will either recommend a stool softener such as mineral oil or polyethylene glycol 3350 (i.e., MiraLax). These medications help soften the stool, making it easier to achieve a bowel movement. If there is concern for a hard stool within the rectum, a suppository or enema may need to be administered. Children should also be encouraged to drink more water and consume high fiber foods (such as fruits, vegetables, cereal, and whole grain breads and pastas). Daily prune or pear juice can help keep the stools soft once the cycle has been broken. It is also recommended to take advantage of the gastrocolic reflex by sitting on the toilet for several minutes after meals.
The key to solving the withholding-pain constipation cycle is patience. The problem did not arise overnight, so the fix may take days to weeks.
- Pediatrics In Review, Encopresis. Pediatr Rev 2010 Sep;31(9):368-74; quiz 374, doi: 10.1542/pir.31-9-368.
- Wolraich M, Guide to Toilet Training. American Academy of Pediatrics 2003.
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