Withholding - alternatives to lactulose?

[WigWamBam]

Dd will be 6 next month, and withholds her poos. We recently saw a paediatrician for a completely unrelated problem, which she thinks is being compounded by the poo withholding. So she has asked us to dose dd up with lactulose. We've been giving it for about six weeks now, and it doesn't make a blind bit of difference - she still hangs onto her poo. With 15ml of lactulose her poo is loose almost to the point of runniness and she complains of stomach pains (but still hangs onto it - heaven knows how), with 10ml she's back to pooing every four days.

If anything giving her the lactulose seems to have made her even more determined not to poo than she was before, but the paed was insistent that we need to get her pooing regularly, and that we need to stop the withholding.

Dd has a good diet with plenty of fruit and vegetables so I'm not sure there's anything I can do diet-wise to help. She's always had issues with pooing, which I've always been very laid-back about treating, but the paed made such a fuss about it that dd has picked up on it and as I say, it's made things worse. The paed won't look any further into the other problem until we sort out the pooing.

Does anyone have any suggestions? Alternatives to lactulose, anything I can introduce into her diet so that she won't realise she's taking it?

I would highly recommend trying to get movicol - I just kept going back to the doctor again and again saying the lactulose wasn't doing anything until they referred us to the paed who promptly prescribed us with some. It is very effective stuff and is easy(ish) to control the doses until you get the right balance (so your DC can poo but know they are doing it IYSWIM)

Washersaurus, I'm coming to the conclusion that I'm going to have to get her to the GP! Will ask about Movicol.

Frogs, I know what you meant and I really appreciate you posting - sorry, I was just thinking out loud a bit really. I hadn't given encopresis much thought as I've only come across it as soiling due to constipation, and I need to have a look to see whether it would apply to dd. I haven't had time yet to check out the websites but will do when I have time to sit and digest it properly.

The visit to the paed and her refusal to do anything until the poo situation is dealt with has given all of this far more importance that I would have liked, and I really think that it's that which has caused dd to dig her heels in even more over the past few weeks.

As a child I had severe water infections etc all because I was constipated continually - I sound just like your dd tbh! I think I would revisit the reward thing - she is older now, you could ask her what incentive she would like, also discuss with her the whole situation and the pain and discomfort from the urine/vagina issues will not get fixed unless she starts poo-ing when she gets the urge. Shame you have just missed the hols would have been easier without adding in the school thing. The other route is suppositries would that threat work?????????

I just wonder if giving her the control of sorting it out would help??????? ie you need to start doing a poo when you need it to make everything else better so how are you going to go about it and what can we do to help?????

Cargirl, thank you for your thoughts. I thought that the holidays would make it easier for her - being able to go at home rather than use the school toilets - but it didn't.

We've talked to her at length about how the pooing and the pain are linked; I had suspected that one of the reasons for the vaginitis might be constipation and have suggested to her times that if she pooed when she needed to the soreness would get better and she seems to take it in, but as soon as it comes to needing to poo again it's back to square one.

Suppositories ... maybe; again, it's more a case of wanting her to go without laxatives if we can. Plus I don't want her to be frightened of the toilet, and suppositories are alarming enough as an adult the first time you use them!

Giving her control over how to deal with it may help though ... although she doesn't seem to care all that much and would probably just take that as carte blanche to carry on not pooing! I guess it's a case of suck it and see really; give it a go and see what happens.

Thank you

The physiology of defaecation is quite complex - although most of us don't think about it. It involves relaxing the anal sphincter and pelvic floor muscles while simultaneously contracting and bearing down with the abdominal muscles. This is usually a reflex action, but can get overridden and out of synchronisation when there has been a painful experience or a long term habit of "holding on". What happens is that all the muscles contract and it causes pain. Although the problem can be a mix of physical and emotional factors, it can take a long time to unravel and deal with the psychological problem and retrain the bowel.

Your dd may give the impression she doesn't care, but maybe deep down there is an anxiety factor?

Movicol can help to increase the normal action of the gut and override the muscle spasm caused by holding on.

Asking her to blow up a ballonn or blow into something while on the loo can also be helpful, as can reading a story, and giving a reward for success. Just a few ideas - does any of this help?

Your description of what happens when there has been a painful experience or a long term habit of "holding on" is an interesting one - it triggered a little flash of recognitiion because it sounds very like vaginismus, and I guess in a way it's the same kind of thing but in reverse! I have never thought about it quite like that, but it really makes a lot of sense to me, and it wouldn't surprise me at all if that was behind a lot of this. So yes, I think you may be right that there's something emotional going on as well as something physical.

I think that reading her a story while she sits on the toilet would freak her out, but I will certainly try the balloon trick, and we'll have another go at a reward system. Again, it's been a long time since we tried and it might work better this time. Movicol sounds like a good bet as well, so I'll ring the GP for an appointment tomorrow and see how we go.

Thank you ever so much.

Just another thought - why not go and see GP without dd to begin with and get all the discussion out of the way? Then take her to see GP for quick, child orientated chat the next day?

Dicussing it with her in the room is not likely to be helpful IMHO.

I agree with sassy about the Movicol, DS1 has them, although his is severe constipation, not withholding, and it's really good stuff.. Can't offer any other advice, sorry

I just wanted add that the problems I now have due to this not being addressed when I was a child are horrid. TBH if it were my child I would really force the issue and use suppositories to get her to go at least every other day until I could get the psycological side addressed. My bowels rule my life...........due to the damage done of witholding and having chronic constipation as a result.

I appreciate your point of view, Cargirl, and of course don't want her to have lasting problems from this, but feel that a more relaxed approach suits both me and my daughter than something invasive like suppositories would allow. I can see your point, really I can, but feel that making a huge issue out of this would be as damaging to her as not addressing it at all. When I say that she gets distressed at being forced to use the toilet, I mean she gets very distressed; she screams, shouts, cries, becomes hysterical, and you would really think that I had asked her to cut her own arm off. Shoving something into her bottom is likely to make her even more hysterical, particularly given the way that suppositories work. They aren't the most gentle treatment available; I remember the first time I used a suppository myself - it was an alarming experience, even as an adult.

We are addressing the problem; I just needed some advice as to other things we could try, particularly as dd's distress has worsened since the paed asked us to force the issue. I don't want her associating pooing with distress any more than she already does.

She's gone to bed with a dose of Califig tonight, having not pooed for the sixth day in succession. Now she's scared it will hurt her and we're back to square one again - the Califig will force a poo, it will hurt, she thinks it will hurt to poo again the next day so she'll hang onto it ... and round we go.

WigWamBam - have you considered homeopathy? Since it addresses emotional as well as physical aspects it may be worth a try?

I totally agree with your laid back approach it's just worrying if they're not going to support you in other ways. My friends dd who had ongoing problems like this benefitted hugely from a cranial osteopath not sure why but it may be worth a try anyway - certainly not invasive! It's a worry that the consultant won't support you - what a mess!

I went through this with dd when she was very small. She got very constipated due to me giving her antihistamines when she had chickenpox - I forgot about that particular side effect. She ended up with an anal fissure and all the problems you describe. My gp gave me a tried and tested programme of a combination of 3 medicines:

Daily doses of a stool softener to break up the rocks - (docusate), a laxative - (senocot syrup), and lactulose. Some people say that movicol is as good as this regimen.

The thing is, my GP warned me that it would take as long to solve the problem as the problem had existed, and she was absolutely right. The first time I didn't persevere and we were right back to square one after a couple of months because i stopped giving the meds.

It took a year of consistant treatment and retraining, and I am still careful about diet, fluids and access to toilets and privacy etc and dd is 9.

It is something that cannot be sorted overnight, but it can be done.

It is as important to deal with the psychological issues as the physical ones and I agree that being as calm and gentle about it as possible is all to the good. I would imagine it would be more of a challenge when dealing with an older child, and professional support and help would be important.

I hadn't thought about either homoeopathy or cranial osteopathy. Might be worth a try, thanks for the suggestions.

The paed is a nephrologist so bowels are probably not her strong point! I think she just wants to get this out of the way so she can rule it out before doing anything else with regard to the urine infections and so on - and hasn't really given much regard to how it's done.

Will see if the GP is a better bet.

3littlefrogs - the paed just seems to want this out of the way quickly so that she can get on with the problem that's her own speciality. She's basically given us three months to get it sorted, and she won't do the scans and things until we do.

Maybe we need to see someone who is more understanding of this kind of problem.

When I was nursing children in hospital, we quite often admitted children to get them established on this sort of treatment. That was years ago, but it was considered to be an important enough condition in those days to warrent professional treatment and support.

That's appalling, I'm an adult and I struggle to keep on top of these things for myself! Laxative suggestions - red grape juice, salad (better than veg) and lots of water to drink.

Ah - all becomes clear. You need a paediatric gastroenterologist, not a nephrologist. The nephrologist probably doesn't have experience of this. These days medicine is so specialised that you have to hit lucky and get referred to the right sort.

wwb once interviewed a paed who took a special interest in this area. from what i can remember, treatment (quite long i'm afraid) involved a loosener like lactulose, a "pusher" to improve gut motility and psychological support and counselling - to help all the family, not just the child. i think she was in the northeast but she may know a specialist from another part of the country, as I don't think you live up there. i'll try and dig out her details tomorrow if you'd like me to CAT you, x

Bundle is on the right track. Where do you live WWW?

Bundle, that would be lovely of you, if you could - thank you. We're in the West Midlands.

I'm honestly beginning to wish we'd never been referred for the waterworks problems in the first place!

Dr Anne Wright at the Evalina childrens hospital, part of St Thomas in London, is totally worth a trip to. She is brilliant.

Sorry meant WWB. No spectacles. I wouldn't be a bit surprised if the waterworks probs were connected TBH. I really hope you get it sorted out. GP might know of a specialist in your area.

Oh, that's OK ... people are always mixing me and WWW up!

Frogs, I've always thought that the soreness could be associated with the pooing issue. I know it can cause vulval and vaginal soreness and have always suspected that the two were linked. I've told her again and again that once she starts pooing properly the soreness will probably stop.

We had words last night, and after saying that she didn't know why she wouldn't poo she finally said that she's worried about it because it always hurts her to poo. So we've (yet again!) had a chat about how hanging onto it makes it hurt because it gets too big and hard to pass easily, so then it gets sore and hurts the next time - but if she poos when she needs to, it will be easier and will stop hurting. But we've been here before! I will be ringing the GP for an appointment after lunch, hopefully we can get something sorted for her soon.

Be prepared for retraining to take time and patience and you will get there.