Q: Every time my 2-year-old granddaughter feels a bowel movement coming, she does everything she can to hold it in. She cries and is obviously in a lot of pain, but she refuses to go. A warm bath sometimes helps, but not always. Could there be something wrong with her physically? Is there anything we can do to help?
A: This can be a scary situation for a toddler. One of the best things you can do to help is be reassuring when your granddaughter is having difficulty with a bowel movement. Only a small number of toddlers who have problems like you describe have an underlying medical condition or a physical problem. But the situation should be evaluated by her primary care doctor. The problem of withholding bowel movements, if not resolved, could lead to worsening constipation, abdominal pain and leakage of stool.
Many toddlers begin holding in bowel movements because they had one that was painful and fear the same thing could happen again. This triggers a difficult cycle. As stool sits in the rectum, water from the stool is reabsorbed, making the stool harder. It also becomes larger as more stool enters the rectum. When it does pass, a large, hard stool may cause a fissure, anal tearing or rectal bleeding and additional pain, leading the child to be more afraid of bowel movements. As a result, the child will develop continued stool withholding and even worse constipation.
Your granddaughter’s primary care doctor can help. The doctor will likely ask about the child’s medical and family history, and then perform a thorough physical exam. The doctor might ask if there is a family history of gastrointestinal problems or other diseases that could cause chronic constipation. These include thyroid disease, cystic fibrosis, celiac disease and Hirschsprung’s disease.
During the physical exam, the doctor will assess how well the child is growing. Poor growth is a sign that there could be an underlying medical condition. The doctor also will look for abdominal problems and examine the child’s anus to make sure there are no anatomical issues that may be causing constipation.
Usually, the history and physical examination reveal no underlying medical conditions or concerns. Rarely, though, they reveal red flags that could indicate a problem. In that case, a referral to a pediatric gastroenterologist is appropriate.
If all is normal physically, the best way to address constipation with a toddler is to reassure the child that it is OK to have a bowel movement. Sometimes adults become concerned that a child is holding stool in because of stubbornness. That is rarely the case. Most toddlers withhold stool because they have had a painful experience with passing stool. Children often respond and learn to relax when they receive reassurance and positive reinforcement.
Also, take steps to keep stool soft, so the child can easily have a bowel movement when the urge develops. To keep stools soft, monitor the child’s diet. More than three to four servings of dairy products a day can sometimes lead to constipation, as can soy products. A balanced diet that includes whole-wheat products, and fresh fruits and vegetables — especially beans, broccoli, apples and pears — can keep stools soft. Prune, plum or pear juice can also soften stools. Too much juice, though, may cause diarrhea and abdominal pain.
For some children, diet changes are not enough to keep stools soft. Medication options are available and safe for children, and include stool softeners and laxatives. But don’t use these medications for a child without talking to a doctor first. Some products are not safe for infants, and a child’s response to medications needs monitoring.
Chronic constipation and stool withholding in toddlers usually takes at least a few weeks to resolve. But, over time, with support and encouragement as their stools become softer, most children realize that having a bowel movement won’t hurt, and the stool withholding will disappear. With a continued, well-balanced diet and positive reinforcement, the toddler can proudly stool without pain or fear.
– Rayna Grothe, M.D.
Pediatric Gastroenterology, Mayo Clinic, Rochester, Minn.
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