Our 3 year old son is in the midst of toilet training, and he has completely mastered urinating, but he is having a lot of trouble with bowel movements. He really wants to wear underwear, but he soils them nearly every day. He holds his bowel movements in for a long time, running around and whimpering, but he refuses to sit on the potty. Eventually he can't hold it anymore, then he soils himself. The whimpering and fussing is beginning to take over the household, especially at mealtimes and playtimes, since he can't sit still and his whole focus is on his body. When he has a bowel movement, he is relieved because the pain is gone, but upset about having to be cleaned up.

We have tried discussing the benefits of using the potty (no mess, no need to stop playing to clean up and change clothes) and he agrees with us, but when he is feeling the need for a bowel movement, he gets too upset to actually use it.

Our response to soiled pants has always been very low-key, and when he is racing around holding in his bowel movements, we remind him to sit on the potty. We have tried to get him to sit on the potty "to see what happens" but so far we haven't had success. Generally he is too busy to sit still for long.

Your suggestions would be greatly appreciated.

Elizabeth

Dear Elizabeth,

I am a family practice physician (and a Positive Discipline Associate) and I help Jane Nelsen answer some of the questions from the website. Potty training often brings up challenges for parents and children alike. Your three year olds struggle with his bowels could be very normal (lots of three year olds don't have good bowel control), but there a few things that make me put on my "physician hat" for a moment. Running around and whimpering for a long time before bowel movements is not really common. It makes me want to ask a bunch of other questions: What do the stools look like? Are they hard and small? or are they rather larger than you might expect from his little body? Does he sometimes leak a little bit of liquid stool in his under pants, either when he is trying to" hold it" or at other times? If the answer to any of those questions is yes, his real problem could be that he is constipated. It may sound funny, but kids can get chronically constipated and this causes them to lose control of their stools and to leak stools. (Although the leaking itself is usually painless) Once a child is chronically constipated, their large intestine gets stretched and has a hard time doing its job normally. Kids can get cramps from this and have problems with bowel movements. Your family doctor or pediatrician will be able to help you decide if his bowels are over full and stretched, or if there is another problem that is making it hard for him to have a bowel movement. Another problem that I would want to make sure he does not have is anal fissures. Anal fissures, which are little cracks in the skin of the anus caused sometimes by large hard stools can cause pain too. This of course makes a kid not want to poop..and then they keep waiting until they can't hold it and then the stool is big again and it keeps the cracks from healing. The treatment for the kind of constipation I am talking about (which is called encoporesis) and for anal fissures is not difficult, but it takes some time for the body to heal. I would recommend taking the time to check with your doctor to make sure that there isn't a medical problem that can be addressed. If you have already been that route (in the last couple of months) here are a couple of other thoughts.

First, it sounds like you have really taken all of the appropriate first steps. You are staying low key and letting your son have as much control over his body as possible. It seems that you are not so upset about his lack of stool control, but are more worried about what happens when he clearly has to go but can't/won't. You have even tried getting him to try to sit on the toilet when he is not in pain. Usually those are the strategies that bring success (another reason the doctor in me got a little concerned).

My suggestions are really only refinements of what you have already tried. First, pay attention to when in the day he seems to have to have a bowel movement. Is it a particular time? Is it related to meals? Our bodies are set up with a reflex that causes the intestines to be more active after we eat so it does not surprise me that he sometimes has problems at meal times.

You may be able to use his "patterns" to your advantage. If you give him a snack before a meal when his body normally seems to want to have a bowel movement, you might be able to get the reflex going (but not quite as strongly). You might try offering to read him a book or playing a game with him while he sits on the potty right after that snack. Another way to use his patterns is to offer him a diaper around the time he would have his stool. This would need to be done in a positive way. You might invite him to take a vacation from toilet training for bowel movements for a week or two and to take a vacation from messy underpants too. He could put on a diaper or pull up for several hours each day, have his bowel movement and then get back in his underpants. (You know he is a big boy, but his body might be feeling like its being rushed and might like a little vacation from that job for a while). Sometimes kids just need a break from the quick pace of their bodies growing up. Another thing that might help is seeing if he can get his stools softer. This will take at least a week to work at all if he is NOT constipated. (If he is chronically constipated, more this will not be likely to work). Things that help kids stools get softer include prunes (first choice) or raisins and other dried fruit (a distant second). These are healthy snacks (and prunes are a good source of iron!). You can use dried prunes, stewed prunes or just prune juice, but to work prunes should be part of the daily routine. Even 2 or 3 prunes every day for several weeks might gradually make the stool softer and reduce the abdominal cramps...which in turn may help him calm down and figure out what his body is trying to do.

As a final thought, and this might be a little stretch for a three year old, you might (at a time when he is not having a problem) ask what would help him when he is feeling really upset when he feels like he may have a bowel movement. Would it help to get a hot water bottle on his tummy to help him relax? To be held quietly? To go to a quiet spot by himself? It is likely that he will not be able to answer you. Either way ask him to have part of him really pay attention tohis body to notice what would help next time he feels like he will have a bowel movement, so that he can get an idea of what will help. Sometimes this intentional focus on the body that is "noticing" instead of just " feeling" can really help kids get another perspective and help with the problem. (Don't ask him about what he learned until after the crisis is over)

You can let him know that you have faith that he will figure this out pretty soon...and that his body will work the way he wants it to. He is lucky to have a Mom like you.

Best wishes!

Jody McVittie, MD

PS. I would love to hear how he finally figures it out. Please email me at goodvittie@everett.com.