Our daughter Claire is four and has been toilet trained for over a year. However, she only likes to have a bowel movement at home. At first, this wasn't a problem. Then we started noticing that if we were away from home at her usual time, she would skip a day of going. Last summer we went away on vacation and she didn’t “go” for four days. She was clearly uncomfortable, and finally after much coaxing she had a huge bowel movement. Now she only “goes” every few days and we can tell that sometimes she’s uncomfortable,, but she won’t “go” until she can’t hold it any more. We’ve tried coaxing, rewards, and even getting angry, but nothing helps. Now what?
You are quite right to be concerned about the pattern Claire has developed, which does sound like what is called withholding. It sounds like Claire, like many other children used to have a familiar routine for having a bowel movement (BM). Some young children only want to use the potty at home. Other children will insist on wearing a diaper or pull-up. A few children will resist going at all unless they have lots of time to get in the mood. A two- or three year old whose preferred pattern is interrupted by a change in schedule has enough physical control to hold in her BM for several days. This withholding can become a problem because if a child waits too long to have a BM, the size of the BM she withholds will become larger and more difficult to pass. Sometimes a child who is holding her BM back for several days will hold it so long that the BM gets hard and dry and is even more difficult to pass. If the BM hurts, a child may want to wait even longer before trying to have another.
Since you are seeing the beginning of this pattern, it is important to take steps right away that will prevent the pattern from becoming a habit.
The first step is to tell Claire that other children often feel the way she does. They like to be at home to have a BM and that's O.K. Then tell her that other children, just like Claire, have to "solve the problem" of holding in the BM because it doesn’t feel good when poop stays inside too long. You can talk to Claire about how sitting on the potty, even if she doesn’t think she “has to go” will help her body to relax and let the poop out. It is often helpful to tell this story using a doll or puppet sitting on a pretend or real toilet. Have the doll sit and relax and take her time until the BM comes out. Claire might have some ideas about what would make it easier for her doll when she's away from home.
The second step is to make sure that Claire is drinking fluids whenever she can. Busy children don’t always drink as much as they should. Drinking more water helps to keep a BM soft and easy to pass. It may also be helpful to limit dairy products, especially milk, to no more than two servings a day. Dairy products are low in fiber, and children who eat and drink lots of cheese and milk may not have room for the higher fiber foods that help make soft, easy to pass BMs. It’s good to offer fiber rich foods such as fruit, dried fruit, whole wheat bread, and cereals with a little added bran. However, if the added fiber doesn’t help Claire to have more frequent BMs, don’t keep increasing the fiber or you can make the problem worse—she’ll have even more to hold back!
It sounds like Claire may already be having discomfort when she holds in or pushes out her BM. If more fluids and fiber don’t help, it’s not a good idea to keep encouraging her to go without getting more advice. If your child is grunting or looking as though she has a stomach-ache before she has a BM, make an appointment with your health care provider to discuss this pattern. Seeking medical care early will help avoid having your child develop a more serious problem, that of stool retention.
“Retention” occurs if a young child continues to withhold her bowel movements so the hard BM hurts when she finally passes it. In order to avoid another painful experience, the child tries to hold on as long as she can to each BM. In holding on, the BMs become larger and harder and, of course, more painful to pass. If this pattern continues, a child's lower bowel can become stretched and the nerves that signal "time to go" become less sensitive. This condition will usually become worse if left untreated. If parents suspect that their child is developing this condition, it is essential to make an appointment with the child's health care provider.
Sometimes a child has been retaining BMs for months before parents realize it. That can happen if the child is letting go of small amounts of BM in little spurts. The BM seems soft, and it doesn’t occur to parents that the child may be constipated. However, the spurts or smears are often a sign of overflow, because the child has a back-up of hard BM as well. This condition requires medical attention as soon as possible. (See the article on withholding elsewhere on my site)
To help your child get the best medical care, keep a record of your child's pattern, noting the time, size and consistency of each bowel movement. In most cases, a child with this problem will need to take medicine to soften and lubricate bowel movements until normal functioning is re-established. As troublesome as this problem can be, it is one that can be resolved quite well with good medical supervision.
Once children resolve the problem of holding in, it can take a little while before they get comfortable sitting on the toilet and letting the BMs out. Parents sometimes find that they have to take a step backward with toilet training so that the child can relearn how to sit and let out her BM. It can be frustrating, but with time, Claire will be able to manage independently.
Meg Zweiback is a pediatric nurse practitioner in Oakland, California. She consults with families young children and often helps children with delayed toilet training, withholding, encopresis, or enuresis.