What to do when my 3-year-old holds poop in and won't go in diaper or on potty?

Question

My son is almost 3 (33 months) and for the past few months, he has been holding his poop in, to the point that he won't go for many days a time. When this started, the doctor advised us to give him Miralax to make his stool softer so it comes out more easily. Even with the Miralax, he still managed to hold it for two days at a time sometimes, but at least it was coming out at all, so we continued with it.

Anyway, we've been giving him the Miralax for months now, and now he's (supposed to be) going to preschool in September, which of course requires that he be potty trained. We don't want to hold him back since he's developmentally ready otherwise, so we started potty training a few weeks ago.

He picked up the potty training really quickly – for peeing – but he still holds his poop in no matter what. If he's sitting on the potty, as soon as he's about to do it, he stands up and just keeps holding it in (and once he starts to stand, if we even so much as ask him to sit back down, he screams and cries).

We have tried everything to convince him (or distract him enough) to sit and poop: reading books, singing songs, playing games, playing with toys, offering him snacks/treats (graham crackers), giving him stickers, etc. Nothing works.

As of today, it has been a week since the last time he pooped, with the exception of a little bit today and a little bit yesterday (both of which ended up all over the bathroom floor since he won't sit down). The doctor says now we should give him an enema to force it all to come out, but even so, that won't solve anything going forward since he still won't go in his diaper or on the potty in the first place (what are we going to do, give him an enema every week, indefinitely?).

The issue isn't that he's scared of the potty itself, since (a) he was holding it before we started potty training, and (b) he knows exactly what he's supposed to do, since he has no problem with peeing (he sits down himself, points it out afterward, knows that it gets emptied into the big potty, etc.).

It's that he just won't poop, ever – not in his diaper, not on the potty – and the only reason why anything comes out at all is because we've been giving him the Miralax every day (and even then, these aren't "full" poops, just whatever happens to come out because it's soft enough that he's unable to hold it all in).

I'm at a complete loss as to why this even started, and what if anything we can do that would actually help. Is it a behavioral problem? Medical? Both?? Help!

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UPDATE: I just wanted to update this question since a lot has changed since I originally posted it. We discovered there was a specific situation where he would go in his diaper voluntarily: in our bedroom closet with the door closed. So we knew then that the withholding was intentional, since it was now established that he could go if he wanted to.

So we let him continue going in the closet and, over time, found that he usually went around the same time each day. Based on that, we then had him sit on the potty when we knew it was most likely he would need to go. We also managed to find two things that distracted him enough to sit (blowing bubbles and playing with his toy laptop).

By doing this, we were able to get him to go on the potty without really realizing it (so he didn't try to fight it), and then made a big deal out of it every time he did. Over time, that helped establish that that's what he was supposed to do, and now he does so voluntarily. He hasn't pooped in his diaper in probably 3 weeks by now.

I wouldn't say he's "fully" potty trained, in that an adult still needs to go with him and distract him (and occasionally remind him when he needs to go in general), but finally we made progress.

Answer 1

You are dealing with two issues here: stool toileting refusal and the associated constipation.

Constipation: Your doctor is probably recommending an enema because an impaction is preventing defecation at this point. I have an acquaintance who has had success in this same situation using a commercial suppository that is administered by eyedropper – you could ask your doctor about it – it may be easier to administer than enema. The impacted feces may smell very bad, and it is important not to react negatively to it (see below). Continue working with your doctor regarding Miralax usage. Some children stay on it for years; your decisions regarding this should be guided by medical practitioners. In addition to Miralax, increase the fiber in your son’s diet (fruits, fruit juices, vegetables, bran and other whole grains), reduce milk products, and increase his water intake.

Stool toileting refusal: This is a behavioral/psychological issue – about 1 in 5 children go through periods of stool toileting refusal. There are varying theories about the cause, and it may be that there are varying causes (all theories being possibilities). It may be caused by constipation (painful defecation means refusing to defecate), associated with the arrival of a younger sibling (a regressive behavior), triggered by parental or societal negative views toward feces (using negative words like “stinky” to refer to it), or precipitated by being pushed before being ready due to the escalating demands of modern life (like the need to be ready for preschool). It is hard to know exactly what your child’s thinking is, but in his mind he may believe that in holding it in he may be able to stop it forever. At this stage of cognitive development, your son will not be able to understand that stool that is withheld will accumulate, so trying to explain it will not help.

Because this behavior began while still in diapers, it suggests that he has developed negative feelings about it. He may have become aware of negative connotations toward feces through societal or parental verbal or nonverbal signals, resulting in shame and embarrassment when he defecates. In a study where parents were taught to praise defecation and avoid using negative terms for feces, the period of stool toileting refusal was shortened (Taubman, Blum, and Nemeth).

I reviewed a number of articles, the most relevant of which are cited below. Suggestions culled from them which might be of help:

• First, clear out any impaction of feces.
• Avoid any negative communication (verbal or nonverbal) with regard to defecation to reduce any feelings of shame.
• Give a diet rich in fiber and plenty of water.
• Give Miralax.
• Do twice daily toilet sitting (after meals, knees higher than hips, feet supported). There is no pressure or discussion of defecation during this time. It’s just 10-15 minutes of sitting and perhaps reading together. Praise should be given (“You sat on the toilet for 10 minutes! That’s an important job for a boy who is three.”)
• Make poop his responsibility (“Everyone’s body makes poop and we have to let it out once a day – your body makes poop and it’s your job to let it out once a day”). This job includes eating right, drinking water, taking Miralax, sitting on the toilet twice a day, doing the first rinse of soiled underwear or disposing of soiled pullups, and personal hygiene following defecation.
• Praise all efforts using behavior acknowledgement rather than personal judgment. (“You remembered to sit on the toilet after lunch without me reminding you! You took care of your really important job” rather than “You are such a good boy for sitting on the toilet. I am so proud of you.”)
• Your first goal is for him to allow defecation to happen. Defecation in the toilet will come second.
• Help him find success in other areas of his life. As he takes on other unrelated responsibilities and finds success, he will feel more confident about taking on this job as well.
• Let go of any timelines you have for getting this done. The fact that you have a September goal may cause you to unintentionally add stress to an already stressful situation. Mastery will happen when your child is ready.
• Try to reduce the stress around the situation in general. Talk about it less. When you talk about it, limit your words to as few as possible and try not to be repetitive in any single conversation – your child will hear you the first time you say something, so to say it a second time in the same conversation gives it too much importance. Try to use the same words, though, from day to day. (“When we poop in our pullups, we have to clean ourselves up. What’s the first step?”..."When we don't poop for three days, we have to soften the poop with the eyedropper medicine.")
• Do not punish for an accident – treat it neutrally – it is the child’s responsibility to fix – praise efforts at fixing.
• Talk about your own defecation. ("Oh, I think I need to poop" and putting a mark on your calendar after you have pooped, or "When I was 3 it was hard to learn how to poop in the toilet, but now I poop in the toilet every day. You will too when you are ready."

Best of luck! This is a tricky problem, but many have walked this path before you with success!

Citations:

Dr. Linda Thomson – To Poop or Not to Poop

Stadtler, A. C., Gorski, P. A., & Brazelton, T. (1999). Toilet Training Methods, Clinical Interventions, and Recommendations. Pediatrics, 103(6), 1359. (article available through your public library)

Taubman, B. (1997). Toilet Training and Toileting Refusal for Stool Only: A Prospective Study. Pediatrics, 99(1). 54-58. (article available through your public library)

Taubman B, Blum NJ, Nemeth N. (2003). Stool Toileting Refusal: A Prospective Intervention Targeting Parental Behavior. Arch Pediatr Adolesc Med. 157(12). 1193-1196. (article available through your public library)

Beth Choby and George Shefaa – Toilet Training

Barton Schmitt, MD – Toilet Training Problems: Underachievers, refusers, and stool holders

Dr. R.W. DuCharme – Toileting Gone Wrong – Made Right

John Rosemond – Give Stool Refusal a Dose of Sternness - Not an approach I would personally try, but you know your child best.

Two Experts Do Battle Over Potty Training - Article comparing the Rosemond approach with T. Berry Brazelton’s Child-Oriented Approach

Answer 2

Is he able to articulate at all why he's scared to poop? (Our daughter was afraid of what happened to the poop after it was flushed. Once she groked that she was good to go.) Finding the reason for his fear will probably go a long way towards you finding a solution for this problem.

Maybe try the book It Hurts When I Poop. Did wonders for my nephew with a similar issue. And my daughter likes it, although having the poop hurt wasn't her issue.

Answer 3

Mary-Jo's answer above is awesome, but I'd flesh out one more idea from our personal experience:

Don't just encourage all poop, specifically encourage diaper-pooping at least as much as you previously encouraged the potty.

In our case, it seemed like our son had the following issue:

1. He knew going on the potty was awesome.
2. He was not able to make himself go while on the potty yet.
3. He was able to prevent himself from going when not on the potty.

As a result, his trying to get better potty-trained resulted in a lot of withholding, and that then led to more painful stools, which reinforced it, etc.

What helped some was making it explicitly clear that pooping in his diaper was awesome. We celebrate, and do high-fives, with the goal of eliminating his percieved sense that it'd be much better to go in the potty. (We'll obviously go back to that eventually, but want to get to a point where he's more capable of passing stool when he wants too-until then, his only control mechanism is just stopping him up.)

Answer 4

From your story, it could be that poop has been tabooed in your son's little mind. Maybe it is associated too strongly with "dirty" or "bad". I would try to lift the taboo, showing by example that it is a very ok thing.

For example, you could try to do it together. I mean show him that you too poop once a day. Let him come in when you are "at work", let him see what happens to poop, and then the flush, etc. Show how "big" it is.

Or, when you or someone else is going to the toilet, you could underline the fact: "Look, Mama is going to the toilet, there is a biiig poop waiting at the door!"

Same with dogs in the streets, if you happen to live in such an environment. "Rooh, look, a big doggy poop right there!" -- "Papa, don't dog go to the toilet?" -- etc, etc.

Answer 5

I can't believe some of the responses, talking about the poor child tabooed and negativity, poor parents, I'm sure they won't want to post anything again, I also have a 3 year old boy who does not like to let go of his poop and I can certainly say all he has been given is praise and I'm sure he will grow out of it, my daughter did the exact same thing at his age and was on movicol over a year, both had great diets, drank plenty of fluids etc, she eventually grew out of it, all I can say is yes it's hard going and can be frustrating as we know they know that they need to poop and hopefully in the toilet, I'm sure your little boy will grow out of it just like mine will, explain to the nursery about him on his medication, I'm sure you will find that they have dealt with the situation before, take care and I hope wish you luck and I just want to highlight that I'm sure your doing the best you can by your son, otherwise you would never of made the post in the first place. X

Answer 6

I would suggest that you give your son a high fibre diet, try to have him sit on the potty and try to have him go poop on the potty and if that doesn't work, I would try suppositories at each diaper change to make sure that he has gone poop in his diaper.