Poo withholding in 4.5 year old - desperate for help

[Howlongtiltheweekend]

Please help with advice/support. My almost 4.5 year old has been withholding his poo for 6 weeks. I know this is really common and I've read lots of threads on here about it happening during potty training but the advice tends to relate to younger children who haven't already been successfully toilet trained for a couple of years.

My DS had a fissure which was started the problem about 6 weeks ago. He refuses entirely to sit on the toilet and can go for up to 4/5 days without going. This led to a vicious circle of withholding, then hardened stools that were painful to pass which then reopened the fissure. After using lacotulose we have been prescribed Movicol instead and told by the Dr that the fissure is completely healed. Movicol has resulted in lots of soiled pants (4 pairs already this morning) where he clearly can't hold onto the whole thing and is letting go of a bit at a time(!) I've tried postitive reinforcement with star charts and bribery and read Anthony Cohn's book which is very reassuring however, but I'm still at a loss as to next steps.

After much upset from both of us, I've taken a different tack and DS is now wearing a pullup as I can't face any more soiled pants and I've told him we can't see his friends this afternoon. I had hoped this might work as an incentive but whilst he's upset about both 'punishments' it just doesn't seem to be enough to convince back onto the loo. I feel awful taking a hardline during what is clearly a traumatic time for him but I'm at my wits end.

Our whole family is being affected as DS can be irritable at best and violent at worst when he needs to 'go'. My DS is starting school in September and I'm desperate to support him and sort it out before then. Has anyone else been through this with a child of similar age?

How much movicol is he on? My 4yr old also has it but shouldn't have enough to go without being able to stop it. It's meant to soften the stool not be a laxative so sounds like he's having way too much

I went through similar with dd at the same kind of age. I didn't want to try Movicol as a friend who was going through the same tried it and her dd (same age) ended up going into nappies too. It seemed like that would just make a much bigger deal of it. In the end we tried increasing the lactulose and a final bit of bribery (only once the lactulose was working) got her going on the toilet without problem. She's still using the lactulose a few months later as I'm nervous of coming off it too soon and going backwards, and also I read that it takes months for their colon to shrink back to normal size after being so compacted, until that happens they won't 'feel' the need to go as normal, and end up constipated again.

Oh and the other factor in the final success was really backing off and not getting stressed about it. It was really hard, especially as she also got grumpy and miserable when she needed to go, but the stress levels from us obviously made doing poos a horrible experience for her, on top of everything else.

Choco he's currently on 2 sachets a day. The doc said he could have 1-3 per day. He's not really leaking, just 'letting go' of a small amount I think. Sorry for the detail but it's not runny, I think it's just the pressure gets too much to hold in! The other issue we have is that he's now wetting sometimes too as the pressure of his bowel pushing on his bladder means he doesn't always get to the loo on time to wee….

Doctor, thanks for the advice. I'm trying so hard with poo songs, bubbles, trumpets and making him giggle to distract him on the loo but I kind of lost it today. Just been a tough couple of weeks :(

Oh I know, it's really awful, sorry, didn't mean to make you feel bad about getting stressed with it. When everything else has failed, sometimes taking a hard line does seem a possibility, but it never worked for us . At one point I was considering asking a friend who does hypnotherapy to see if she could help, as by that point dd wasn't having any trouble doing poos, it was just fear stopping her. She turned a corner shortly after so we didn't need to try, and to be honest I couldn't tell you exactly what did it. I hope you can find something that works.

Ah no you didn't make me feel bad Doctor, I'm just questioning everything at the moment!

Funnily enough, I also have a friend who does hynotherapy and was going to ask her. DH is more sceptical than me so wants us to have this weekend to see if we can turn things around ourselves. I supposed I just feel like we're not getting to the root of the fear.

We went through a horrible summer of withholding immediately before DS1 started school. He was 4.7 at the time and at his worst he withheld for 12 days . He was irritable, lethargic and utterly miserable - everyone commented on how he wasn't himself at all. He would doze and lie around for large portions of the day. It literally ruined our summer!

We did lactulose (useless) and Movicol (resulting in the dreaded 'overspill' and lots of soiled pants), both at the direction of the GP. Then we saw another GP, who immediately figured out what was going on and he referred us for an appointment with Dr. Cohn (well worth it if you live near London or Herts where he has clinics).

He advised us to bin the Movicol, if it wasn't working for us, and use whatever laxative did work. He then gave us a prescription for Picolax (a very strong laxative), to 'clear him out' and then we had to experiment to find the right maintenance dose of our chosen laxative (we used Ex-Lax, which is senna in little squares of chocolate). It took us a couple of weeks of experimenting to figure out how much it took for him to poo once a day, but we got there eventually and just being given a plan of action by someone that understood what we were going through was amazing. We gave the Ex-Lax in the morning and it works in 8-12 hours, so he would poo after he came home from school. It worked for us. Movicol, OTOH, was far too unpredictable. I just didn't want him soiling himself at school.

My advice to you, above all, would be to reassure your DS. Tell him that you're going to figure this out together. Make sure he knows you're on his team and you will find a solution. Once my DS understood that I would help him share this burden and I was taking responsibility for fixing it, he relaxed a lot and he trusted me to help him. Whatever you do, don't use laxative suppositories - one GP gave them to us and IMO this borders on child abuse and only made things worse.

Hi Juneau - Thank you this is invaluable. We're not too far from London so will check out the clinics. I'll find out a bit more about Ex-Lax too.

I've heard good things about Movicol but as you say, the constant soiling issues seem to outweigh any positives from the laxative affect it is having.

Good to hear about your experience and I take on board your advice re support and finding a solution together.

Re: Dr. Cohn. If you get an NHS referral you may have to wait a few weeks. However, if you have BUPA or similar you can usually get to see him quicker. We managed to see him the following day, thanks to DH's cover via work and a free appointment in his diary!

Alternatively it may be that the impaction is not cleared out. When trying to clear an impaction the movicol needs to be increased up to 12 sachets a day until the stools are liquid then you reduce to a maintenance dose which might just be one or a half a sachet a day. Whatever laxative you decide on to ensure regular stools you still need to ensure the impaction is cleared out. Day or night wetting suggest that the impaction is not cleared.

Ok that makes sense but there's no way I will be able to get 12 sachets into him, he just about tolerates two per day mixed with juice.

I guess I need to get back to the doc and ask for the more powerful, one dose laxative as recommended by Juneau to clear the impaction then keep going with a regular dose….

IME there is no quick fix. Our DD1 is a withholder. It started at about 3.6 and we are still on the road to recovery 2 years later.

Medication helps, we are on movicol and dulcolax. A routine for doing a poo every day is also really critical. I have spent hours sitting with DD1 reading to her while she gets relaxed enough to do her poo. It's paid off as she now goes every morning after breakfast without fail.

I have been at my wits end on so many occasions, and have been incredibly cross with DD1 - I am only human and the stress of dealing with poo on a daily basis is hellish - but being relaxed about it and understanding that you will both get there in the end helps. It's a case of one step at a time and being prepared for lots of setbacks.

Good luck to you both.

I mean 3 years later DD1 is 6.

soupmaker, did you find that your DD would be incontinent or soil herself on movicol? So far this morning DS has gone through 2 pairs of pants and then soiled our bed, after a frantic attempt to withhold his poo by sitting down whilst I was dealing with the last change. I know movicol is great at getting things moving but I don't know how to deal with this constant soiling issue. I'm worried about him going to preschool tomorrow. He has a total fear of doing a poo on the loo so he's continually soiling. Is this part of the process?

Really grateful for all of your advice and comments.

If fear of the loo is part of the problem (this was an issue with my DS too), then could you let him use a potty instead? We have two BabyBjorn Potty Chairs, and he felt safe sitting on that. They are much bigger than your normal potty and higher up too, so comfortable for an older DC to use.

Alternatively, many loo seat inserts are too small for a DC of four years old, but we found a folding travel one that was big enough, so have you tried that to make him feel more secure? When DS1 finally agreed to poo on the loo he needed the seat insert and a step for his feet for ages, but those little things, that you can control and help with, can make a big difference.

I've currently got him sitting on the loo with my phone and the Angry Birds app - a new game for him and only to be played with whilst on the loo. Whilst in pants and shorts poo was practically flowing out of him (TMI) but of course, now sat on the loo, nothing at all…..

I'm about to go out and look for a new padded seat to make it more comfortable for him to sit for a while longer. Thanks for advice juneau.

Could you ask the doc for glycerin suppositories? Not very nice to insert, but they were the key to getting my poo-withholding DS to go. They work from the other end, so if there's a hard bit of poo that isn't coming out and the movicol is just making the top stuff loose and it's seeping around the hard bit, the suppository might help it slip out. My DS wasn't quite 3 the last time we had to use them though, so I'm not sure how it goes with an older child.

I had this with dd2 over a longer period of time. I agree with the getting him cleared out and then continuing.
What they said with dd2 was something like:
Day 1: 4 sachets of Movicol
Day 2: 8 sachets
Day 3: 10 sachets
Day 4: 12 sachets

(stopping if full clear out had happened).

Once the full clear out has happened, then you stick with the 2 sachets for as long as needed (about 18 months for my dd) and gradually cut down to 1, then 0.5 and very very gradually off.

And you praise heavily for any going in the toilet.

I used to put the movicol in almost 50/50 squash/water, and she had a special goblet to drink it out of, and she could use a straw.

Hello again. Yes, DD1 would - still occasionally does - soil on the movicol. I always put her in pull ups the two times we've done a clear out. You really do need to get to the stage where it is runny liquid to be sure they are clear.

The critical thing about the movicol is that it keeps everything soft so there is no pain when going which in our case would make DD1 withhold and get constipated again. It takes a very long time for the bowel to retrain too.

She withholds as a habit. Both wee and poo. It's a long story but the answer for has been medication and changing behaviours. We still have issues with her attempting to hold in poo every now and again which always results in soiled pants because it's not possible for her to stop the bowel movement due to her medication.

Thanks for this. Can I check how you administer so much movicol in one day? Can you combine several sachets in one drink? I've checked the instructions but I'm not clear. Could I give him 3/4 sachets in one cup of juice?

noblegiraffe, I was hoping to avoid the suppositories if I can. I'm just not comfortable with the idea but it's an option I guess if I can't sort it orally. Thanks for you advice.

Yes, combine them in one drink. Much easier than forcing lots of drinks down.