Stool withholding in nearly 4 year old

[mebeforeyou]

DS is nearly 4 and just before Christmas he had a one-off bowel movement where he appeared to be constipated (sorry TMI - large poo got stuck half in/out, it was painful, blood everywhere, and he was very distressed).

This has never happened before or since, he definitely does not have constipation as an on-going issue, however since then he has become frightened to go to the toilet and is withholding going for a poo. He can get so agitated and upset going to and from the toilet until he simply can’t hold on any longer. He does poo daily, or occasionally every alternate day, and he’s holding on for hours or a day before he goes. He keeps saying it will hurt but then after he’s been he is happy and says it didn’t hurt at all.

The GP was not really interested, said he could prescribe Lactulose as a last resort, but he didn’t seem to get it that DS is not constipated- he is frightened that it will be painful so it’s more a psychological barrier that we need to overcome.

At home we will make him sit on the toilet when he gets really agitated until he goes, giving lots of reassurance and cuddles while he is on the toilet. However for the past two weeks at nursery (3.5 days per week for 6 hours) he has had near-misses or soiling every day. He is always told that the staff will sit with him if he needs to go and is worried but he never tells them, and then they have discovered him in a soiled mess in the toilets. Today he got himself and the toilet in such a mess they had to close the toilet for cleaning - I’m mortified and upset for him.

Does anyone have any suggestions to help him conquer this fear before it becomes entrenched?

Have a look on the ERIC website if you haven’t already, lots of advice on there.

I'm afraid I don't have any answers but just wanted to send you sympathy as we are going through similar so I know how distressing it is. I will keep an eye on the thread for ideas for my little one.

Our LO is almost 3 and not yet toilet trained. One traumatic incident in the summer triggered the withholding for him, having never had a problem with poo previously. We were prescribed lactulose and then movicol but it made the problem so much worse as he wasn't constipated so the medication made him poo every few minutes and made him so sore which reinforced his fear that pooing would hurt. Once we stopped lactulose/movicol, things started to improve but it has been almost 5 months since he came off the medication so it's been really slow progress. Just as you describe, he is never in pain when he actually poos but sometimes in advance he is afraid that it might hurt and will hold on for days with lots of discomfort, getting very distressed and soiling himself regularly. The periods of mostly normal pooing (in between holding on episodes) are getting longer and longer for us so I can finally see light at the end of the tunnel.

Just as it sounds like you are, I would be really, really cautious with using lactulose/movicol if his stools are soft and he's not in pain when he goes. If you do end up having to use a stool softener, we found large amounts of Sudocrem as a barrier cream was the only thing that helped ease the soreness. Admittedly, it is easier to use that with nappies than pants.

We ended up seeing a paediatrician specialising in continence issues (I can look up her name if you want to go down that route). She said pooing every day/every other day is great and just what he should ideally be doing so your DS is doing well already. She said the rectum can become enlarged when children withhold so she was interested in the diameter of his poo and would have been concerned with poos more like a cucumber than a frankfurter. She said to make sure he is drinking lots of water with lots of fruit/veg/dried fruit to make sure that his poo stays soft so that he doesn't have another bad experience. She said having lots of diary can result in constipation so to keep an eye on diary intake. She recommended Calfig to encourage him to poo when he's gone longer than 2 days without pooing.

Other suggestions I have picked up from a health visitor which you are probably well aware of already:

• try to get his knees up high sitting on the toilet (knees well above hips) so he's in a better position for pooing
• try to get him leaning forward on the toilet so that his thighs are putting pressure on his abdomen to help with pooing. She suggested using toy cars to get him to lean forward but that's probably more relevant for sitting on a potty.
• she told me to try to keep the toilet as a fun place and minimise pooing discussions so lots of stories/singing etc rather than focusing on pooing. (I've never managed this with a hugely distressed child desperate to avoid pooing )
• she told me to try blowing on the toilet as the bearing down uses the same muscles as pooing. We've tried blowing bubbles on the toilet and blowing out pretend candles.

I really hope he improves quickly - hopefully he will get a bit more confidence as he proves to himself that it doesn't hurt each time he poos and the fear will reduce. Sorry for the essay - this has taken over my life for the past few months! Lots of luck...

Sorry, dairy not diary!!