Withholding bowel movements: information for health care providers

Early recognition and treatment of patterns of withholding and retaining bowel movements can prevent persistent problems, including encopresis.   

 The Problem 

If a child develops a pattern of holding on to or retaining bowel movements, over time he will develop a problem with bowel control.  Parents will notice that even though the child is skipping several days between bowel movements or seems uncomfortable, he does not want to pass a B.M.  Sometimes small amounts of B.M. will pass out, streaking pants or showing up in a diaper.

If a child repeatedly withholds bowel movements for several days, the large intestine will gradually stretch in order to hold on to the large amount of bowel movement that accumulates there. As the mass gets larger it may become more difficult to pass.  The child is more reluctant to push it out, and a cycle of withholding and retaining begins.  

If a child continues to retain bowel movements, he will become less sensitive to the "time to go" feeling because the muscle wall has stretched and the nerves are less sensitive to pressure. That is why a child says that he "doesn't have to go".  She cannot feel the sensation anymore. Parents may notice that their child is crouching forward, red faced, looking as though he is straining to push out a bowel movement.  Often, that posture is seen because the child is struggling to hold a bowel movement in and he is bending over to help clench the muscles.

Small amounts of bowel movement may pass even though the child is trying to hold it back.  If the child is out of diapers, parents may notice soiling of underwear. The soiling usually distresses children and parents. These soiling accidents can add another layer of difficulty to the problem because the child may be scolded for not making it to the potty in time. He may feel ashamed or embarrassed for disappointing her parents or making them angry.

If parents suspect that their child is withholding or retaining bowel movements they should call their health care provider for an appointment.  It is usually  helpful if parents bring in a record of how often the child is having bowel movements. Include the size (small, medium, large, huge) and its consistency (mushy, soft, formed, hard) of each movement.  Parents may feel strange keeping this record, since they are not in the habit of looking at bowel movements closely, but it will be very valuable in helping the child's health care provider determine the extent of the problem.

Parents, health care providers, teachers and family members should be counseled that the problem of withholding and retention is primarily physical, not psychological. <95% of constipation is “functional” or “non-organic”, meaning that there is no underlying pathology.  However, these labels are misleading to non-medical people. It must be clearly explained to parents that the diagnosis of non-organic or functional constipation does not mean there is not a physical problem requiring treatment.  These problems are rarely a result of emotional difficulties, but they can definitely be the cause of stress for parents and children. Any behavioral difficulties or family conflicts that have emerged as a result of tension about using the potty or toilet usually resolve once the child is successfully treated medically.

The Solution

•  Helping parents and the child understand that this problem is very common.  Parents shouldn't blame themselves for not recognizing it earlier or for expressing frustration to the child before they realized that the child could not control the problem on her own.  

•  A physical examination is helpful but usually not necessary before initialting treatment, especially if the problem is acute.  If the child has had a history of constipation since infancy, organic causes should be investigated.  

•  Reviewing the child's patterns of passing bowel movements in order to create the best conditions for establishing regularity.  If a child is still in diapers, a break should be taken from toilet training. If a child is using the potty or the toilet, it will be easier to develop new elimination habits if parents provide their regular times to sit and relax in order to have a bowel movement. The child's feet should rest on a stool so that he can bear down more easily.

•  Increasing fiber in the child's diet will help to make bowel movements softer and easier to pass, but fiber should not be increased until the child is having daily bowel movements.

•  Taking advantage of the body's natural reflexes that stimulate bowel movements. Many children will be able to have a bowel movement more readily after drinking a warm beverage or eating a meal. The feeling of warmth and fullness at the base of the stomach usually stimulates a bowel movement after fifteen minutes.  Other children may be helped by taking a warm (not hot) bath or by placing a warm, not hot, heating pad on their abdomen for ten to fifteen minutes.  

 •  "Cleaning out" the accumulated bowel movement, usually using a combination of laxatives. The most common medication recommended is Polyethylene Glycol, or Miralax, a gentle osmotic laxative which softens bowel movements by drawing water into the bowel.  If a child is uncomfortable, glycerine suppositories may be prescribed for the initial cleaning out period. The child will have many large bowel movements over two to three days. The cleanout is complete when bowel movement transitions to liquid (“melted milkshake”) consistency.

•  Maintaining daily doses of a stool softener or laxative.   Parents must  be counseled that the child will need to take medication for an extended period of time, usually for several months after the daily pattern has returned. A good rule of thumb is that medication should continue for as many months as a problem has existed. It should be tapered very gradually.  If parents discontinue medication too soon, the problem tends to recur.

•  Record keeping will help to monitor bowel movement timing and consistency.  The goal is DAILY soft bowel movement. Since the underlying pathophysiology of retention is stretching and relaxation of the colon, the bowel must be kept empty to regain muscle tone and sensation. If a child reverts to pattern of skipping days, laxative dosage should be adjusted.

•  Most children will respond to stool softening type laxative.  For some children, however, the retention continues even when the bowel movement is soft.  This type of retention without constipation usually needs to be treated with stimulant laxatives or suppositories to allow the bowel to be retrained. 

 • Follow up with health care provider in 2-4 weeks, then every 4-6 weeks.  Most children will need treatment for minimum of 3 months.  Treatment for as many months as it took for the retention pattern to develop is a good guideline. 

For a detailed overview of constipation and encopresis:

http://www.medicine.virginia.edu/clinical/departments/pediatrics/clinical-services/tutorials/constipation/causes