When a child refuses to poop

The Pediatric Insider

© 2014 Roy Benaroch, MD

Michelle wrote in: “We trained my 3 year old son approximately 3 months ago, and it’s been great. He’s been having virtually no accidents. The problem is that he’s terrified of making ‘dirty’ on the toilet. He does it in his pamper at night when he’s sleeping. He’s very verbal about it, and tells me that he’s scared to let the dirty come out. It’s really difficult to deal with because there are days when he holds it in all day, and misbehaves all day because he’s in pain. All of my friends tell me to give him laxatives to make him go, but my pediatrician recommended against it because he said he doesn’t want to mess with his muscles, and he’ll get over it eventually. I trust my pediatrician completely, but I wanted to hear your thoughts.”

Here are three parenting truisms: you can’t make kids eat, you can’t make kids sleep, and you can’t make kids poop. So issues around eating, sleeping, and the potty are often the biggest parenting challenges, a least for younger children. Parents wish they had a way to “fix” these issues, or “make” their child do what they know their child needs to do. It can be frustrating, but raising children doesn’t always work like that. Children really do have ultimate control over their own eating, sleeping, and pooping. Why do children sometimes hold their stool? Sigmund Freud felt that stool holding was part of the anal psychosexual stage, and that a children who rebelled against potty training would develop anal-retentive personalities. He also thought that boys in particular had a fear of castration, and that stool looked like a little penis, so boys didn’t want to even symbolically lose their little penises into a toilet. Fascinating stuff, Freud—though it’s worth remembering that his specific analytic theories were just about 100% wrong, even though he deserves credit for figuring out that experiences and subconscious thought affected our outward behavior. In other words, I doubt Michelle’s son is holding his stool because he’s afraid his penis is falling off, but I do believe that his fear could be related to other experiences he’s having a difficult time articulating.

Freud’s theories aside, I think the most common reasons for kids to hold their stool are more ordinary: (1) they like being in control; and (2) stools sometimes hurt. Whatever the initial cause, stool holding inevitably leads to larger, more-painful stools, which makes the child try even harder to hold the stool. I’ve called this the “constipation death spiral.” Fixing stool holding means interrupting the cycle of holding leading to pain leading to more holding.

One thing you can try that will not work: talking. I’m not saying you shouldn’t talk about this with your child, but honestly, once your child learns it hurts to poop, you’re not going to be able to talk him out of it. Sure, you’d love to crawl into his little brain and say “Relax, honey. If you let the poop out it will feel better and you’ll be OK.” Good luck with that. Instead, try all of these methods, all at the same time:

Don’t make passing stool any more uncomfortable than it already is. Don’t try to force it, and don’t punish any behavior that’s involved with stool. Don’t belittle the child or insult him. Avoid saying things like “don’t act like a baby” or “you’re making me mad.” Don’t show even with body language that you’re disappointed or upset, even after a stool accident—all of that just feels negative to the child, and will reinforce a holding habit.

Please, please don’t rely on enemas or suppositories. Maybe once every ten years I’ve suggested one of these, and I’ve usually regretted it afterwards. Almost all constipation and holding, no matter how bad, can be managed without sticking things into your child’s bottom. Believe me, once you start wresting with things down there, it will only get worse.

Make stools more comfortable by using an oral, daily stool softener. You can get exact doses and instructions from your pediatrician. The key here is to use a consistent daily dose to keep stools soft and painless, and to not stop using the stool softener until all memories of the painful stools have disappeared. This usually requires months of therapy. That may sound discouraging, but it’s much better than going on and off medications for years. The main medication you’ll use will be a softening agent only, though sometimes we have to add a laxative to get the bowel squeezing. Again, rely on your own child’s pediatrician for specific advice here.

Michelle mentioned a concern that medications might change the muscles of the bowel. While it’s true that with long term use some laxatives (including Exlax and Senokot) can cause changes in muscle functioning, the stool softeners (like Miralax) are not addictive in any way, and don’t permanently change anything. They just make stool softer. In fact, by relieving the pressure of a big retained mass of stool, softeners allow the muscle wall of the colon to return to normal. No one should be afraid of using these sorts of agents to help their child.

Encourage healthy eating, though don’t harp on it or make it a big deal. More fruits and vegetables, and drinking more water, can help. More dairy can make things worse. But, again, don’t harp on diet or punish your child because of food issues. That will lead to even bigger problems. You will not solve a holding habit by changing diet alone.

Set aside a “potty time” every day for Junior to go sit on the pot, to wait to see what happens. A good time for this is right after dinner. Don’t let Junior just sit there a few seconds and have a little tiny BM—encourage him to sit a long time, read a story, or play with your phone (I think some Samsung phones are water resistant!) Do whatever keeps him happy. This should not come across as a punishment. The idea here is to stop relying on whether Junior says he does or doesn’t have to “go”—just tell him it’s time to go, once a day. And don’t rush.

One final idea: add some fun with something called “The Poopy Party”. (Works best for boys over age 3)

By the way, as with many of my posts, all of this applies to ordinary, healthy, neurologically typical children. If your child has GI problems or developmental challenges, other approaches might be more appropriate. Please talk with the doctors who know your child best.

With time and patience, stool holding will stop. The approach needs to be gentle, non-judgmental, and consistent—and even with that, it takes time to develop new habits. Good luck, Michelle, and let us know how it goes!

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5 Comments on “When a child refuses to poop”

  1. Diane Says:

    FDA TO STUDY SAFETY OF ADULT-ONLY LAXATIVES PRESCRIBED TO CHILDREN(Miralax)
    FOR IMMEDIATE RELEASE

    Contact:
    September 22, 2014
    Carol Chittenden, Empire State Consumer Project cachitter@aol.com 585-831-7124

    FDA TO STUDY SAFETY OF ADULT-ONLY LAXATIVES PRESCRIBED TO CHILDREN

    Rochester, NY – Due to serious safety concerns raised in an FDA Citizen Petition filed by consumer group, Empire State Consumer Project (ESCP), last week, the US Food and Drug Administration (FDA) agreed to study the effects of polyethylene glycol 3350 (PEG 3350) laxative use in children. The group submitted the petition in 2012 on behalf of parents who say their children have been harmed by polyethylene glycol 3350 drug products. There is special concern about the safety of PEG 3350 laxatives like Miralax, which are not approved for use in children, and are not approved for more than seven days use. Many children are prescribed multiple daily adult doses by doctors off-label, often for months or years at a time. The ESCP petition calls for an investigation into the effects of PEG 3350 on children and a boxed warning on PEG 3350 products. The boxed warning was not granted, but the FDA has decided to update the labeling of prescription PEG 3350 bowel preparations with more stringent warnings and precautions for patients with certain health conditions.

    The safety concerns reported in the FDA Citizen Petition are symptoms similar to those of ethylene glycol toxicity. The petition grant includes an agreement by FDA to study the potential for PEG 3350 to degrade into ethylene glycol (EG) and diethylene glycol (DEG), and to study the long term effects of PEG 3350 products on pediatric patients. Ethylene glycol and diethylene glycol are chemicals used to make antifreeze. Both are toxic to the central nervous system, liver, and kidneys when ingested. In recent history, DEG contaminated cough and acetaminophen syrups killed hundreds of adults and children. In 2007, the FDA issued a warning for consumers not to buy toothpaste from China, as some brands were made with DEG.

    The FDA Adverse Event Reporting System (FAERS) shows over 7,000 adult and child adverse event reports that include at least one PEG 3350 product, including a number of deaths. The number of reports rose from 2,257 in 2012, when the FDA Citizen petition was filed. In 2009, the FDA Drug Safety Oversight Board acknowledged neuropsychiatric, metabolic, gastrointestinal, and kidney events in children who took PEG 3350 laxatives, but felt that “no action was required” at that time:

    “The Drug Safety Oversight Board discussed reports of metabolic acidosis, metabolic acidosis with increased anion gap, and neuropsychiatric adverse events in children using polyethylene glycol (PEG) products. Metabolic acidosis is a disturbance in the body’s acid-base balance and causes too much acid in the blood. In some situations, metabolic acidosis can be a mild, chronic condition; however, it may lead to shock or death in severe cases. Neuropsychiatric adverse events may include seizures, tremors, tics, headache, anxiety, lethargy, sedation, aggression, rages, obsessive-compulsive behaviors including repetitive chewing and sucking, paranoia and mood swings.” “It is unknown if prolonged duration in solution would change the chemical properties of PEG-3350, and what the actual content of ethylene glycol or diethylene glycol or other low molecular weight PEG would be under such conditions.”

    In addition to the ethylene glycol and diethylene glycol children may be exposed to through the degradation of PEG 3350, the FDA has tested 8 lots of polyethylene glycol 3350 and found ethylene glycol and diethylene glycol contaminants in the product itself:

    “To better understand the level of polyethylene glycol impurities in PEG, the FDA Chemistry and Manufacturing group evaluated PEG 3350. This analysis of eight lots of PEG 3350 confirmed the presence of small amounts of ethylene glycol and diethylene glycol in all lots tested. Based upon the recommended daily adult dose of 17 mg daily dose PEG 3350, the maximum daily exposure of ethylene glycol would be 0.005 mg/kg/day for a 60 kg patient, or 0.015 mg/kg/day for a 20 kg pediatric patient (approx 5 years of age). Other low molecular weight PEGs were not included in this analysis. However, it is not known if any of these LMW species are absorbed and if so to what extent. Understanding the human absorption profile of LMW species is the first step needed in trying to understand the possible contribution of PEG 3350 use to the development of adverse events in children using this product chronically.”

    Empire State Consumer Project has since petitioned the FDA to issue a Drug Safety Communication regarding the finding of ethylene glycol and diethylene glycol in all lots of PEG 3350 it tested, so that parents of study participants and all parents can be made aware of the potential for PEG 3350 to contain ethylene glycol and diethylene glycol. This petition for a Drug Safety Communication was denied. The EPA recommends that children not be exposed to more than 20 mg/L or 20 parts per million (ppm) of ethylene glycol in drinking water per one day or 6 mg/L or 6 ppm per day over 10 days. The adult doses of PEG 3350 tested were found to contain 0.3 mg of ethylene glycol of daily exposure for a 44 lb. child. This exposure is in addition to any EG and DEG exposure that may be found to occur from PEG 3350 degradation of the laxative products. The health effects of long term exposure of children to PEG 3350 are not known, although risks from short term exposure to EG and DEG are well documented in humans.

    Empire State Consumer Project is a 501c3 registered Not-for-Profit Organization dedicated to reducing the use of chemicals toxic to human and environmental health. We accomplish this by educating consumers and industry, conducting product testing and reporting, and by advocating for regulation where needed to protect the public interest.

    Resources

    Empire State Consumer Project FDA Citizen Petition and FDA Response
    http://www.regulations.gov/#!searchResults;rpp=25;po=0;s=FDA-2012-P-0566;fp=true;ns=true

    NIH Grant to Study PEG 3350 in Pediatric Patients and Test of 8 Lots
    http://grants.nih.gov/grants/guide/rfa-files/RFA-FD-14-088.html

    Empire State Consumer Project, Inc.
    http://www.empirestateconsumerproject.blogspot.com

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  2. tamyria Says:

    I read this particular post a few times because I know of someone going through this particular problem with a seven year old. The child turns 8 in November and just recently, March or April of this year, has begun pooping in their pants. They never had the problem before and now they just refuse to go when they need to. Instead they will hold it in as long as they can until it comes out, or on some occasions they will just go on themselves. Now their parent has tried miralax as their pediatrician told them to use it and all that has seemed to do is cause the child to have a sort of diarrhea problem but they still refuse to go when needed and just the other day ran out of clean undies. We have tried talking to the child about it to get to the root of the problem but it hasn’t helped. We also have a problem with getting them to actually change the dirty underwear, telling them that they will get a rash if they sit in their poop only gets the response of “so” or “I don’t care.” We do have a nine month old baby living in the same house so we thought maybe it was acting out because they wanted the attention that we have to give the baby, however we have spoken to them about that as well and they deny it every time. We try not to get onto them too much for doing it but in the last month or so it has become an everyday occurrence, most days they go through six or more pairs of underwear but a few days ago was very bad, as I said they ran out of clean undies not because we didn’t wash them but because they where going so much in them. Is there any advice on how to stop this problem for older children?

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  3. Kelly Says:

    I was wondering if you could suggest a daily stool softener for a 5 year old that is not habit forming, and safe to take long term ?

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  4. caldron2010 Says:

    We also use fiber gummies daily to keep stool soft – I don’t like the chemicals in the stool softeners and have heard nothing but horrible things about Mirolax from mom groups that I am involved with. My son is turning 5 in a week and a half and he still holds. We have tried literally every method that has been suggested to us over the last 3 years and have even hired a behavioral specialist to come to our home to work on the potty time. He understands the concept, it doesn’t hurt when he poops and he does run to the potty to poop about half of the time, but never EVER two days in a row. He only poops every 2-3 days sometimes up to 5 and that is when we use the suppository. I’m terrified that this is causing irreversible damage to his intestines and there is NO reason why it is happening. I’m at a loss and it is literally the single most frustrating thing I have ever dealt with in my life.

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  5. Dr. Roy Says:

    caldron, you’ve been through a lot, and I don’t want to make you second-guess yourself…. but those issues you may have heard from the moms’ group about “Miralax” are a load of hooey. The FDA has looked into it, the huge ped GI association has looked into it, the AAP has looked into it — it’s just fearmongering nonsense. You need effective therapy here, and you’ve been unnecessarily scared away from one of the best tools we’ve got. I urge you to visit with a Ped GI to get your answers from someone who knows what they’re talking about. Best of luck!

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