Potty Problems

It’s really common for toddlers and preschoolers to have trouble pooping, and I am frequently asked about how to resolve children’s constipation. It can be emotional and exhausting for all involved - the upset, the denial, the hopping and wiggling, the lethargy and low appetite. This has come up again recently (including with my own kids!) during quarantine, and there’s a couple of reasons that might be: change from our regular routine, different foods due to reduced availability, lower activity levels due to stay-at-home orders, and maybe some household stress in the mix too. I’m going to run through some of the reasons that kids have trouble going to the bathroom, some of the pitfalls to avoid, and some of the solutions. Fair warning, there is lots of poop talk ahead!

CAN'T poop or WON'T poop?
The first thing that it’s important to distinguish is whether the problem is physiological or psychological. Constipation is a physiological problem, where the stool is too hard or backed up to pass easily or without pain. It is likely to be a few days between bowel movements, and when they do happen, they will typically look small, hard, and lumpy. There is a chart (the Bristol Stool Scale) for determining what your poop is telling you about your bowels. On this scale, a 1 or a 2 would be associated with constipation. This can happen at any age, and for most of the same underlying reasons.

The other cause of children’s problems with pooping is psychological, which I will refer to as ‘withholding’ rather than constipation. If this is the issue, it may still be a few days between bowel movements (or not), but when they do happen, they will likely be typical looking stools (3 or 4 on the Bristol scale), and full evacuation is possible. There is often some overlap here, with an initial case of constipation (hard stool, difficult to pass) causing pain and distress, which then makes the child afraid to poop again (withholding). This can quickly become a vicious circle!

Once you know what the issue is, by looking at the form of the child’s bowel movements and referencing the stool chart, you can consider a couple of different approaches. Remember: if the child has true constipation, psychological interventions (e.g. rewards, punishments) will not help their stool to soften. If the child is withholding, physiological interventions (e.g. laxatives, suppositories) will not help them to feel comfortable and in control on the potty, and can in fact do the opposite. Correctly identifying the cause is key! Let’s assume it starts as physiological, and begin by tackling constipation.

​Constipation

​Starting with the simplest of interventions (which is always my approach with children), step one is making sure the child has enough fiber and fluids in their diet. The daily fiber requirements for toddlers (1-3 years old) are 19 grams per day, and for 4-8 year olds this goes up to 25 grams per day. This is considerably more than most young children get! Kids often have a fair amount of processed foods in their diets and lack fresh fruits and vegetables. There is also a difference between soluble and insoluble fiber: the first absorbs water, creating a gel (e.g. oatmeal, rice, apple flesh, lentils) while the latter is hard to break down and adds bulk to the stool (e.g. bran cereal, popcorn, blackberries, pears) which keeps things moving along. Insoluble fiber is usually in the skin or outer coating of fruits, vegetables, whole grains and legumes, while the insides of those foods tend to be higher in soluble fiber. Both can help with constipation, but soluble fiber absorbs water, so it can make things worse if the child is dehydrated.

A basic guideline for fluids is a minimum of 8 oz of water per year of age per day (<8 years old), with additional fluids from milk and foods (e.g. soups, yogurt, fruits and vegetables). If you’re adding fiber to their diet, it’s even more important to make sure that they’re getting adequate fluids - more fiber without enough water can cause more constipation.

Certain foods can increase the likelihood of constipation: apple sauce, white bread, white rice, bananas, gluten (in sensitive individuals), red meat, and too much milk and cheese can all contribute to firmer stools. Salty foods (e.g. pizza, chips, deli meats, salty snacks) can also lead to constipation, because sodium causes the body to retain water, reducing the amount in the colon. It really is important for children to get five servings of fruits and vegetables per day and for the majority of the grains they eat to be whole grains, not refined, to meet their fiber requirements, and to balance out sodium intake. The easiest way to stay on top of this is to offer a fruit or vegetable at every meal and snack. During the current quarantine that may be harder than usual, as access to fresh produce may be more limited, but do what you can with what you’ve got available.
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Physical activity is also important for regular bowel habits. Children aged 2-5 years old should get at least 60 mins of active play per day, preferably double that, and time spent outside tends to yield higher activity levels (1). With childcare facilities and playgrounds being closed, kids aren’t necessarily getting the same level of physical activity at the moment. Try to get them out in the backyard as much as possible, if you have one, and go on a daily walk/scooter/bike ride around your neighborhood (following social distancing guidelines, of course).

If your child gets adequate fiber, fluids and activity but still seems to have hard stools, the next step would be to offer a few ounces of prune juice or whole prunes to get things moving. Prunes contain high levels of sorbitol, a sugar alcohol that holds water in the colon and stimulates bowel movements (2). Whole prunes have more sorbitol than prune juice, plus some fiber, so they may be more helpful. That being said, this age group is fairly sensitive to fruit juice - it tends to cause diarrhea in young children due to the high sorbitol and fructose content and the immaturity of the child’s digestive tract, which might actually be helpful here. Pear and apple juices are good options for this, in addition to prune juice (3).

Mineral oil, a petroleum-based product, is a common over the counter laxative. More healthful alternatives are flaxseed oil and olive oil, both of which are shown to be as effective as mineral oil for getting the bowels moving (4), with the benefit of healthy fatty acids too. These are all considered ‘lubricant laxatives’, as they coat the intestines, preventing some water loss and smoothing the passage of stool. Ground flax is often suggested for constipation because it is so fibrous and adds bulk to the stool, but only if the child is drinking adequate fluids.

A lot of families I’ve worked with have given their children polyethylene glycol 3350 (AKA Miralax) at some stage to get the bowels moving. This chemical is an osmotic laxative, meaning it draws water from the body into the bowel to soften the stool. The use of Miralax in kids is controversial (5), and the manufacturers do not not recommend giving it to children under 17 years old unless under the guidance of a doctor (6). They also say that it shouldn’t be used for longer than seven days, but many people take it on an ongoing basis. Personally, I have yet to see a case of constipation that couldn’t be resolved with diet and lifestyle interventions, and getting young children’s bowels dependent on laxatives is not ideal for future gut function.

Magnesium citrate is a natural saline laxative which draws fluids into the bowels from surrounding tissues, like Miralax, but it is a beneficial mineral (essential for relaxing muscles and nerves) rather than a questionable chemical. Powdered magnesium can be added to water at bed time, and chewables are also available; I favor the powder because you can control the dose, and it gets more fluids into the child. Different brands have different serving sizes, but the RDA for this age group is 80 mg for 1-3 year olds and 130 mg for 4-8 year olds. Supplementing with higher doses is typically necessary for a bowel movement and is safe if used occasionally: Pedialax chewables contain 400 mg magnesium per tablet, with 1-3 tablets recommended for 2-6 year olds in a 24 hour period. Excessive magnesium can cause diarrhea (which is why this works); long term use (more than a week) of any osmotic laxative is not advisable, because it can upset the electrolyte balance in the body and cause dehydration. Magnesium citrate is a good option for an acute case of constipation, while the dietary recommendations above are best for ongoing management.

Probiotics can also be helpful if a child is prone to regular constipation, as chronic constipation (typically defined as infrequent, hard to pass stools for 3 months or more) can indicate an imbalance of microbes in the gut (7). Certain strains of Lactobacillus and Bifidobacterium have been shown to help with stool frequency and consistency (8); ideally your child would have a stool test to determine the right strains for them. Chronic constipation can also be a sign of food allergies or sensitivities (9), so that’s another avenue to explore with your child’s health care provider if physiological problems persist.

I also want to mention the use of rectal laxatives, for completeness. It can be tempting to ‘help’ the child poop by administering a glycerin suppository or an enema - it’s hard to see them struggle! That being said, these are last resort measures which should be done under the instruction of your pediatrician, for severe cases of constipation only (defined as less than one bowel movement per week). If your child hasn’t had a bowel movement in a week, or has constipation combined with a fever, vomiting or severe abdominal pain, consult with your pediatrician.

​Withholding

Even without an initial case of constipation, many kids between 2-5 years old will go through a phase of withholding. The ​transition from diapers to the potty or toilet is a significant milestone, and many kids feel apprehensive about it. Also, the first time they see their poop in a potty can actually be quite scary for some kiddos - they aren’t used to seeing it when using diapers, and if they do, it usually looks a little less intimidating.

This is also the age when kids are starting to develop more control over their bodies: they can walk without help, they can perhaps get dressed without help, etc, and, they are also starting to explore boundaries and assert their independence. Two areas where they can successfully start to assert their own autonomy are their eating habits and bathroom habits, which is why it is so common for these two domains to be the major battlegrounds in this age group.

The goal with psychological struggles is to get the child to feel confident about pooping, to calm any fears they may have, and to encourage them to do it by themselves (with your support), so that they can feel in control of their bodily functions. One widely used strategy for this is a reward system, particularly during potty training. It can be really tempting to offer them candy or gifts for passing bowel movements, but ideally we want children to be internally motivated to use the toilet, because they’re listening to their bodies and they feel better when they’ve done it (no more anxiety, stomach pain, distraction from game playing, etc). This is what will give them the sense of mastery that they need, and is often enough for many children. 

So, what does this look like? Let’s say kiddo is squirming in his seat, clearly needing to poop. Ask him what feelings does he have in his body? Observe that he looks uncomfortable, reflect back that he is complaining of a tummy ache, and that’s probably because the poop wants to get out. It doesn’t need to be heavy-handed or persuasive, the goal is to have him notice what’s going on in his own body, and choose for himself how he wants to handle that. The more we can teach them to associate holding the poop in with pain and discomfort, and associate letting the poop out with relaxation and ease, the more motivated they will be to keep trying. The child may need some coaching while sitting on the potty - encouraging words like “I know you can do this!” when he is screaming “I can’t!” and “you’re in charge of your body!” if he’s upset that the poop seems to be calling the shots, are supportive statements that keep the control with the child. Maybe he wants to hold a parent’s hand, or have a book read to him, or have a favorite toy enact a successful potty trip. When he is successful, help him feel proud of his achievement, reinforce his power and autonomy in this domain, and have him check in with his body to see how much better he now feels. This positive emotional state and physical comfort will be incentives for listening to his body right away next time he feels an urge, rather than holding it in.

You know your child and whether this will work for them. If they are already accustomed to reward systems and incentive charts, positive experiences and praise might not cut it, and that’s okay - you can still keep the incentives linked to the event. For example, a naturally rewarding outcome of mastering potty issues could be picking out some new big kid underwear at the store, or ditching the changing table topper on their dresser to make room for a special toy or treasure box, or certificate of toileting success. Sticker charts can be helpful as visual stepping stones to these end goals, and can actually be useful to the parents too: if you have a family calendar, putting a sticker on each day that the child poops can help you keep track of how long it is been between bowel movements, so you don’t have to try and remember it!

Timing is also important. There is a natural urge to poop typically half an hour after eating, so you could try having the child sit on the potty thirty minutes after breakfast, for five minutes of reading time, just to see what happens. This should be a relaxing activity, not a toilet time out! Some kids are resistant to being told what to do and when, particularly in this age group; giving them choices is a way to empower them. For example, would you like to have potty time after breakfast or dinner? Would you like to use the little potty or the big toilet? The upstairs bathroom or the downstairs bathroom? Which book would you like to read while you sit?

Positioning is another factor to consider: Little potties allow the child’s feet to touch the floor and create a natural squatting position that makes it easier to pass stools; sitting on the grown-up toilet usually involves a certain amount of muscle engagement for balance, plus the legs are dangling. Using a step stool or a kids’ Squatty Potty can allow them to fully relax on the toilet, and promote full bowel evacuation.

Finally, relaxation is key. The best way to get your kiddo to relax their muscles is to give them a warm bath, ideally with a scoop of Epsom salts (which are magnesium sulfate). A soothing soak - or active play time - in the tub for 15-20 minutes after dinner can often be just enough to relax the bowels before bed.
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​The Bottom Line

Most kids will experience constipation or withholding at some point during childhood. Make sure you know the cause (physiological vs. psychological) before you intervene, start slow, and involve your child so that they develop a sense of ownership of their bodily functions. I find that parenting often involves weighing short-term goals against long-term goals: we are often keen to achieve the short-term goal (getting this kid to poop in the next 24 hours) and intervene to make that happen, for everyone’s sakes! We don’t want our kids to be in pain or distress. But, when we take a step back, our long-term goal is probably to have children who respond to their body’s cues appropriately, without fear or over-reliance on external support (from parents or laxatives). If you’re providing a good balance of foods, fluids, and physical activity, coupled with encouragement, humor and patience, they will most likely poop when they are ready. And everyone will feel relieved! (Pun intended.)

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If you'd like some personalized support for your child's tummy troubles, please feel free to contact me for a remote consult.