JOHN SHARRYanswers your questions
Q
My four-year-old boy (five in August) will not poo in the toilet properly. He will do his wees fine but resists and puts off doing a poo.
When we ask him if he wants to go, he say no. However, five minutes later he will have pooed in his pants. This is frustrating and messy. He sometimes says that he didn’t feel it coming, which may be true, yet at other times I catch him crouched down straining and you can see that he knows what he is doing.
I have tried lots of things to get him to use the toilet, such as treats and charts, as well as trying to change his diet and giving him prune juice, but he has not responded.
I am just wondering if anyone else has had similar problems. I had hoped he would have grown out of this by now, but it seems to be getting worse. He is still wearing pull-ups and is due to start school in September. Please help.
A
Constipation in young children, which can lead to soiling (encopresis) is among the most common conditions that GPs treat in their surgeries. While there can be a variety of causes, frequently, the problems start with the toddler being constipated and then experiencing the passing of a stool as uncomfortable or even painful.
Once this happens, they can resist going to the toilet and start holding on to their poos. The child becomes tense about the prospect of using the toilet which goes against the relaxed state of mind you need to be in to let go and empty your bowels. Sadly, this can easily become a vicious cycle.
The more they withhold, the more constipated they become, which in turn makes it harder to let go and use the toilet. Over time the constipation can worsen and the child’s colon can become impacted, which can lead to soiling or encopresis.
At this point, they have lost full control over their bowels and faeces can leak out sometimes without their full awareness. This is a messy problem that is embarrassing for children and parents.
Tackling the problem requires a multi-pronged approach of medication, positive training and diet. The first step would be to take your son to your GP to examine him, to determine the level of constipation and to prescribe medication as needed. Your GP may do this himself or may refer your son to a specialist paediatric clinic.
There are two types of medication that 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.
The retraining process is to help your son positively to relearn to use the toilet. As he may associate using it with negative or painful experiences, you want to overcome this and make it a positive experience. The crucial step is getting his co-operation to have “another go” at tackling the problem together.
Reading a children’s book together on the subject can really help. Try such ones 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.
Special charts and rewards are very helpful in retraining and the key is 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 or special treat when he does his first poo in the toilet, even if it is by accident. It is also important to make sitting on the toilet very comfortable for him.
Make sure he is secure on a comfortable child’s seat and make sure he is not dangling and his feet are secure on a small step so he feels grounded. When he is on the toilet you can read stories together or play his favourite music or whatever else helps him relax. You can even practise blowing bubbles together and the blowing motion is linked to the same motion of emptying the bowels.
He should get special 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. However, if he makes a mistake he should only get sympathy and never be punished, given that he is not fully in control and likely to feel very embarrassed about the problem.
The third approach to consider is looking at your son’s diet to help 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 to loosen his stools.
However, it is important to remember that diet is really about prevention of future bouts of constipation and may not usually be enough in itself to clear his current constipation and certainly not if it has become encorpresis.
Solving encopresis can be done but it does take a great deal of patience and work, and it can be helpful to seek professional assistance.
Some of the children’s hospitals or specialist health settings run special soiling or encopresis clinics where you can benefit from a multidisciplinary approach to the problem that includes doctors, dietitians and behaviour specialists.
Ask your GP or public health nurse about what is available in your area.
Dr John Sharry is a social worker and pyschotherapist and director of ParentsPlus charity. His website is solutiontalk.ie.
Readers' queries are welcome and will be answered through the column, but John regrets that he cannot enter into individual correspondence. Questions should be e-mailed to healthsupplement@irishtimes.com