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TOILET LEARNING THROUGH PLAY AT ANY AGE
Scientific studies have shown... WHAT NAPPIES, HEALTH, RESOURCES
ARE THERE RISKS TO EC / BABY-LED / EARLY POTTY TRAINING?
This blog post is a response to the many articles by Dr Steve Hodges that pop up all over the internet. I’m going to be quoting this one from The Huffington Post as an example: A doctor responds “Don’t potty train your baby!”
[Summary: Babies who use a potty really are at risk of chronic constipation. But so are nappy wearing toddlers who have their own ritual for poos and all fully potty trained children… Once you accept that, you can manage the risk while still pottying / ec-ing your baby. These are the signs to look out for in your baby or toddler: 10 signs of constipation every potty training parent should know.]
Dr Hodges is an American paediatric urologist. He works at a medical centre attached to a children’s hospital in North Carolina in the USA where he sees children with urinary conditions, many of which should never have happened. These conditions are upsetting, debilitating and stressful for entire families, so it must be incredibly frustrating for him to know that they’re largely unnecessary; i.e. they could have been prevented by different toileting habits. By and large, they’re not brought about by bad luck, but by lack of awareness of a developing problem.
I agree with everything he’s trying to prevent. I think he has integrity and the best interests of our children at heart. (I particularly like the treatment program he recommends for chronic constipation, which causes far less family stress than anything prescribed over here in the UK – more on that later.)
Yet, it’s clear his preventative strategies (don’t potty train before age three) are aimed at the lowest common denominator rather than your average ec-er. In seeking to clarify his position (and silence the vocal commenters on his early blogs) he shows his ignorance of how ec works in other cultures.
Take this quote, in which he compares Western culture with his vision of native ec: “What’s more, in much of the developing world, toilets aren’t the norm; instead, people squat, a position that, research demonstrates, makes elimination much easier. And when you don’t need to worry about finding a toilet (behind a bush will do), there’s less reason to hold. It’s all about access.”
A baby pottier responded “I lived in the woods with no running water for years, and believe me when you have more than a few people pooping in the same area there are systems, and rules, and locations, with serious comeback if they are not followed! This man knows nothing of pooping in the great outdoors.”
It’s tempting to pick up on his lack of knowledge around ec and dismiss him as not knowing what he’s talking about, when in fact, I agree with everything else he says in this paragraph. Squatting is accepted as the natural position to poo. And it is all about access.
So even if he’s put your back up, give him the benefit of the doubt. He’s trying to prevent your child from ending up in his clinic. Keep an open mind and don’t let your own set of beliefs and prejudices prevent you from seeing the consequences of pottying-gone-wrong.
Our lifestyles often make the version of ec/baby-led pottying we practice a far cry from the natural process we’re hoping to emulate.
Like baby pottying / ec? Like Born Ready on Facebook:
What’s So Wrong With Starting Early?
The problem for ec-ers, is that Dr Hodges says you should wait until age three to toilet train and that any potty training before age two is a recipe for disaster.
And yet, even his own published research suggests this isn’t really the case. The title suggests that early potty training is responsible for the kind of problems he sees in his clinic (daytime wetting, urgency, night wetting, recurring UTIs, overactive bladder) but he concludes that constipation is the cause, rather than the age at which a child potty trains.
“Our results linking constipation with both early and late [training children] with increased incidence of dysfunctional voiding perhaps imply that constipation, and not the age of training per se, is most important to the development of voiding dysfunction in children.”
So it’s constipation, rather than age of toilet training that causes ‘voiding dysfunction’.
However, it’s much easier to give a blanket message “Don’t take your kids out of nappies before they’re three!” than to educate parents on how to avoid chronic constipation in toddlers. Partly because preventing constipation requires parental effort and awareness – and not everyone is into that… (But I’m sure you are So learn what to look out for.)
By the way, if you’re feeling relieved because your family has a great diet and constipation won’t be a problem for your baby – please keep reading! It’s not that kind of constipation that we’re worried about.
So Is Early Potty Training Risky, Or Not?
As a prospective or current baby-pottier, what are you supposed to make of this?
Everything about baby-led potty training / elimination communication makes sense to you. You know that super-absorbent nappies are a very recent invention. You know that in Western countries, babies were out of nappies by the time they were 12-24 months old only one generation ago. You know that in the majority of the world, where nappies aren’t used, everyone manages just fine…
And yet, the figures are frightening. You’re warned against early potty training on every mainstream website you’ve ever visited.
“Children who train early are likely to regress.”
“Don’t push them into potty training before they’re ‘ready’.”
And, Dr Hodges again, in his previously mentioned paper, says: “Children who potty train before age 2 are 3.3 times more likely to be constipated and 3.7 x more likely to experience daytime wetting.”.
Wait… That last figure.. Surely Dr Hodges means children who were ‘coerced’ (bribed/punished/shamed) into early potty training are the ones who are at risk?
No he doesn’t.
He says parents of his patients report that their toddlers virtually ‘trained themselves’ at around 18 months old.
It’s not the method of early training that causes the problems, it’s the responsibility those kids have and the environment they live in – and that’s the same environment that we all live in, to a greater or lesser degree.
Dr Hodges does explain this, but you need to mine his articles for information rather than skimming the headlines and highlights.
Here he’s talking about starting pre-school:
“Think about it: You’re placing a little one in an unfamiliar environment where, for possibly the first time in her life, she has no family members around for half the day, and you’re expecting her to interrupt her teacher during the story circle and announce that she needs to use the toilet or to climb out of the fort she’s just built with her friends and make her way over to the potty. Whoever thought that was a good idea has surely never set foot in a pediatric urology clinic.”
And it’s not just educational or childcare settings. There are social constraints at home too.
I’ve overheard a conventional nappy-using parent say to her nappy wearing son: “Hey! Stop that! You can’t poo here there aren’t any changing facilities!”.
I’ve seen ec-ers guiltily lament: “She signed to poop, but there wasn’t time because we were running late, and when we got there she wouldn’t go. When she next signed I couldn’t take her because we were on a train and then she fell asleep on the way home and went straight to bed.”
And I’ve lived: “No poo this morning, nothing at nursery, and now all she wants to do is tuck up in bed…”
We lead very very busy lives.
And any child who leads a busy life is susceptible to voluntary holding which can lead to this kind of constipation. Learn to look out for signs of trouble.
BUT ON THE WHOLE, PARENTS WHO POTTY ESCAPE UNSCATHED, RIGHT?
I’ve read about regressions, post graduation ‘potty pauses’, night wetting and pooping problems many times on pottying and ec forums during my 8 years in this game.
Every time I respond to a post and explain something about chronic constipation I get questions via private message.
Often people who would never have posted themselves – they don’t want to discuss their long term struggles in a group where everyone is reporting their early successes.
If you’re not aware that ec-ers can and do come unstuck in the toddler/preschooler/reception class years, then you’ve only heard one half of the story.
For these parents, their early success has turned into an unfathomable battle.
Their child, who didn’t soil a nappy for 15 months straight, has started to poop in their pants just as their peer group are potty training ‘properly’.
Or maybe they’ve started wetting the bed having been dry forever.
Or they’re obviously holding (either wee or poo or both). They resolutely refuse to be ushered to the potty or toilet. The child’s personality changes during holding and to their horror, the parents find their personalities have changed too. Patience is running short. There seems to be no common ground. They’re battling over bodily functions in a way that baby-led potty training was absolutely supposed to prevent!
And their gentle/attachment/child-led parenting approach leaves them with very few options to get back on track.
Some Posts Just Scream ‘Chronic Constipation’ At Me
What makes me answer an innocent Facebook enquiry with information about holding, encopresis (leaking stool) and constipation? I mean, it’s a pretty grim subject to introduce. It can easily be seen as scaremongering, interfering or ‘making a medical diagnosis’ and lots of people take offense.
The sad fact is, I recognise the danger signs because I’ve seen them first hand.
I lived through chronic constipation with one of my kids and I know we should never have ended up in that situation. I learned an awful lot about a condition I didn’t even know existed before we were in the thick of it.
And importantly, I learned what to look for to stay one step ahead of a relapse. What to look for in my other children to make sure that they never had to go through what that poor child went through. And I instinctively use those skills every day.
So now, I can see constipation coming a mile off – and you need to know how to spot it too.
Everyone who practices baby-led potty training or ec should take on board the underlying message that Dr Hodges is trying to publicise. Make sure you know what to do to prevent your own personal disaster.
You can read about the triggers I watch out for here: Ten Signs of Constipation Every Potty Training Parent Should Know.
Some Facts About Constipation and Holding
It’s estimated that every year in the UK, 28% of kids suffer from some sort of constipation – mostly while they’re young, but if they’ve had chronic constipation once it’s likely to resurface again and again – even into teenage years. Especially if it’s not treated properly.
Constipation causes bedwetting and your child won’t grow out of it. Chronic constipation is the number one cause of secondary bedwetting (bedwetting that occurs after a period of night time dryness). If you thought you’d cracked nights and then suddenly you haven’t – make sure you rule out constipation as a cause. (Dr Hodges’ website will help: www.bedwettingandaccidents.com)
Chronic constipation causes soft stool soiling / leaking and skid marks. Constipation. Not laziness and not a failure to wipe properly (though failure to wipe will cause skidmarks, if your kid has been wiping successfully for 3 years, they haven’t suddenly forgotten how to do it.) If your child is ‘leaking’ poo and they seem unaware of it, that’s chronic constipation. If your child is ‘dropping’ chunks of poo as they walk across the room, seemingly oblivious, that’s chronic constipation too.
A child can be chronically constipated and comfortably pass a normal looking stool every day. It can be an invisible condition for many months before the onset of characteristic symptoms. The gut can hold three months worth of stool without overflowing!
Then there’s problems with holding wee… Many children will go through phases of holding their bladders longer than is healthy. Increased holding causes the bladder to spasm, which causes the child to hold to fight it, which causes the muscles to thicken, which causes the bladder to spasm, which sets up a vicious circle. Holding urine leads to recurring UTIs, overactive bladders (bladders that spasm), urgency and night wetting. This is exacerbated when a large mass in the rectum puts pressure on the bladder or squashes it, decreasing its capacity.
Our lives, schools, preschools, nurseries, diets and even the position in which we poo (sitting rather than squatting), all stand against us having healthy bladders and bowels. It pays for everyone to know what to look out for so that they can step in as early as possible to reverse the damage.
An All-Parenting-Styles Problem
The problems of chronic constipation in young children reach far beyond parents who ec or potty train ‘early’. But those of us who have used a potty from the baby days stand a much better chance of recognising it when we see it and catching it before it becomes a family trauma.
If you have a friend who is struggling with potty training conventionally – make sure they’re aware of how constipation might be hampering their efforts.
Although diet, exercise and changes to routine can all play a role in constipation, situational factors also concern Dr Steve Hodges (the Paediatric Urologist who is all over the internet with articles like this one in the Huffington Post: “Don’t potty train your baby!”. You can read my response to Dr Hodges post here: Are there risks to ec / baby-led / early potty training? )
In this blog I’m going to look at situational causes of chronic constipation, give some tips on how to tackle them, and warn you of the child-led approach that can catch ec-ers out.
Social Skills vs Toilet Training
Dr Hodges says:
“Babies and toddlers simply don’t understand the importance of eliminating when nature calls. Knowing how to poop on the potty is not the same as responding to your body’s urges in a judicious manner.
Once kids learn to put off peeing and pooping, essentially the definition of toilet training, they tend to do so often and for as long as they can. Children — and I mean all children — don’t like to interrupt their lives to use the bathroom.”
This is the ‘laziness’ argument against potty training and I don’t like it.
I hear it from parents all the time “He’s too lazy to use the toilet so he… wees in his nappy at night / wets his pants every day at preschool / wees on the sofa when he watches tv”. It might make sense to an adult, but children aren’t mini adults, and this is passing the buck.
‘Laziness’ can be shorthand for habit and conditioning. It can also mask a situation over which a child has no control – if they can’t feel or don’t consciously recognise that they need the toilet (and the fact that it’s blatantly obvious to you doesn’t mean they’ve actually noticed themselves) – then ‘laziness’ doesn’t come into it.
However, when little children do recognise their body’s signals yet still don’t act on them are they really choosing ‘play over potty’ or has the decision become more complicated than that?
At home, with a potty close by, my toddlers would always use it.
Put them in a nursery or preschool setting where they had to ask to use the toilet – interrupt circle time, interrupt an adult conversation, decide which adult they should ask, ask far enough ahead of time to still make it – and (unsurprisingly) they weren’t so reliable.
What should be a very simple “oh, I need to do a wee, let’s deal with that” becomes a social minefield.
This doesn’t get much better as they get older. My kids frequently come out of school absolutely desperate for the toilet because there hasn’t been time to go during the day.
They’re not allowed to go unless they ask. To ask at lunchtime they need to find a dinner lady and then wait in a queue for a pass. That’s half their break time wasted so of course it’s going to be a deterrent. They’re not allowed to go to the toilet even if they’re walking right past them, because they need to clear it with a teacher first. They’re discouraged from going during lessons and are told to wait and ask again later.
Obstacles, obstacles, obstacles!
This is still happening at age 8 and I’m not the only parent who has to send my children back into school to use the loo before we can set off for home.
So what chance does your 15 month old have at nursery?
How to Avoid Chronic Constipation In the Toddler Years
Toddlers and preschoolers are very vulnerable to chronic constipation. It can develop silently (i.e. with no symptoms) and modern, busy lives are enough to put a child at risk.
So how can you keep constipation at bay?
The first thing is to recognise these 10 signs of chronic constipation. If you know what you’re looking for, you can nip this in the bud before it gets out of control.
The second thing you can do is to put systems in place to help your child to poo every single day.
I know the NHS website says it’s fine to poo every three days, and I know you know someone who poos every other day and has the most amazing gut health, but your rule of thumb should be: poo every single day.
Babies have a soft bowel and it’s easy to stretch. But as soon as it’s stretched, peristalsis doesn’t work properly, the nerves don’t work properly and you have a runaway problem.
If you ever get as far as a serious bowel clean out (and I hope you never will), you’ll be aiming for a poo every single day and you’ll have to be vigilant for months or years to prevent a relapse into stretched rectum territory. This is enough for me stand by ‘daily pooping’ as the ideal.
If you’re looking for websites to justify longer gaps between bowel movements, don’t worry, you’ll find them. But if you have an irregular pooper or a toddler with a pooping pattern that skips days watch for other warning signs and always keep daily poops in the back of your mind.
Setting Up For Success At Nursery and Preschool
Almost everyone who practices ec or early pottying worries about how their child will transition to nursery or daycare or the childminder.
Will the nursery understand? Will the childminder follow your recommendations? Will your child signal or sign or ask like he does at home?
These are natural concerns and can usually be laid to rest by talking to your caregivers and discussing how things work at home.
But unfortunately, even in the most enthusiastic and accommodating nurseries (and pre-schools!), things can go quietly wrong… and due to the nature of chronic constipation, the connection isn’t always obvious.
The bowel can hold three months worth of poo without you noticing a problem. Three Months!!
Now, every parent would notice if their child didn’t poo for three months! But that’s not how it happens. The bowel fills to capacity, little by little, over a much longer period of time. Probably six months or more. By the time you spot undeniable symptoms of chronic constipation it can be very difficult to pinpoint a cause.
The best way to prevent chronic constipation 6 months down the line, is to keep a close eye on your child’s toileting patterns when they start childcare – and to make things as easy as possible for them.
Try to ensure that your child:
Where Ec-ers / Baby-led Pottiers Go Wrong
The trouble with advice like “make sure your child does a poo every day!” is that it doesn’t sit well with ec-ers. If you can feel your hackles rising, maybe you recognise this objection:
“I’ve taught her to listen to her own body. She always poos when she needs to. She obviously doesn’t need to poo now. I’m not going to force her!”
Engineering a potty op for your toddler at the end of the day is not ‘forcing’ her to poo against her will – that’s impossible. But you are creating the opportunity for her to relax and go. It’s fine for you to do that.
Or you might object to the routine-y-ness of it?
“I’m not going to impose a toileting regime! How can I say to my child “it’s time to sit on the potty” when he doesn’t need to go? It’s ridiculous! I would never take over like that. It’s his body. He gets to have control.”
I understand both the logic and the sentiment behind this reaction. But I’m afraid that you do need to instigate a toileting routine because if your child isn’t pooing every day of his own accord, it might not be because of decisions he’s making.
It might be down to the structure of your day.
If you want your child to have complete control over his own toileting needs, you have to put him in an environment where that is practical 24 hours a day. No classes, no shopping trips, no public transport, no car journeys, no childcare, no school runs with older siblings – nothing that happens by the clock in an adult world. Just total freedom and easy access to a pot.
If you impose an adult world and adult priorities on your toddler’s little life, then you have to step in if he gets caught up in it and doesn’t poo all day.
Don’t worry – it’s not as hard as you might think, and if you admit to yourself that something might have gone awry, you needn’t feel like you’re compromising your principles.
Unless your tot has pottering time, when they’re not rushed, not deeply engrossed in something and not falling over themselves to get time with you, you need to make time for that potty sit.
A calm sit-on-the-potty-with-a-book-before-bed can mean the difference between an empty bowel and the beginning of a build up.
(If your toddler is very resistant to sitting on the potty before bed, yet there has been no poo today… get creative! You need to get them relaxed on the pot and you need it to become part of your routine.)
Wait… Is This A ‘Regular’ Potty Pause, Or Is It Constipation?
If your child is skipping poos or has erratic timing or refuses the potty when you offer before bed, you might well be wondering…
And it’s a good question to ask – but unless you’re seeing the signs you’re probably ok.
I’ve written this blog to make you worry – because I want you to recognise this as a serious problem that might affect you. But that doesn’t mean that every blip you have on your ec-ing journey is a reason to panic
There are many other (more likely) reasons for your current dip on the roller coaster.
Teething, illness and developmental leaps (learning to crawl, stand, walk, jump with two feet, talk, start using grammar) can all make an ec’d baby or toddler suddenly unreliable.
Couple any of those with a drive for independence or a rebellion against your pottying style/schedule and you might decide you have a ‘potty pause’ on your hands.
But the symptoms of constipation are distinct from the everyday ups and downs of an ec-ing journey. Not every blip is a disaster waiting to happen.
Understanding constipation means you’ll notice when a blip starts to look more like a habit.
And then you’ll be ready to step in.
What About Regression? And Psychological Factors?
Yep, disruptions to family life can also align with a blip in pottying success.
But you do need to be careful with assigning cause and effect.
Any kind of upheaval can cause a child to be intensely occupied with other things and stop noticing (or reacting) when they need the toilet.
That said, it’s easy to overlook constipation – with it’s root 6 months in the past – if you think you have a psychological explanation for a backwards step.
For example, siblings are often born right around the time when constipation will begin to show. Is it a disruption to family life that’s caused your ‘relapse’ or is the cause lost in the memories of 6 months ago?
Bedwetting might be tied to the psychological stress of starting school but if you’re an average kind of household it’s far more likely to be the result of something physical: An exhaustion that means your child doesn’t wake when they normally would, or a mass of stool in the rectum that has been building for months… A small change in toileting habits due to the new school day, might mean that backed-up poop is now pressing on the bladder at night.
I’m not suggesting that constipation is the cause of all bedwetting or all daytime accidents in all children who were once potty trained (though Dr Hodges implies it pretty much is, and he treats kids with wetting problems day in day out). But it’s something you should rule out before looking for more complex causes. (With the help of your doctor of course. You won’t want to miss a UTI or diabetes by not seeking medical help.)
What If My Child Poops Every Day?
If you’re managing successful evening potty time, or your tot poops daily – willingly and easily of their own accord – then surely they can’t be constipated!
Well, actually….. they can be constipated, yes.
All it takes is for those daily poops to not quite clear all the stool from the bowel and you have the makings of a problem.
That’s why there are 10 signs that you should look for. Any one of them is worth keeping an eye on. If you start to see a few, or notice the more severe ones. it’s worth getting a doctor’s opinion.
Remember, irregular pooping isn’t a prerequisite for chronic constipation.
Knows who to ask when they need to use the potty. Be specific. It might be easier for you to say “ask any of your carers” but that leaves your child with a decision to make at the crucial moment. If at all possible, pick one. Even if this is done daily on arrival. Oh look, Jackie’s looking after you today! When you need to do a wee or a poo, find Jackie, ok?
Knows how to ask to use the potty. Should they interrupt a conversation? Can they sign from across the room? Can they ask during dinner? If your child can talk, give them the exact sentence they need to say and get them to practice it with you. Say to Jackie “Jackie, I need to do a wee” and she’ll help you.
Is familiar with the setting. Take them to the toilet when you arrive and before you leave. Let them get used to using the toilet with you there so that you both know the set-up.
This also means you’ll watch your child use the facilities and know if anything else is throwing them. Are the toilets too high? Can they reach the paper? Do they need to ask for help to wipe or will they be spotted and assisted? Are they worried about the doors?
Little things that are almost impossible to find out from end-of-day toddler round-ups but are immediately obvious if you’ve seen them for yourself.
If you’re pottying and your nursery / daycare isn’t well geared up for ec, bring in your own potty or adapter seat (the same model as you have at home). Help your child to use it in the nappy changing cupboard or wherever it’s going to live. Familiarise them with the set-up so that they know what to expect.
Has time at the beginning and end of the day to poo at home!
This is vital and often overlooked.
A great many children don’t poo at their childcare setting (whether they’re out of nappies or not). Mornings at home can be terribly rushed and in the evening all time is precious. Your baby is delighted to see you but also exhausted; You’re tired too and know you need to crack on with the bedtime routine.
BUT – ask yourself every evening: “Did they poo today?”
If not you need to sit them on the potty and give them a chance!
Settle them on the pot by any means necessary. Start very low key and see how minimal you can make it, but if it takes 5 minutes of tech, that’s better than skipping the sit.
Let them sit for a while – long enough for the poo to come. And it will come if they can relax in a familiar position in a familiar setting.
Be aware that this is your job! Don’t think “Oh well, they’ll go in the morning.” Because maybe they won’t…
you might not see any of the classic symptoms as your child becomes chronically constipated. You can move from frequent and easy potty use to severely constipated so smoothly that you never see it coming. Your child might even have been chronically constipated before you started potty training.
What is chronic constipation?
When a child is chronically constipated, a mass of poop builds up in the rectum or colon, stretching the bowel. Fresh poo moving through the bowel gets trapped behind the blockage and 'builds up' filling and stretching the bowel behind the impaction.
When that soft poo finally squeezes around the blockage, some will stick to it, building the block like an internal stalagmite. The rest of the 'overflow' poo reaches the rectum very soft because it hasn't been processed into a solid stool.
Babies and children who potty train early are at risk of chronic constipation because their bowel control can exceed their social confidence. If they feel the urge to poo at a time when it's inconvenient to do so, they hold on.
But sometimes, if they hold on that bit too long, when they finally poo not everything comes out - and that can be the beginnings of a blockage - without any classic constipation warning signs. (It can also be the beginnings of a holding habit, and that's even harder to deal with.)
Chronic constipation often builds up 'invisibly' but there are signs that you should look out for in your ec'd / potty trained child. I've listed those that I learned from experience.
Disclaimers and "Don't Panic!" Warnings:
1) These are the signs that I personally look for. I'm not a medical doctor - this is personal experience.
2) Although I say constipation can build 'silently' that doesn't mean that your perfectly happy, healthy, regularly pooping toddler is ticking time bomb. If you don't see signs of a problem - there is no problem :) Please don't panic.
3) If you're looking at my list and wondering if a particular sign applies to you, then it probably doesn't! Give it a fortnight, try to remember to look out for it, and see what you think then.
4) Remember that full blown chronic constipation is a condition that builds over a long period of time. Some of these signs give me a vague unease, others make me take action and still others have me thinking 'Ugh! How did we end up here?!' I've included the signs that hint at trouble to come, as well as the 'if you find yourself here get help!' clangers. I'll try to make it clear which is which.
Things to look out for:
Saying they need to poop, going and finding the potty, sitting down, but then not doing anything.
If the 'false alarm' happens once, it's nothing. If it happens twice in a day, or twice in two days, or several times over a week, that's suspicious. Can you explain it? Is your child unwell? Are they getting confused in a toddler kind of way? If not... then maybe there's something else going on.
If you've dealt with constipation before, assume you have the beginnings of a backup (i.e. stool backing up in the rectum/colon) and flush to be safe. If you've never been here before, keep an eye on it and see whether any of the flushing recommendations appeal to you.
In the mean time, introduce regular 'sits' at bedtime or around your child's preferred time to go. If you've had a false alarm and your child hasn't pooped by bed time, sit them on the pot for a few minutes to give them a chance.
Try not to give them anything too absorbing to do during this time. Read them a story. Let them play with their usual potty things. Don't resort to bribery with the ipad unless you have to because if they're too distracted they might not poop.
Buuuuut... if the ipad is the only way to get them to sit and give their bowels a chance, use it. Getting the poop out trumps parenting technique when you're faced with possible constipation in a potty trained child.
Two-tone poops / dual consistency poops.
If the start of the poop is hard and well formed, but the end is very soft or even sloppy - that can be an early warning sign.
If you can see a hard section and there's obviously a soft section behind that has started to move past it in places - that can also be an early warning sign.
Having said that, poo is going to depend on diet, so if you can immediately explain what you're seeing, that's just fine. Poop should be universally soft, yet formed, but every deviation isn't a disaster waiting to happen.
(Remember, chronic constipation can lead to very soft poops all the time, so if every poo is a cowpat of soft poop, that might not be so good...)
Keep an eye on your diet and watch for other signs. If in doubt, flush (because, really, there's no harm in a bit of extra fruit and water). If your child has a tendency towards constipation, flick that switch in your brain that puts you into 'monitoring mode'.
Yes, poo smells. But if it reeks so badly you want to puke, that's not a good sign.
If your child's poop falls into this camp, you'll know it… and it will probably have been happening for some time. The odd smelly poo is neither here nor there, but every time - doctors office for you - you're beyond orange juice and watermelon.
Gritty soft poops or very sticky poop.
If you see gritty piles of poo (especially if you're doing a DIY flush), that is not a good sign. If you see grit and it stinks... get thee to your doctor.
Likewise stickiness. If you're scraping poo off the base of the potty, that's not good. If the smell means you're gagging while you're about it, that's not good at all.
'Gritty' or 'sandy' poo it will be a normal kind of poo colour - maybe a bit darker - but will form more of a pile than a hotdog. The grit is bits of old poo washing off the big blockage. You won't see this kind of grit in the absense of other signs. If your child has eaten something that will produce granular poo - nuts maybe? - that's not what I'm talking about here.
Poop with girth.
A child's poo should be about half the width of their wrist. If it's thicker than that, the bowel has stretched.
You won't believe me that this is a serious enough symptom to start a cleanout, but it should be on your radar. At least go mad on the natural laxatives for a bit and encourage drinking water.
Varying quantities that you can't explain.
If your toddler eats pretty consistently, but they don't poop consistently, take that as a warning and try to clean them out.
Flush, flush flush - either from above or below.
(Yes, you do need to monitor what is going in and what is coming out. Until you're actually in dire straights, you don't need to monitor this with precision, but you should be generally aware of what's going on. Pebbles one day and a potty filled with stinky slop the next: not good! Same sized smooth sided hot-dog poop every day: probably nothing to worry about here.)
Change of bowel movement timing or frequency.
For example, if your child used to poo at 7am every morning like clockwork and they stop doing that, start to pay attention.
Are they still pooping every day? Or does the odd day slip by without a poop? Has that once-a-day routine become once-every-two days? Are there particular days that go by without a poop? Nursery days? Grandparent days?
Unexpectedly pooping in pants.
If your potty trained child suddenly has dirty underwear, pay attention.
Even if it's just a liiiiitle bit - either soft or crumbly or skid marks.
They're probably denying all knowledge of having done it. This is not laziness. It's physical. And they really don't have any idea that it's happened. Believe your child. Doctor's office for you.
(If they're old enough to wipe themselves and you can explain it - relax. A sloppy poo that they didn't wipe properly. A hurried poo on the way out of the door so they barely wiped at all. Not a big deal. But if it's happens once a week. Then twice a week. Or there's too much poo for a wipe-gone-wrong. Or you have a history of this kind of thing. Then it's worth getting checked out.)
Change in self initiation.
If your child always used to self initiate (independently sit on the potty to do their poo, or deliberately signal their need using speech or sign language) and now you mostly send them based on body language - you're probably noticing a holding behaviour.
What happens if you don't send them when you see that holding behaviour? Do they wait 5 minutes then go by themselves? Or does the urge pass and not return for a few hours? If it's the latter, that is not a good sign. Book yourself in to the doctor (and know what to say when you get there).
This is the kind of holding where you can tell your child is holding but they will deny it until they're blue in the face.
Whether they're 30 months or 4 years old, if they've stopped what they're doing and focussed all their energy into trying to hold while swearing blind they don't need to wee or poo, and this happens every time, you have a problem.
You might notice this in their mood if you don't pick up on classic holding behaviours (e.g. clenched bottom or frantic racing). If they've been a horror for hours but finally wee/poo and come off the potty a changed child - all delight and giggles - that can indicate a holding behaviour too. You'll recognise this pattern if it's been going on a while.
ANY SIGNS RELATED TO WEE?
Ah! You've noticed that these signs only relate to pooping.
There are also many signs related to peeing that can mean your child is invisibly constipated - and sometimes to an incredible degree. Night wetting, daytime accidents having previously been potty trained, urgency (no apparent warning and then suddenly a flood), frequency (forever needing to do a wee), recurring UTIs, holding while denying needing to go....
If you have any of these signs, you'd do well to make sure your child isn't backed up (i.e. chronically constipated) before you explore other possible causes.
Reduced appetite (nowhere for the food to go because everything is moving so slowly in the gut), stomach aches, irritability (can be caused by the constipation or by the holding if you've got that going on as well).
Pop belly. If a child has a very large mass of poop growing inside them they can have quite the pop belly - but lots of toddlers are pot bellied and it has nothing to do with constipation, so this might be one to analyse with hindsight!
Nappy/Diaper rash. If your child doesn't wear nappies/diapers and suddenly has nappy rash - that might be related to chronic constipation. If very small quantities of poop leak out unexpectedly, they can cause irritation. Rubbing between the bum cheeks can cause redness and soreness, or the child might scratch themselves and end up with spots.
Getting The Right Help
If any of those sound familiar enough that you're about to call your doctor, make sure you read my doctor's appointment cheat sheet before you walk through the surgery door.
Knowing what to say at that first appointment can save you months of frustration and wasted time. (This cheatsheet is not about undermining your doctor or questioning their knowledge - but it is about understanding their recommendations and knowing how to get them to stand by their treatment plan. It can take months to successfully treat chronic constipation and you will want to be in this together - it's not like picking up antibiotics and never going back.)
Treatment often involves the long term use of laxatives and length of treatment is proportional to the time a child was constipated, so if you delay seeking help by 6 months, that might add 6 months to your laxative treatment time. Don't hang about.
Home Cleanouts: Flush Madly!
If you're at the 'suspicion' stage and don't think you need to get a doctor involved, there are two ways to treat mild constipation. The idea is to flush out the backup and keep the stool soft so that it's easy to pass every day.
1) Flush from above: with natural laxatives (lots of water plus pears, prunes, apples, pineapple, kiwi fruit, melon) or medical laxatives if you've been here before and are comfortable using them.
2) Flush from below: with glycerol suppositories to fix short term problems, or micro enemas to treat chronic problems. If you're familiar with these, you'll know which you prefer and why.
If you're not familiar with the different kinds of laxatives, suppositories or micro enemas, take a look at my doctor's office cheatsheet where I explain the different treatments for chronic constipation, encopresis and chronic holding. I also outline the pros and cons of each from a parent's perspective.
Chronic constipation is a very common childhood ailment. Every doctor is familiar with the condition and the laxatives used to treat it.
Yet it took 18 months and 4 doctors for me to finally understand the severity of my daughter's condition and embark on a treatment plan that actually worked.
This wasn't because any of those doctors prescribed the 'wrong' treatment. It was because I didn't know how to tell whether those treatments were working effectively. And as it happened, they were barely working at all.
Asking the right questions, and knowing something about what to expect of a treatment before you get started, can make a huge difference to how quickly your child starts to recover.
And that's what this cheatsheet is all about.
Disclaimer: I feel like I'm walking a very fine line by writing this. I can not possibly diagnose your child. Even if I was qualified to do so (which I'm not - I'm not a medical doctor) it's impossible to give tailored medical advice via article on the internet.
But what I can do, is give you some questions to ask your doctor during your appointment. Not to undermine them or question their diagnosis but to make sure that you're very clear about what is and isn't being treated, what you can expect at different stages of treatment, and how you know whether that treatment is working.
Explaining Yourself Properly
In order to prescribe adequate treatment, it's vital that your doctor understands the severity of your child's condition.
No doctor is going to assume the worst, when so many children are merely 'constipated from time to time'.
If you're visiting because you've seen a couple of warning signs and you don't want that to escalate, you wouldn't expect the same treatment as someone who has seen those same warning signs on and off for six months, or someone who has had 6 months of encopresis (leaking of sticky or crumbly poop).
So be as specific as you can and if you suspect that your child has some kind of blockage or impaction, make sure you explain why. Try to remember when you first saw any symptoms because that will help your doctor guess at what your child's insides might look like.
TREATING CHRONIC CONSTIPATION: A RECAP
For an overview of how chronic constipation is treated and the types of laxatives prescribed, please read this blog: Treating Chronic Constipation
To recap: Chronic constipation has two phases of treatment:
1) The Cleanout Phase. Clear the backup, clear the impaction.
2) The Maintenance Phase. Maintain a clear bowel to give the muscles and nerves time to recover.
You need to consider both of these phases in relation to your child's condition and the treatment you have been prescribed.
If you're seeing your doctor as a preventative measure, you probably won't have much of a cleanout phase. If you suspect your child is properly backed up, you should be able to identify the two phases of treatment.
Five Vital Questions That You Should Answer on Every Visit To Your Doctor
Answering these five questions will help you no end:
1. What exactly are you treating? Try to get your doctor to describe what they think your child's bowel looks like, and how they arrived at that conclusion. Without an abdominal Xray, this will probably involve guesswork... Perhaps they think there's an impaction the size of grapefruit? Or maybe they think there's no impaction at all?
Painting a mental picture of your child's intestines provides a context for the treatment plan and it is extremely useful for you both to establish a starting point. Better yet, maybe they'll draw you a diagram.
If you've seen symptoms that don't match what your doctor is describing you'll be able to clarify things from the outset.
For example: if you have overflow soiling / encopresis or three days between huge sticky poops that stink the house out and your doctor doesn't describe a large blockage and a creditable mechanism to explain your sypmtoms - they've not realised the severity of your child's condition.
The same goes for any bladder related symptoms. If you suspect chronic constipation as the cause and your doctor isn't treating a large hard blockage that's pressing on the bladder, you're not on the same page.
2. How does the prescribed treatment work? Ask your doctor to explain the mechanism of their prescribed laxatives. Have you been prescribed a stimulant laxative, or an osmotic laxative, or both?
You need to understand how this particular treatment will address your child's condition. This will relate back to question 1: what exactly are you treating.
Before you visit your doctor, make sure you have a general understanding of how laxatives work. This means you'll understand your treatment plan - which is a great first step to having a sensible conversation with your doctor.
3. How will you know your treatment is working? And what do you do if it isn't? Ask how (and when) you'll know that the treatment has worked. Ask for answers related to bowel movements or behaviour rather than length of treatment (try this for a month) or quantity of laxative consumed (keep going until you finish the bottle).
Both are fine strategies for a treatment plan, but no good for knowing if it's working as it should. Running out of medication, or finishing a course of treatment is not an end point! That might be a good time to reassess, but a predetermined schedule does not tell you whether you've acheived your aim.
What will you see? What will you smell? How will your child's behaviour change?
Asking what your doctor expects to happen will also help you think about how to prepare. Would it be unfair to send your child to school? Would it help to structure your day in a particular way?
It's also vital to ask: What if this treatment doesn't work as expected? What can you learn from that and what should you do about it? See my story below for an example of how this conversation might go in an ideal world.
If you're expecting to have to clear an impaction, you'll want to know how you'll know your clean-out phase is complete.
4. Does your prescription match the instructions on the packet? And how much water does your child need to drink to get good results?
Some laxatives give a different dosage on the packet to the one the doctor prescribes so you can't always check the instructions to remember what was said. Your doctor will be thinking about what usually works, taking into account the manufacturer's dosage guidelines, and your child's age and weight.
Some work best if you 'top up' with extra drinks because the dose of medicine itself is kept small and easy.
Do you have any flexibility? Does your child need to drink everything in one go or can you pace it throughout the day?
Have a think about practicalities too. Can you realistically get that much liquid into your child in the time available? Will you need the school to help out? Will that require a doctor's note?
If you have been prescribed (or asked for) glycerin suppositories or pre-prepared micro enemas and are worried about any aspect of anal medication, ask about anything that's worrying you.
5. When should you see your doctor again? If this is your first appointment and you've seen signs of impaction, always, always come back. This is mostly for the UK peeps who need to book non-emergency appointments two to three weeks in advance. Book your next appointment on your way out of the surgery - you can always cancel three days before if you decide you don't need it.
Treating full blown chronic constipation can be a lengthly, frustrating and isolating process.
Pleas for help in facebook groups say things like "I'm at the end of my rope." "I just don't know what else to try." "I'm at my wits end."
Don't let yourself fall into that position. Seeing your doctor regularly is as much for your own sanity as for your child's health. You will need support as you administer the treatment - and your doctor can provide bucket loads of reassurance if you're proactive with your appointments.
An Ideal Conversation With Your Doctor
Let's start with a conversation that was far from ideal, and then craft a much better discussion that results in exactly the same treatment being prescribed.
This was my experience after explaining my 3 year old's intermittent bouts of encopresis and withholding poop. At this point I knew absolutely nothing about chronic constipation. I only knew that previously prescribed treatments hadn't lead to any improvement.
Doctor: Give her 2.5ml of senna before bed and she'll do a poo in the morning.
Me: What if she doesn't?
Doctor: She will.
Me: But what if she doesn't?
Doctor: Don't worry, she will!
Me: What if she wakes up in the night to poo? Will she lose control and poo in the bed?
Doctor: Oh no no no no no. It will fine.
Me: So... how long do we take it. A week? Till we finish the bottle...?
Doctor: Until she is going again.
This doctor had no clue what she was dealing with. And neither did I.
She prescribed a conservative dose of Senna - a stimulant laxative - hoping that it would coax along any slow poo without causing my daughter stomach cramps. For another child - that might have been just perfect, but for us it was never going to work.
Days later, with no result, I called the surgery. I had seen no change in her erratic pooping pattern. I recieved a message back: double the dose. Still no result. So a few days later I called again. "Keep doubling the dose". By now I'd lost all faith in my doctor and I felt like I was in some kind of medication freefall. And I had no idea why the treatment wasn't working.
Now here's my ideal version of that conversation - with the same treatment plan and the same outcome:
Doctor: Give her 2.5ml of senna before bed and she'll do a poo in the morning.
Me: OK. How does that work and how's it going to help?
Doctor: Senna is a stimulant laxative. When it reaches the intestine, it causes the walls to contract and squeeze the poop in the tubes towards the rectum. We want to get the dosage right - so that the squeeze is gentle enough not to hurt, but strong enough to move any poo that might be stuck. She's only little, so let's err on the side of caution and start with 2.5ml - that usually works pretty well.
Me: OK. So, what if it doesn't work?
Doctor: Well, that means one of three things. Either there's more poop than I thought and the medication isn't triggering the contraction, or there's a blockage further down so we're pushing the poop but it can't go anywhere, or this dose doesn't produce enough of a contraction in your child for it have an effect.
Me: OK. So, what should I do if it doesn't work?
Doctor: Try it for 3 nights, if it doesn't work, double the dose for the next three nights. If that doesn't work, double the dose again. Don't worry, it's perfectly safe to do that. If it's still not working, we'll have learned something useful and can tackle the problem in a different way.
Me: What if she wakes up in the night to poo? Will she lose control and poo in the bed?
Doctor: Oh no, don't worry about that. This is a very low dose of senna. Enough to compliment peristalsis, but not enough to cause her intense urgency.
However, you can learn a lot from looking at the poop she produces. If it's soft or loose then that's the fresher poop moving through. If she's not pooped for 3 or 4 days, you should be seeing much harder poo coming through as well - the stuff that's 4 days old. If a week goes by and you're not seeing that - that's suspicious. There might be a larger blockage that we need to break down in a different way.
You might also notice a change in the smell. Stool that has been hanging around in the bowels for days smells pretty bad! As the fresher stuff comes through it will smell different.
Me: So, how long should she need to take it? Do we stop when the fresh stuff comes through?
(Jenn's note: I totally made this next bit up, but either option sounds like a reasonable strategy for a mild case of constipation.)
Doctor: (maybe) You'll need to keep going until she produces a poop that looks and smells normal. If she does that every day for a fortnight on the medication, you can stop taking it and see if she keeps up the rhythm by herself.
Doctor: (maybe) Use it every night for a week. Then use it in the evening if she doesn't poo by herself during the day. Keep an eye on her for a month. If you find that you're still using it, come back.
Me: A month! That seems an awfully long time!
Doctor: (maybe) Don't worry. It's not going to do her any harm. It's a very low dose. It's just keeping her bowel ticking over. We need to make sure anything old gets pushed through and nothing else gets stuck for a while.
Me:<Beetles off to make appointment for 2 week's time>
You see? In the ideal conversation I'm really clued up on why we're trying this treatment, how the doctor expects it to work, and how we'll know if we need to try a different angle. And even though it was never going to work, we could fail quickly and gracefully and with complete faith in our doctor.
As it was, the experience undermined the confidence I wanted to have in my doctor's recommendations.
I ended up pushing for a referral to a paediatrician - who was extremely annoyed to have us cluttering up his clinic.
When his prescribed treatment didn't work either (but only because I didn't ask these questions) we switched to a different paediatrician with a better bedside manner, a more aggressive cleanout strategy and the foresight to order an Xray. Things started looking up after that!
Booking Your Own Follow Up Appointments
When we were signed off by the consultant and referred back to our GP, I booked an appointment every fortnight for at least two months. We'd had so many failed treatments by that point, and relapse is so common, that I decided to report our progress whether they wanted to see me or not.
I don't recommend harassing your GP every fortnight for the duration of treatment - which can be months or years - but in the beginning you need to know that you're on the right track - and failing to properly finish a cleanout or get daily clearence from your maintenance dose will set you up for a relapse!
Plus, visiting a doctor can give you hope. Just having somewhere to discuss maintenance dose adjustments can make you feel less isolated and more like there's an end in sight.
You can pay back the NHS by getting your child properly clean and avoiding years of ongoing treatment.
Full Blown Chronic Constipation: Don't Be Fobbed Off!
Let's say you've had months of symptoms and have just read something or spoken to someone which made you feel relief... "That's it! That explains everything!" You think you're dealing with full blown chronic constipation complete with an impaction and backed up stool in the colon so you book a visit to the doctor. Do Not be fobbed off with maintenance style treatment options.
You need to clear out the bowel as soon as possible so that it can start to shrink back to size and heal.
With high doses of oral laxatives, combined with daily enemas, your child could be clear within a week or two. That same child would still be impacted 6 months later on 2 sachets of movicol a day.
An Xray Can Make A Massive Difference
If you're in this up to your eyeballs, it won't matter how often you read about physical damage to the rectum, there are still going to be times when frustration gets the better of you. Those times will be dramatically reduced if you've seen an Xray that proves this is beyond your child's control.
If it is immediately obvious to your doctor that your child has a large impaction, they might be quite casual in the way they prescribe treatment. To them, this is simply a physical problem with a physical solution. Prescribe a treatment to clear the blockage, then shrink the rectum and move on.
But to you and your child this is everyday life.
You're going to be living with some sort of treatment every day for weeks or months - and when that involves repeatedly convincing a youngster to 'get with the program' you can end up with a real battle on your hands.
You'll have to find your way through time consuming treatments, restricted family outings (if you need to stay in because there's going to be a lot of messy trips to the toilet), cajoling, explaining, reasoning, bribing, helping and trying not to show your exasperation... all while giving siblings their fair share of your attention.
So what looks like a very simple treatment can play havoc with household harmony.
And in that situation, having an Xray to remind you of what you're up against can keep you sane and committed to a thorough long term treatment despite all the difficulties it presents.
Does having an Xray change the treatment your knowledgeable doctor would prescribe? It does not.
Is an Xray necessary for diagnosis? Not for a doctor who sees chronically constipated kids day in day out, but it can be an eye opener for a GP who thinks they're treating mild constipation.
Does it help parents to successfully treat impaction? YES it does! And a second Xray is great for showing that the clean out phase has worked and there's hope around the corner.
My Top Tip For A Successful Cleanout
Know Your End Point!
If you're prescribed a movicol or miralax cleanout, it will involve taking large quantities of laxative over a number of days. Remember: a cleanout is over when your child is clean, not when the treatment plan ends.
Several times I followed a given prescription rather than studying the poop that it produced.
For example, a prescription might state:
Take 2 sachets of movicol on days 1 and 2,
Take 4 sachets on days 3 and 4,
Take 6 sachets on days 5 and 6,
then switch to a maintenance dose.
So you might think the cleanout would end after day 6 - but in fact the cleanout doesn't end until you see poop that smells fresh and looks like silky smooth chocolate custard.
A stubborn or long term blockage might not even start to break down until day 4 or 5 of your first cleanout. So just as the cleanout is starting to take effect, you could end up switching to a maintenance dose.
That's hopeless but it's more common than you might think. The backup gets cleared but the impaction hangs around, slowly building up again and causing symptoms to return 6 weeks down the line.
You need to check with your doctor how many days you can keep going on the maximum cleanout dose, or what you should do if you reach day 6 but your child isn't clean.
6, 8 or 12 sachets of paediatric movicol per day should result in Silky Smooth Chocolate Custard Poops. If the poops are grainy, sticky or stinky: you're not done. If they look like solid hot dogs: you're not done either. Silky. Smooth. Chocolate. Custard.
Suppositories and Enemas Will Give You Your Life Back
If your child has encopresis (soiling) or shows strong holding behaviours (focuses intently on holding while denying that they're doing it) suppositories and micro enemas will make your life a million times easier than it has been.
If you can convince yourself that they're not evil and don't amount to sexual abuse (they're not and they don't) then they will become your best friends.
In the UK your doctor might be reluctant to prescribe them - because they don't clear a backup - but our consultant was fine with me using suppositories to manage our lives as long as I followed his laxative program at the same time. My GP happily prescribed micro enemas when I asked for them.
HOW DO SUPPOSITORIES HELP?
The things that most impacted my life with chronic constipation were the soiling, the holding and the unpredictability of the treatments (take this laxative and wait for somewhere between 8 hours and 48 hours for it to take effect). All were instantly rectified with suppositories.
By guaranteeing a poop at a convenient time every single day we were able to keep the rectum clear (despite it being a toneless flappy bag after the cleanout) and my daughter's pants and bottom clean.
In theory, we should have been able to get the same effect with osmotic laxative. Get the dose just right and you get a daily soft-but-formed poop. But in real life it was impossible. My daughter had no trouble holding for days because her rectum was damaged so she didn't feel the poop, and when she did her automatic clamping response took over. Trying to adjust the dose when you have a 2 day lag time between consume and effect was maddening. Too little: no poo. Too much: liquid leaks.
But with a suppository we could focus on the consistency of the stool without needing to trigger the natural 'aha - time for a poo!' response. My daughter, the champion holder, never attempted to hold against the suppository. She always sat herself on the potty and produced a poo around 4 minutes after it was inserted.
No more leaking. No more rashes. No more involuntary holding.
Despite the ongoing treatment plans, as soon as we discovered the magic of suppositories our lives were immediately so much easier.
It was years before her body fully recovered. I cannot imagine how hard it would have been to live through that without suppositories to help us.
You don't even need a prescription. You can pick them up at your local chemist. For age 2 to 5, try the 2g ones. For age 6 and up you can get away with the 4g adult size (which every chemist will have in stock).
Horses For Courses
There's a steep gradient of the severity of constipation so of course not all treatment plans will be the same...
The 'get clean' part can be a nightmare if there's a large impaction, but if there's nothing major going on then a consistent push from behind with a steady dose of laxative can work out fine.
The trouble is, it can be very difficult to know where you stand before you start treatment - which is why it's so helpful to have a clear picture of what your doctor thinks they're treating, and how they expect that treatment to work.
They might be right, or they might be wrong, but at least you know what they expect to happen - which means you can ask the right questions if you see something different.
Theoretically, it’s so simple! Get Clean and Stay Clean!
1) If there’s backed-up stool in the rectum or colon: clean it out.
2) If there’s an impaction that isn’t easily shifted: persevere and clean that out too.
3) Then don’t let it happen again!
In practice, it can be far from easy, so it’s good to understand why.
(This post explains the mechanism for clearing and treating chronic constipation. If you’ve noticed one of my early warning signs, please don’t panic!
Here I’m relating what I learned while treating my impacted child. It took us 4 doctors and 18 months to finally understand the severity of the problem and embark on a proper treatment plan. It then took months to get back to anything resembling normality, and years of vigilance to stay one step ahead of a relapse.
Staying ahead of the condition for my other children is a far cry from that experience. Paying attention to their poop schedule, adding laxative fruits to their diets as needed, knowing when to insist on more water, and flushing with a laxative if we stray into ‘worrying’ symptoms – these are all very quick fixes.)
Chronic constipation is a build-up of stool in the rectum or colon. It’s something that happens gradually, so by the time you get ‘proper’ symptoms – like encopresis (leaking poo) or enuresis (wetting) or those awful sticky stinky poops I talk about here – the poop that started it all has been stuck in the bowel for a very long time. It’s been compacted into a dense ball with age-old poop in the middle and fresher poop stuck around the outside. And it can be bigger than you think possible (after 6 months of laxatives and cleanouts the impaction in my 4 year old’s rectum was still the size of a grapefruit).
The impaction is stuck; Wedged in a tube that doesn’t have the muscular strength to dislodge it. And it’s a compounding problem because the more the bowel stretches, the weaker the muscle tone becomes.
Then there’s the other problem caused by the impaction: the backup.
If you imagine your gut as a motorway, the impaction is an accident blocking all three lanes and the only way around is to creep along the hard shoulder. Just like traffic would pile up behind the accident, poop piles up behind the impaction – and that’s the backup.
Now, in the traffic analogy, police would clear the accident and traffic would flow again – but that’s not usually how bowel cleanouts work. Flushing from above (by taking oral laxatives) is like opening another lane. All the backed up cars can now maneuver past the accident, but those three lanes are still blocked.
It’s an easy mistake to clear the backup and think you’re done. But if your child is going to heal, it’s really important to completely clear the impaction too.
THE AFTER EFFECTS
When both blockage and backup are cleared, you might think you can relax – but again it’s not that simple!
The muscle that once housed so much poop remains stretched and weak – like a balloon that has been inflated and then let down. It can take a long time to return to a tight, springy, healthy state – and it’s not something it can do by itself.
Without help, fresh poop that reaches the stretched section of the gut will get stuck – because the bowel is too saggy to move it along properly. And we all know where that leads..
If this has been going on a long time, all of the rectum and part of the colon will have been stretched to some degree – by either the impaction or the backup. So there might not be much ‘normal’ sized bowel left at the end of the digestive tract, to keep things moving.
That’s why phase two of the treatment “Stay Clean” is not as easy as it sounds.
This is where you’ll hear of long term laxative use, and perhaps be confused by it.
Stimulant and Osmotic Laxatives
You’re likely to come across two types of laxative when treating chronic constipation: Stimulant laxatives and osmotic laxatives. (See the NHS laxative pages for more information.)
Stimulant laxatives act on the wall of the gut and cause it to contract – pushing all the contents forward. This is how peristalsis works, but stimulant laxatives give a lot of extra oomph!
If you don’t have any experience of different types of laxatives, these are probably the kind that you think about- the stuff of cartoons and comedy scenes. (Don’t worry – if you use them to help your child, you won’t be aiming for anything like those extreme reactions!)
Simulant laxatives can be helpful when the muscle tone is so weak that you can’t clear the remains of a blockage, or can’t keep stool moving swiftly enough through the bowel to ensure a poo every day, or you don’t have any involuntary ‘push’ to get all the waiting stool out of the rectum.
Examples: Senna and bisacodyl are stimulant laxatives. Senna is sometimes used during the ‘maintenance’ phase of a cleanout (i.e. when you’re keeping the bowel moving and empty so that it has time to shrink back and heal) – often in conjunction with an osmotic laxative.
Osmotic laxatives cause your gut to retain water. That’s all they do.
One of the functions of colon is to dry out the stool, i.e. extract water back into the body to be regulated and excreted as urine. Osmotic laxatives prevent water from leaving the gut and draw water from the surrounding tissue into the stool.
(They do this by changing the osmotic potential of the liquid in the poo. Essentially, the poopy water contains a high concentration of laxative, the body notices and water enters the bowel to dilute it. When the laxative is consumed with lots of water, the water stays in the bowel because it has a higher concentration of laxative than the surrounding tissue.)
This has two important effects:
1) It keeps the stool soft (and can be taken in different doses to vary the consistency from ‘soft but formed’ to ‘liquid’)
2) It bulks up the stool (i.e. makes it bigger)
PEG3350 (branded as movicol or miralax) is a very popular osmotic laxative – prescribed for both cleanouts and maintenance.
Lactulose is also an osmotic laxative, as is sorbitol – an indigestible sugar similar to lactulose that occurs naturally in apples, apricots, gooseberries, grapes (and raisins), peaches, pears, plums, prunes, raspberries and strawberries.
The role of laxatives in treatment
1) Cleaning out a soft backup.
High-ish doses of an osmotic laxative will turn fresh poo moving through the gut into poo soup. This soup has two functions:
a) To flush any loose stool along with it
b) To soften anything that’s too big to be swept along
For the laxative to do its job, you need to be flushing fluid through the colon. If you’re trying to clear a backup with a maintenance dose of laxative you’re not going to get very far! A maintenance dose is enough to bulk up the stool while keeping it soft – but it’s not going to dissolve or flush anything…
2) Clearing an impaction
This takes longer, because the impaction needs to dissolve in the poo soup. If the soup is too thick, rather than dissolving the impaction, it will coat the blockage with another layer of fresh poo. Not at all what we’re after!
The impaction has probably been around for months (or years) and will be very dense. It’s not going to dissolve easily. You need to flood it with fluid that’s as close to water as you can get and ideally you want it to sit there a soak for a bit. Even then it can take days to see the first breakdown products come out: dark gritty poop that stinks to high heaven.
I know what you’re thinking… “Wouldn’t it be better to use actual water, rather than poo soup?” And you’re right! That’s why enemas are so effective (and not nearly as scary as you probably imagine – especially if your only point of reference is the old Carry On films.)
A micro enema comes in a soft squirty bottle that is smaller than your smartphone. It takes a few seconds to administer and a few minutes to work. But it can only work on an impaction in the rectum – it won’t flush anything backed up in the colon.
3) Keeping the rectum and colon empty during the ‘saggy balloon’ period.
With the impaction and backup cleared you move into the maintenance phase: i.e. maintaining a clear bowel.
At this point, bulking the stool is just as important as keeping it soft.
If you’ve just completed a clean out, you’ll be anxiously looking for signs that the bowel is healing. Does your child poop every day? Are they responding to their body’s messages (i.e. do they seem to be holding or not noticing when they need to poop?)
Unfortunately, neither efficient peristalsis nor stimulation of the rectal nerves is likely to happen with just one day’s worth of poo if the gut is used to accommodating several weeks’ or months’ worth at a time…
A maintenance dose of osmotic laxative bulks the poop out enough for it to ‘touch the sides’ so the gut can practice working properly. Without that bulking agent, one day’s worth of poop might be too small to be moved properly by peristalsis, get stranded, and have to wait around until it’s big enough to be squeezed along. Any poop left stranded in the colon would get dehydrated (that’s the colon’s job) so you’d end up with smaller denser poop by the time it reached the rectum.
You want to avoid this!
Which is why long term laxatives are prescribed – and why you need to remember to keep taking them (even if the idea of being on long term medication fills you with horror). If it helps, try not to think of it as medication, so much as a crutch. You’re not altering the way the body works, just giving it a chance to work with what it’s got.
Don’t be fooled by the wrong type of fibre
It took me a long time to understand the fibre dilemma, so I’m going to outline it here. Hopefully you’re more clued up than I was and this is old news!
There are two types of fibre: insoluble and soluble. You want to focus on soluble fibre.
Until we were at least 6 months into treating the constipation, I equated ‘roughage’ (as my mum used to call it), with fibre.
Bran, brown bread, brown rice, fruit skins, vegetable skins – these things meant fibre to me and are often listed as helpful when treating constipation in adults.
So, when faced with chronic constipation, I assumed that kind of fibre was going to be a big part of the solution – even though we already ate everything in that list.
But it turns out, too much roughage isn’t helpful at all. You need some – yes – but keep an eye on it! Too much causes big poops and stretches the gut that you’re trying to shrink.
Everything I listed above contains insoluble fibre.
What you really need, in the aftermath of chronic constipation, is soluble fibre. Soluble fibre acts like an osmotic laxative, drawing water into the stool to bulk it up while keeping it soft.
For soluble fibre you need porridge (oatmeal), nuts, beans, apples…
So when I thought I was helping by giving my 5 year old shreddies for breakfast, I really wasn’t. Porridge would have been a much better idea.
(That’s one of the things I do now, actually. If I spot any warning signs, porridge becomes the breakfast staple for a while. Then, when things are ticking along, the kids get more choice again.)
Nerve Damage and Self Initiation
Unfortunately, it’s not only muscle tone that is affected by stretching the bowel. You also need to deal with nerve damage.
If your child was leaking poop, or had crumbly poop falling out of them, or completely stopped self initiating (taking themselves to the toilet without prompting from you) – it might have been due to nerve damage in the rectum.
Nerves in the rectum, near the sphincter, fire when the rectum stretches – to tell the brain that there’s a poo waiting to come out.
If the rectum is always stretched, those nerves stop firing. Your child might lose sensation altogether (be unable to feel when they need to go and not notice when a bit of soft body temperature poop leaks out). They might also lack the cues that help them ‘push’ to help their body poo (and their stretched impacted rectum can make pushing ineffectual anyway).
The nerves can take a long time to heal. So if you’re certain your child is clean but they’re not self initiating as you expect – consider the physical reasons for that before jumping to behavioural conclusions (hates the bathroom, is frightened of the potty, is too lazy to go etc).
Withholding Habits and Leaking Poo
If your child has a holding habit, it might be due to the type of poop that was always ‘knocking at the door’. The anal sphincter can tell the difference between solid, liquid and gas waiting in the rectum. Solids give you plenty of warning, liquids cause a clamping of the sphincter to keep them in, and gases can be released.
In some cases of chronic constipation, poop always arrives in the rectum very soft – because there was no space in the colon for it to be processed properly and it had to squeeze past the large blockage. The sphincter goes into ‘liquid panic’ mode and clamps shut. This should trigger your child to race to the toilet, but if it doesn’t… the sphincter muscle stays clamped tightly shut. If it’s clamped for long periods of time every day it can get tired – so tired that it doesn’t close properly in it’s default ‘relaxed but closed’ state.
A tired sphincter can cause problems long after the bowel is apparently back to normal – with small unexpected leaks at the first sign of soft poop for several months or years.
(This is one of the reasons that finding a good maintenance dose of laxative can be tricky. Too much and the soft poop leaks out, too little and there’s not enough bulk to trigger the daily bowel movement. Again, enemas and suppositories can really help with this.)
What if you’re in the early stages?
If you’ve experienced some of my early warning signs and are worried that you might be at risk of developing chronic constipation – don’t be alarmed by what you’ve read here. The difference between early warnings and the full blown condition are like chalk and cheese.
Clearing a large impaction and allowing the gut to recover – that takes time and treatment.
Clearing the beginnings of a backup that hasn’t had time to impact, or hasn’t reached a problematic size – that’s not nearly such a big deal. Cleaning out will be quick and easy. If the gut has only been stretched a little bit and not for very long, then staying clean will be more about monitoring your lifestyle and diet than anything else.
Diet and Food Intolerances
If your child has a problem with constipation and you know it, then you’ve probably already looked at their diet. Hopefully they’re eating plenty of fruit and vegetables and not too much processed food. You might also have added in a few extra sorbitol containing fruits and some soluble fibre foods for good measure.
But do you need to consider ‘special’ diets?
Should you go dairy free? Or gluten free? Or both?
You’ll find plenty of internet advice that recommends restricting your diet for good gut health, but when I took my daughter to the consultant and asked about this he couldn’t have been less interested.
So assess your situation on its own merits and do what you will. You can get tested for celiac disease (gluten intolerance) but read up on it first so that you know in what circumstances the test works best.
I know of parents who swear that taking probiotics or eating natural yogurt makes a daily-soft-but-formed poop massively more achievable. I know other parents who have tried this and not noticed any miracles.
Whatever you try to tinker with, keep in mind the aim of the game: Clear the backup, clear the impaction, don’t let it happen again.
Remember: Any change in diet only counts towards preventing a relapse.
Don’t use dietary changes to try to manage the chronic constipation you’re facing right now. Use a proper cleanout regimen. And if your child was impacted, don’t rely on diet to control the immediate aftermath of the cleanout. Make sure you have an alternative plan in place to keep the bowel clean and empty while it shrinks back to size.
Unfortunately, relapses are very common.
In his book “It’s no accident” Dr Hodges says 50% of patients relapse. On the internet groups I’ve participated in, relapse is always under discussion.
Relapse can mean one of two things:
1) The cleanout wasn’t 100% effective so stool backed up again
2) You didn’t manage to stay clean even with a clean start
Take a deep breath and start again.
Get support from anywhere you can find it, but especially your doctor. Parents who have been through the same thing will have a huge amount of empathy – and also inspirational tales of what life is like on the other side.
Your child needs your help.
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