By Steve Hodges, M.D.
A funny, sympathetic article posted on Romper bears a title many parents can relate to: “I Can *Not* Get My Kid To Poop In The Damn Toilet.”
In the piece, frustrated mom Danielle Campoamor seeks to solve the mystery of her 3-year-old’s refusal. But the explanation she settles on — that pooping in the toilet is just “damn terrifying” for her son — misses the mark.
Yes, for some kids, the “splash of the poop in the potty can trigger all sorts of scary thoughts,” as she notes in the piece. But for many children — almost certainly including Campoamor’s son — fear of the splash or the flush is not the primary fear behind the refusal. It’s the fear of pain.
These kids are chronically constipated.
When you chronically delay pooping, stool piles up in the rectum and hardens, so pooping hurts. Human beings do not like to do things that hurt! We will always find ways to avoid pain. For a constipated 3-year-old, the way to avoid the pain of pooping is simply not to do it — until you simply can’t hold anymore.
Campoamor seemingly dismisses the possibility that her son could be constipated. She writes that “dealing with a steady stream of poop-filled diapers assures me that my son is having regular bowel movements.”
She should not be so assured!
Many severely and chronically constipated children poop every day. They just don’t fully empty, so “regular” is meaningless. In fact, many of these kids poop multiple times a day, a red flag for constipation.
[Access our FREE DOWNLOAD: “12 Signs Your Child is Constipated.]
What makes this boy’s constipation so evident are the contents of his diapers, as described by Campoamor: “the diarrhea poops, and the huge poops, and the tiny poop nuggets that always escape the confines of a soiled diaper.”
Three smoking guns!
Let’s start with “huge poops,” which are the number-one sign of constipation. XXL poops, toilet cloggers, adult-sized poops coming out of small kids — these signal that the rectum has not been emptying regularly.
As for those “tiny poop nuggets,” well stools shaped like rabbit pellets, marbles, or pebbles, are classic signs of constipation, as you can see in our “How’s Your Poop?” chart. (To download the chart for free, click here.)
Heck, I wrote an entire book, Jane and the Giant Poop, to teach kids that soft, mushy piles of poop are the goal!
As “Dr. Pooper” tells Jane in the book:
Healthy poop is a blob,
not formed in a shape.
It’s like pudding,” the doc said,
“not a log or a grape.”
“What you want to come out
is a soft, gloopy mound,
like a heap of frozen yogurt
that swirls round and round.
The diarrhea Campoamor describes is also a classic sign of constipation. It means soft, fresh poop has managed to ooze around the hard, old mass clogging her son’s rectum.
Concluding that pooping in the potty is “damn terrifying” for her son, Campoamor decides she will continue to give him “the space and time he needs” until he’s ready. I appreciate her patience, as I’m all for giving kids time and space. In fact, one reason we have an epidemic of toileting dysfunction is that children are pushed, often by preschools, to toilet train too early.
However, for children with clogged rectums, time and space won’t solve potty refusal. These kids need laxatives — and, in some cases, enemas or suppositories — to flush out mass of crusty old poop and keep stool soft, so pooping no longer hurts and kids give up the holding habit.
I offer specific treatment recommendations in “What To Do If Your Child is Constipated (Hint: Treat Aggressively).”
Trying to potty train a constipated child is a futile and highly frustrating endeavor, for parents and kids alike. It’s critical to resolve the constipation before pursuing potty training any further. That’s rule #2 in “7 Super Important Rules for Potty Training Success: A Guide for Parents,” a short guide I wrote for parents.
When a parent tells me her child won’t poop on the potty, constipation is the first thing I look for. But you have to know the signs! Many severe cases of constipation go unrecognized by physicians, because they tend to feel a child’s belly and ask how often the child poops.
These are not helpful measures! Tiny, wiry bodies can harbor giant masses of stool. The more telling signs are the size and consistency of the stools. (In children who are already toilet trained, pee and poop accidents are big red flags for constipation; so are underwear “skid marks” and peeing with extreme urgency and/or frequency.)
What if a 3-year-old is absolutely, without a doubt, not constipated but will still only poop in a pull-up? What if the child poops a nice pile of mushy every day but still freaks out at sound of the flushing or the disappearance of their poop down that mysterious hole?
Well, that’s when I recommend a method, detailed in The Ins and Outs of Poop by Thomas R. DuHamel, Ph.D., that helps the child gradually work up to pooping in the toilet. First, you encourage the child to poop while wearing a pull-up and standing up in the bathroom. Once she feels comfortable with that, she shifts to pooping while sitting on the toilet but still wearing her pull-up. As DuHamel explains, wearing the pull-up “helps them relax their poop and pee muscles, in part by assuring them that their poop will not drop into the toilet.”
The progression continues: The child then sits on the toilet with a small slit in the diaper, then a progressively larger hole. DuHamel writes: “There are some children who continue ‘need’ their diaper even after it is nothing more than a belt around their waist.”
The final step is for the child to poop on the toilet with no pull-up at all.
In my experience, DuHamel’s progression works well for children whose refusal is not caused by constipation. But I want to emphasize that ruling out — or clearing up — constipation is critical.
What Potty Training Books Get Wrong
Most potty-training books don’t even mention constipation — I know because I recently read 14 of these books! But even the books that do address withholding treat it as a minor, passing issue.
Campoamor herself tries to put her latest parenting challenge in perspective, writing: “I know that, on the whole (pun intended) this is nothing more than a minor inconvenience.”
In reality, it’s a big deal that can have severe and lasting consequences!
Chronic constipation is the top cause of bedwetting, daytime pee and poop accidents, and chronic urinary infections — conditions that are a major source of stress, embarrassment, and exhaustion for parents and kids alike.
I run a medical clinic and a Facebook support group full of parents who only wish they, or their doctors, had recognized the signs of constipation when their kids were in preschool. Now these folks are dealing with kindergarteners who have accidents in class, bedwetting 10-year-olds who won’t go on sleepovers, even teenagers who are terrified they may go off college with giant pull-ups.
Enuresis (wetting) and encopresis (poop accidents) can be resolved with aggressive treatment, such as the Modified O’Regan Protocol (M.O.P.). But fixing these conditions takes a long time and is no fun. It’s a heckuva lot easier to prevent these problems by nipping constipation in the bud when a child is 3.
If I sound alarmist, it’s because my patients have a long, long history of constipation, and nobody noticed. In many cases, X-rays show these kids have softball-sized masses of stool in their rectums, and yet their pediatricians had no idea they were constipated. Somebody’s got to sound the alarm!
Campoamor is absolutely right that "the age that a child masters toileting has absolutely no correlation to future abilities or intelligence.” But for many children, it has everything to do with what’s going on in his rectum.
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and coauthor of five books, including The M.O.P. Book: A Guide to the Only Proven Way to STOP Bedwetting and Accidents, Bedwetting and Accidents Aren't Your Fault, and Jane and the Giant Poop.