Monday, September 1, 2014
How to Potty Train a 3 1/2 Year Old
My son & daughter-in-law have been trying to potty train their 3 1/2 year old daughter. She has no trouble urinating in the potty but she refuses to have a bowel movement in the toilet. She is in pull-ups and goes through many (10-12 per day) with just enough bowel excretions to have to change her. They have talked to their peditrician and she put her on medicine (a stool softener) but she is still having problems after months of dealing with it.
This sounds as though your family may be facing two common problems among preschool-aged girls, both encopresis and the refusal to stool in the potty or toilet. It is actually fairly common for preschool age children to be willing to urinate in the toilet but not stool. It is as though the solid nature of the stool makes it seem as though a part of them is being flushed away, a product of their new cognitive skill of imagination, belief in magic, and fear of drains. Children without encopresis, who are aware of their need to have a bowel movement but who fear flushing away a part of them, tend to have one or two large stools per day. They often bring the parent a diaper when it is time for the stool and want to be cleaned right away when they are done. Children with encopresis tend to do what your granddaughter is doing, have smelly stool leaking frequently throughout the day in small amounts.
Current thinking about encopresis is that the child has had a painful bowel movement experience one or more times previously and now tries to avoid stooling by resisting the urge to stool. Of course, this means it really is even more painful to pass an even larger and harder stool when eventually they do have a large bowel movement. The frequent stool leakage is from more liquid stool leaking around the hard stool mass. It is difficult for the child to feel the leakage and hold it in because the lower bowel and rectum are so stretched out and the nerves compressed by the stool mass that the nerves cannot carry the sensations to the spinal cord and brain.
You can see that this is not really a child's fault or a problem the child can solve on his or her own. It is not a problem of willfulness either. Small children don't enjoy pain any more than we adults do. So they do what they can; hold the stool in and hope to avoid pain. There is no explaining to the child that what they are doing will make a bigger problem. That does not of course make it any less distressful of a problem to deal with for you and her parents. So what to do?
First is to take a deep, slow breath in and out and start working to make changes in diet and routine that will eliminate the constipation, allow the bowel to recover from stretching and the nerves from compression, and get things back on track for regular, non-painful bowel movements for the child. Removing the hard stool mass is a must. Enemas are a possibility but most doctors prefer to start with a laxative to create push from above the stool mass combined with a stool softener to bring more water into the stool, keeping it soft and easy to pass. It takes some experimenting to get the dose right. Every child's bowel operates a bit differently, so it is important to work with the child's regular doctor or with a pediatric gastroenterologist, if her doctor prefers to refer her for specialty care, to get it right for her.
Healthy bowel function is promoted by drinking plenty of water and eating foods high in fiber such as fruits, vegetables and whole grain products such as whole wheat bread and crackers to help keep stool soft without needing medication. Lots of active exercise such as riding tricycles, running, jumping rope and playing at the park also keep the bowel moving along well as does limiting television and video viewing so that she isn't sitting around inactive for long periods of time.
It is possible that your grandchild has a problem with regular wave-like movement of the bowel muscles called peristalsis. However, dietary fiber and regular activity are still the best ways to treat the problem.
I hope this information is helpful and that a resolution of the problem comes quickly for all.
Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University