JOHN SHARRYanswers readers' queries
Q
My son is four and a half years old. He will not poo in the toilet. He says he doesn’t know when it’s coming. He had a bout of constipation many months ago and would then hold on to it. He makes bits of poo in his pants now. Has a muscle stopped working? And, if so, how can it be fixed?
A
It sounds like your son might have developed a condition called encopresis, which means he has lost full control of his bowel movements and thus experiences soiling.
The condition usually starts when a child who is constipated experiences making a bowel movement as painful. Passing a hard stool may cause them to gain a small anal tear which makes further bowel movements hurt. This pain makes them avoid going to the toilet, which aggravates their constipation. They then get into a habit of resisting the natural urge to make a bowel movement and begin to “hold on to their poos”.
Over time, the constipation can worsen and the child’s colon can become impacted, which can lead to soiling. At this point they have lost full control over their bowel movements and faeces can leak out without their full awareness. They have unexpected accidents and more often do poos in their pants than in the toilet.
When your son says he does not know when they are coming, he is likely to be telling the truth and when he avoids going to the toilet it is likely to be out of genuine anxiety.
Though a messy and embarrassing problem, encopresis can be successfully treated. Generally, a multi-pronged approach of medication, positive training and diet leads to the best results.
The first step would be to take your son to your GP for an examination to determine the level of constipation and to prescribe medication as needed. Your GP may do this himself or refer your son to specialist paediatric clinic. Two types of medication can be prescribed: one to be used over a short period to clear your son’s impaction and one to be used over a longer period while you retrain him to use the toilet.
In parallel, it is important to start a positive retraining process to help your son relearn to use the toilet. He may associate going to the toilet with negative or painful experiences; you want to overcome this and make it a positive experience for him.
In doing this, the key is to get his co-operation in having “another go” at tackling the problem.
Reading a children's book together on the subject can really help, such as Clouds and Clocks: A Story for Children Who Soil by Matthew Galvin or It Hurts When I Poop!: A Story for Children Who Are Scared to Use the Potty by Howard Bennett, both of which are targeted at your son's age group. There is also a good free downloadable booklet Beating Sneaky Poo available from dulwichcentre.com.au.
Using special charts and rewards is very helpful in retraining, and it is important to start with small steps. For example, he might gain his first star or reward for simply sitting on the toilet at agreed times, or even doing his wees in the toilet (which he does already). He can then gain his first big star/special treat when he does his first poo in the toilet (even if it is by accident).
It is also vital to make sitting on the toilet very comfortable for him. Make sure he is secure on a comfortable child’s seat, that he is not dangling and that his feet are secure on a small step so he feels grounded.
When he is on the toilet you can read stories together, play his favourite music or whatever else helps him relax. You want to get him into a relaxed state of mind so he can learn to “let go”, which is crucial in making a successful non-painful bowel movement.
You can even practise blowing bubbles together, linking the blowing motion to the same motion of emptying the bowels. He should get a lot of praise and perhaps a special treat for letting you know when he thinks a poo is coming so you can go to the toilet together.
Importantly, if he makes a mistake he should only ever get sympathy and never be punished, given that he is not fully in control and is likely to feel very embarrassed about the problem.
The third aspect to consider is looking at your son’s diet to reduce his constipation in the longer term. This means taking steps to increase his intake of high-fibre foods such as fruit, vegetables and whole grains, as well as making sure he drinks plenty of liquids such as fruit juices – including prune juice, which can help with loosening his stools. However, diet is really about prevention of future bouts of constipation. It may not be enough in itself to clear his current constipation and certainly not if it has become encopresis.
Though not often spoken about, encopresis is a common childhood problem that GPs and health professionals see on a regular basis. It can be solved but it takes a great deal of patience and work, and it is generally helpful to seek professional help. Some of the children’s hospitals or specialist child mental health services run special soiling or encopresis clinics where you can benefit from a multidisciplinary approach to the problem that includes input from doctors, dietitians and behaviour specialists. Ask your GP or public health nurse about what is available in your area.
For details of John Sharry's Autumn parenting courses in Dublin, Cork and Galway, see solutiontalk.ie
Dr John Sharry is a social worker and psychotherapist and director of ParentsPlus charity. Readers’ queries are welcome and will be answered through the column, but John regrets that he cannot enter into individual correspondence.
Questions should be emailed to healthsupplement@irishtimes.com