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Dr. Alan Greene on the Reluctant Potty Pooper

Question

My 4-year-old son has a history of withholding bowel movements. He's potty trained for urine just fine but refuses to poop in the potty or toilet unless under extreme duress, and after a few weeks of trying, we've given him his diapers back. He's now happy to poop every day, hence avoiding the anal fissure problem, but what keeps kids from pooping in the potty? With him being 4 and in junior kindergarten, this is a concern for us. Any ideas?

Answer

Children have a deep, urgent desire for growth and mastery. They would love to be able to poop in the toilet like their parents. This longing is profound, and will win out eventually. But in your son's situation it sounds as if he is trapped in what I call the D3 cycle: discomfort, dread, delay.

Children can enter the D3 cycle at any point. Sometimes it begins with an uncomfortable experience passing a hard stool created by a change in diet or a brief illness. Sometimes the starting point is simply the fear of sitting over the gaping hole in the potty. Sometimes children are engaged in playing and choose to ignore the urge to poop, holding the stool in to delay interrupting a fun game.

Whatever the starting point, they end up having a painful experience. When the next urge arrives, the child decides to delay pooping in order to avert what happened last time. The longer he delays, the firmer the next stool becomes. When he finally does poop, the event is even more uncomfortable -- confirming his fears. What he dreaded was true!

The D3 cycle must be broken before moving ahead with potty learning.

Sometimes going back to the "good old days" of using a diaper can break the D3 cycle. The child relaxes, the stools get soft, and the tension disappears. Sometimes modifying the diet can result in soft enough stools to break the D3 cycle. In some children the D3 cycle is so entrenched that in order to break free, they need a stool softener to take the process out of their control.

One excellent way to soften the stools is with mineral oil. Ingesting the oil makes the stools slippery enough that the child can no longer delay, and soft enough that the stools no longer hurt.

Mineral oil is available over-the-counter in the laxative section of drugstores. You might find it in several flavors or just plain. Plain mineral oil has no flavor. It's tough to swallow right off a spoon, but there are a number of excellent ways to disguise it. Many kids enjoy mineral oil blended with a beverage, on toast and jam, or in a grilled cheese sandwich.

Before embarking on a mineral oil regimen, speak with your child's pediatrician to be sure that it's appropriate for your child. I also recommend taking a multivitamin during mineral oil therapy (at some other time of day than when he ingests the oil), since the oil can interfere with vitamin absorption.

The starting dose for mineral oil is about one teaspoon for every 10 pounds of body weight. This may be given either as one serving daily, usually in the evening, or divided into a morning and an evening dose. If the child doesn't begin having soft stools daily, increase the dose by one teaspoon daily until you reach a dose that works. (Don't go above three times the starting dose without checking with a physician.)

Once you've arrived at a dose that works, keep him on this dose for about two weeks. Then gradually taper the mineral oil dose over another two weeks or so.

Once the D3 cycle has been broken, it's time to revisit the issue of pooping in the potty.

Often the quickest way to success is to make steady, small steps forward, rather than moving him straight from diapers back to the fearsome potty.

First, encourage him to do his pooping in the bathroom -- like you. He can keep his diaper on, he can be across the room from the potty, but he's in the right room. Once he has comfortably pooped in the right room for three days or more, he can take another little step when he seems ready.

Next, have him poop sitting down. He can sit on the floor, on the potty with the lid down, on the potty with the lid up, or wherever he wants in the room.

If he's been sitting on the floor, he should then move to the potty or toilet. If the lid has been down on the potty or toilet, now lift the lid. He still gets to wear the diaper.

The next step may be to simply remove the diaper and have him go in the potty. Many kids will move from the last level to this one with unexpected ease. If you gauge that this will not be the case for your son, you can instead cut a little hole in the bottom of the diaper. He can go as before, and the poop may or may not fall into the potty. As the days go by, make the hole larger and larger.

By freeing him from the chains of the D3 cycle, and by taking a huge task that had inspired dread and breaking it down into small achievable steps, you can set him free to enjoy the growth he's longing for.

 

The information on this Web site is designed for educational purposes only. It is not intended to be a substitute for informed medical advice or care. You should not use this information to diagnose or treat any health problems or illnesses without consulting your pediatrician or family doctor. Please consult a doctor with any questions or concerns you might have regarding your or your child's condition.