Toilet Training and Constipation

When to worry

by T. Berry Brazelton, M.D., author of Toilet Training: The Brazelton Way

How to Tell If Your Child Has Constipation: A constipated child will have hard bowel movements that cause pain on the way out. Often a constipated child will also have a stomachache, and lose his appetite. Sometimes there can even be fresh red blood on the surface of a bowel movement that was hard enough to tear the membranes in the child's anus. A constipated child will move his bowels less often than usual, but what is usual for one child may not be for another. Some children (and adults) pass stools several times a day, and others only once every few days.

Soiling: Too many children respond to the pressure to be toilet trained with constipation. Although they may have initially accepted routines, and appear to be using the toilet, they may unconsciously begin to hold back. The result is a hardened stool. The longer the child goes without moving his bowels, the larger and harder the stool becomes. Eventually, liquid bowel movement leaks around the hardened stool, staining diapers or underwear.

A parent is bound to think this is diarrhea, when it is in fact just the opposite. If a parent tries to stop what she mistakenly thinks of as diarrhea (for example, with rice water or other home remedies, elimination of fruit juice and fiber, or medicines to control diarrhea), the constipation will of course only become more severe.

Chronic Constipation (Encopresis): As bowel movements become larger and larger, and are retained longer and longer, the child's intestine is stretched and becomes less able to push the bowel movements toward the rectum. Very quickly the process—pain, withholding, leaking around the constipated stool, stretched and weakened intestines, and fear of having a bowel movement—becomes a vicious cycle. This vicious cycle is referred to as chronic constipation (encopresis).

With constipation and then liquid leaking, you can be sure the child has a hard stool that may hurt his anal sphincter when he tries to pass it. The child's fear of pain is likely to cause further tightening of his anal sphincter. The first step, with your pediatrician's involvement, is to use stool softeners given by mouth to help your child empty his rectum of stool. Your child will need you to reassure him that with this medicine he can move his bowels without pain. "This medicine will make your poop soft so they won't hurt you." You must offer help for both the physical (hard, painful stools) and psychological (fear of pain) aspects of such severe constipation.

When to Worry: Constipation is common, and sometimes runs in families. At least 10 percent of all children go through periods of constipation. But when the child's stools begin to be less frequent, and when they harden, a parent needs to pay attention. A hard bowel movement can hurt. It can cause a small, superficial, but painful tear called an anal fissure. Then a child will begin to withhold bowel movements in order to avoid the pain.

Though constipation is common, occasionally it can be a sign of a more serious medical condition (for example, appendicitis, hypothyroidism, lead poisoning, celiac disease, and Hirschsprung's megacolon disease). In these cases other symptoms are usually present as well. Some medications can also cause constipation. If a child who seems constipated develops severe abdominal pain, a fever, bloody stools, or vomiting, call your pediatrician right away to be sure that there isn't a more serious medical problem. If the usual remedies for constipation (some of which are described below) haven't worked, then it is important to ask your child's doctor to check for medical conditions that can cause constipation.

If a child withholds his stools and develops constipation, his large bowel (colon) begins to expand with the retained feces. Over time, the colon can lose the muscle tone that is necessary to be effective in pushing bowel movements along and out. This condition, stools retained for a week or so in a toddler, can lead to a temporarily enlarged and weakened colon (called megacolon). As with chronic constipation, brownish fluid begins to leak around the hard, stuck bowel movement. As we said, this is not diarrhea. You can feel the full intestine when you press into the child's left lower abdomen. The child may complain of pain as you press, or as he tries to have a stool.

When you seek medical advice, many clinics recommend enemas or suppositories that are likely to add to the child's resistance about having a bowel movement. In most cases, though, it was his resistance that caused the megacolon in the first place. I believe that when this is the case, any treatment offered must take into account the child's resistance and respect his protectiveness about this part of his body. Try the measures outlined below for constipation before you use any intrusive methods. If the doctor feels that they are necessary, prepare the child and reassure him that he will feel better and not need these measures later. If he becomes very anxious or resistant, psychological counseling can help.

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