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Two months ago, my 4.5 year old daughter had an illness that caused her to be constipated. At that time, it hurt to go poo. She has recovered from the illness, but has been afraid of pooping ever since. I have tried all sorts of things: rewards, removal of treats, not talking about it, talking about it, laxatives. She has is just convinced it will hurt even though it is coming out in her knickers.

I am at my wits end. In September she will hopefully start kinder garden (we live in Bulgaria). But we need to sort this out first.

Any advice will be appreciated.

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    Hi! Have you looked up any of our questions on the subject? Look up Encopresis in particular, as while your daughter may not have that exact problem, it's related, and many of the same concepts may apply. – Joe Aug 11 '15 at 21:55
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First of all: recognise the fear as something real, but describe it as something that used to happen, and that does not happen now.

"Remember when you had a problem, and it used to hurt to poo? It's so good that poo doesn't hurt now!"

Have a sticker chart to reward prompt pooing. Celebrate success, do not punish set-backs. Children need to learn the signs of needing a poo; these signals can become distorted if a child begins "stool withholding" and they may need to re-learn those signals.

You may find this book useful: It Hurts When I Poop!: A Story for Children Who Are Scared to Use the Potty

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Constipation in children is as common as rain, and as you've discovered, it's a self-perpetuating problem. Please abandon the idea that this problem will be resolved by September. It won't. It's going to take months.

There are lots of reasons this doesn't go quickly:

  • One of the colon's jobs is to reabsorb water from stool. The longer the stool stays in the colon, the harder and drier it becomes. Thus, voluntarily holding back a bowel movement because of fear of pain becomes a self-fulfilling prophesy.
  • Treatment requires a significant change in a lot of aspects of her intake, and this is often hard for parents to maintain (they don't have time/are impatient for results/etc.)
  • The child's sense of decorum or her willingness to please isn't as well developed as her fear of pain.
  • The child will be afraid of bowel movements until she's had at least a month or regular, soft, pain free bowel movements, more often two or three. She actually needs to forget how painful a bowel movement can be.
  • The rewards of a risky proposition (having a voluntary bowel movements) aren't great enough to induce her to try.
  • Talking about it, or trying to reason with her, is absolutely fruitless. Kids this age have their own enchanting and frustrating sense of (il)logic.
  • Forcing the issue by using dramatic measures only focuses more on the problem, and brings it's own set of potential problems.

The best approach is a low-key dietary and behavioral approach that incorporates a lot of changes maintained over a long period of time.

For you:

  • Don't express worry, disappointment or frustration in front of your daughter. None will help.
  • Keep a daily food, fluids (guestimate) and stool diary. You never know what might be a contributing cause, and this way you see what works, as well.
  • Accept her fear as absolutely reasonable and respectable for her. Respect the fear. Don't give her false reassurances. That will only teach her that you're not to be trusted on this issue (and maybe, therefor, others?)
  • Patience, patience, patience. This is an opportunity to build trust.
  • Focus on process over product, that is, praise her efforts, not her successes. This may sound very strange, but it's really invaluable advice. Praising her for pooping will teach her that she's admired and loved in part for her mere ability to poop. Praising her for being courageous in trying new things, sticking with the program, doing things that she might not like for a greater good, problem solving together (how to drink a smoothie at school?), etc. will teach her that she's admired for things she can use in other circumstances, too.

For her:

  • Increase fluid intake immediately. If she is well hydrated, her colon won't reabsorb as much fluid from her stool; her stool will be softer and less painful to pass. Any fluid id preferable to none, but pear juice and diluted prune juice are special in that they contain non-absorbed sugars which draw water osmotically to themselves.
  • increase her fiber intake. Not only with the standard vegetables, but be creative: make stewed fig and/or prune puree with honey (or something) to spread on whole grain bread or crackers. The four P fruits (pears, peaches, plums and prunes) are rich in fiber. (NB: if you increase her fiber intake without increasing her fluid intake, it will make the problem worse, not better!)
  • Make smoothies! Use her favorite fruits (plus the ones above), add flax seeds or flax seed oil.
  • Give her flax seed oil (2 tsp. per day)
  • Make her rewards for sticking with the program substantive: does she like to have her nails done? Giving her a manicure with a pretty translucent polish (or bold, if you like) on a Saturday is a fun activity. Make sure they are rewards she really likes.
  • Save invasive methods (e.g., enemas, suppositories) for measures of last resort. (By this time, you should have at least spoken with - if not actually seen - her primary care provider.)
  • Never use an over-the-counter laxative for your child without talking with her primary care provider first.

Easier said then done: this is a process. Invest in making it positive for both of you.

Constipation
Constipation in children
Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition <-- read and discuss with your doctor if the above doesn't help Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN <-- read if you want to feel really grateful for your daughter's relatively minor problem

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