Monday, July 31, 2006

Withholding Stool


I have a four year old who is having problems going doodoo. What she will do is hold it for days, she will get down on her knees and almost struggle not to go. She usually ends up going in her pants, just a little bit then when I put her on the toilet she sits and holds it in again yelling about how she does not have to go. When she finally does go it takes her quite a bit of work. The worst of it is the size of it. It has got to be so painful for her, my daycare lady actually has to break it up before she can flush. Here at home it is the same way, so big in diameter that it will not go down the pipe. How can such a huge doodoo come from such a little girl?? I have tried everything from greens to grapes, even stool softeners. Is there anything you can suggest that may help her out?

“Desperate for Daughter to Doodoo”

Dear “Desperate for Daughter to Doodoo”,

Stool withholding or Encopresis is a condition that occurs in children who do not defecate when they need to. Instead they hold in the stool, the longer the stool is held in, the more water that is absorbed from the stool into the body. This results in a hard, large stool. The longer the child holds in the stool, the harder and larger the stool becomes. The colon and rectal vault accommodate the large stool by stretching and expanding, which allows the stool to become larger and thus a vicious cycle begins. The larger the stool, the more painful it is to defecate and because it is painful the child holds the stool in longer. Sometime the child holds the stool in so long or the stool becomes so hard that diarrhea or loose stool seeps around the blockage and children end up soiling themselves.

Usually children develop stool withholding or Encopresis because they had a past experience passing a hard stool due to constipation. They remember the bad experience and fear that stooling will hurt again, so they hold in the stool to avoid the pain. (1) The child does not realize that holding in the stool makes the situation worse because they are too young to understand cause and effect. When a parent sees a child holding in stool and in distress, it is quite upsetting and as a result psychological effects worsen the situation.

There is a thought that there may be a genetic predisposition to stool withholding. It is believed that children with Encopresis absorb more water from their stool in the large intestine leading to hard stools which are painful to pass. This is an explanation why many children with stool withholding have a history of constipation since infancy.

The first step in treating Encopresis is to evacuate or clean out the colon. (1) The large stool that distends the lower colon needs to be removed so that the colon can shrink down to its normal size. The best way to evacuate a colon is with a Pediatric Fleets enema, but this procedure is invasive and may be very stressful and only add to the psychological effects of stool withholding.(1) Therefore many Doctors and Nurse Practitioners will attempt evacuating the stool with alternative methods. I prefer to have a child sit in a warm bath, with the water high up over the belly a couple of times per day until the stool is expelled. The minute a child gets out of the bath, I suggest liberally applying Vaseline to the rectal area so that the stool can slip out easier and the child will not be able to hold it in. I recommend telling your daughter that the Vaseline is special medicine to help her go doodoo. Most children believe this and it helps them go. It is also a good idea to put Vaseline around the rectal area each time the child sits on the toilet to have a bowel movement.

The next step is to set up scheduled times for your child to sit on the toilet. Specific time sitting on the toilet should be incorporated into your daughter’s daily routine. Instead of asking your child to sit on the toilet when she feels the need to go, choose periods during the day where the child must sit for 3 to 5 minutes everyday regardless if they need to go or not. First of all, scheduled times to sit on the toilet eliminates the need to coax or battle over toileting. Secondly, if you wait for a child to tell you when she needs to go, she will tell you that she doesn't need to go when she really does because she is afraid that it will hurt. Also, a child may not sense the need to defecate because her rectum is so distended she may not feel the sensation the way that a child without a distended colon feels it. The best time to schedule time sitting on the toilet is after meals and in the morning because this is when the colonic motor activity is the highest. (1) Putting a stool under your daughter’s feet when she is sitting on the toilet may help. Proper foot positioning while defecating can help her push the bowel movement out. (2)

In addition to evacuation by using enemas or baths, colonic evacuation can be done with the use of laxatives. Although you said that you already used laxatives, laxatives alone usually do not work. A combination of all therapies together tends to be more successful. Sometimes the type of laxative used or amount given needs to be adjusted. This can be managed best with the assistance of your daughter’s Doctor or Nurse Practitioner.

Mineral oil works many times if given in the correct amount. One tablespoon of Mineral oil blended in the blender with your daughter’s favorite juice twice per day is a good start. Senna products have also been very successful for many children. If you have tried many over the counter products with no success, you can discuss with your Doctor or Nurse Practitioner the option of giving Miralax. Miralax is a prescription medication which is very successful in treating children with constipation and stool withholding.

The important thing to remember about giving laxatives is that they have to be used regularly. The laxative should be used on a daily basis until the stools are a soft consistency and no longer painful to pass. It’s important to continue the laxative until stooling is no longer feared by the child and they forget that going to the bathroom hurts. Some children need to stay on the medication for 3 to 6 months in combination with other therapies before they can be weaned from it. Some parents are under the impression that the medication doesn’t work because after giving the medication a few times they discontinue it and the stool returns back to the hard painful stools that they were before the introduction of the teatment. If the medication is given intermittently, the hard stools return, the child has a bad experience stooling and the cycle begins again.

In order to maintain soft stools once they are obtained, diet and exercise also needs to be addressed. Although you already tried grapes and grains, it is also important to increase your daughter’s fluid intake and avoid foods that tend to be binding. In some children, soy, rice and bananas cause hard stools and may need to be limited or removed from the diet to prevent constipation. Increasing the amount of foods that promote stooling such as peach nectar, prune juice, frosted mini wheats and oatmeal also helps. Exercise increases peristalsis, or the movement of the intestines and helps a child move her bowels. It is important to make sure that your daughter has exercise daily.

A child on a laxative should be monitored regularly by a health care professional in odor to watch for fluid and electrolyte imbalances and improper absorption of nutrients. In addition, a healthcare professional needs to monitor your child’s care to rule out other health conditions that may cause or contribute to hard stools. A child that has no response to therapy or persistent problems many times will have testing done to rule out other conditions that cause constipation. These conditions may include Hypothyroidism, Cystic Fibrosis, Celiac’s disease, electrolyte imbalances, Diabetes, lead toxicity, internal or external anal lesions or Hirschprung’s disease. Although in most cases, constipation is due to diet and inadequate stooling practices a further investigation may be warranted if symptoms persist. In some cases a child with persistent problems with constipation or stool withholding is referred to a Gastrointestinal Specialist for a further work up and treatment.

If your child has a distended abdomen, fever, vomiting, loss of appetite or increasing abdominal pain associated with constipation or stooling it would be important to have her evaluated right away to rule out an intestinal obstruction or other complications of constipation.

(1) Chronic Constipation in Children: Rational Management. Consultant for Pediatricians. 2003; April:152-155.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. W.B. 2nd ed. Philadelphia, PA:Saunders Company. 1994: 1044.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Advice About Pediatric Health Conditions

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