Toddler poop issues are one of the biggest stumbling blocks in potty training. In Stubborn Toddler Poops Part 1: The Behavioral Side I covered the developmental and behavioral reasons for poop issues to develop and offered some strategies for working through them. Today, I’m going to tackle another common poop issue, a more medical problem: constipation.

Constipation can be challenging to detect because kids often still poop regularly. But, there are often some tell-tale signs, well illustrated by this question:

Q:

Dear Dr. Gwenn:

My 2 year old son always cries when he poops. He tells us when he has to poop but then it can take sometimes close to an hour for the poop to come out.  It’s as if he holds it in. The poop is sometimes hard and accompanied by a little blood and other times very loose, so I don’t think he’s constipated. I also have him eat a lot of fruit, some juice and water. Could there be something seriously wrong?  Is there something we should be doing?

A:

Poop problems are very common in young children and can produce a great amount of discomfort. And, more times than not, have a very simple explanation. However, whenever a child is as uncomfortable as your son, it’s always a good idea to call your pediatrician to truly get a handle on the situation and start treatment for what’s causing the discomfort.

Even though your son is having rather regular bowel movements and you have him on a high fiber diet, his history is very suspicious for constipation – that’s the reason for the small stools at one point in time and the loose stools at another point in time. The loose stools are actually leaking of some stool around the hard, small stools that are not cooperating to move forward.  When this occurs, it’s not uncommon for the child to develop some irritation and superficial tears called fissures in the rectal area which creates a small amount of blood streaking.

You are correct that he is holding back the poop. Once a child has one painful poop at this age, the child becomes quite reluctant to poop again which only makes the situation worse. This creates a viscious cycle which often won’t break when it gets to this point without the aid of stool softeners.

There are many myths about stool softeners, the most common is that they are addicting. That is simply not the case. Stool softeners allow the situation to calm down not only so a child can poop without pain but so the intestine can heal and return to it’s normal function again.  Think of the intestine like a big slinky. It has a certain amount of elastic coil that allows it to push the stool along which allows us all to have bowel movements. Hard stools stretch out the elastic areas of the intestine like an overstretched slinky. This adds to the difficulty in a child being able to poop. So, stool softeners help buy time to correct a few problems – medical and behavioral. In some kids this can take a few weeks and in others a few months. Your pediatrician will help you sort out those finer details and pick which stool softener makes sense for your son.

Sorting out which came first the hard stool or the behavioral issue is like figuring out the answer to the chicken and egg question. What’s important is to look forward, fix the problem and know you’ve learned something about your child’s body to help him be more healthy in the future.

Disclosure:

I have partnered with Pull-Ups® to serve as a Pull-Ups® Potty Training Partner. I have been compensated for my time commitment to the program, which includes writing articles for Pull-Ups.com, offering tips and advice on the Pull-Ups® Facebook page. However, my opinions are entirely my own and I have not been paid to publish positive comments or endorse the product.

Two issues that often cause a great deal of frustration when potty training toddlers are poop and preschool pressure. I received this question from a grandparent a while back that well captures both issues.

Q)

Hi:

We have been trying to potty train our 3 1/2 granddaughter.  She does pretty well with the pee, but bowel movements have not been successful. She says “the poopy doesn’t listen to her”. We can’t send her to preschool because she has to be fully potty trained.

She is the middle child and is very social and smart. We have tried rewards but nothing seems to work. Her brother didn’t train until he was close to 4. We can’t understand how she can be so smart in every area but seems to be resisting with this. Do you have any suggestions?

Grandma Lee

A)

Dear Grandma Lee:

This is not an uncommon situation. Many children do just fine pooping in their diapers or Pull-Ups  but hit a huge wall when it comes to doing the exact same thing in the toilet. While trying to help the child move to the next step, a clash of wills typically develops pausing the entire process.

It’s important to keep in mind that your grand daughter only has two ways to control this situation. She can control her ability to poop and she can control when she poops. These factors also feed into the war of the wills.

In many ways, she’s telling you she wants to be left alone, which makes sense in many ways because this is her body and her body’s biological process. The good news is the majority of children become fully trained by the time they are 4 years of age if left to their own devices. You saw this with her brother. As long as she is pooping regularly and without discomfort, you don’t have to worry about other poop issues such as constipation so there is no reason to put too much pressure on her or intervene with medication. If, however, her poops are infrequent, hard, or very small, you may want to consult her pediatrician for a constipation evaluation since that will factor into her ability to poop comfortably and may be why “her poop won’t listen to her”.

It can be stressful when preschools place a requirement on needing to be fully potty trained before entering school and I can understand your frustration. There are many daycare/preschools now that understand the developmental range of potty training and do not have this strict a requirement and in fact help with the training process at the school for this very reason. This may be a good juncture for you to explore those sorts of preschools if you have that flexibility to do so. The more national chains would be the place to start and other parents in your community can give you suggestions of schools with similar developmental potty “guiding” philosophies as well.

Finally, potty training has little to do with intelligence and everything to do with biological development. Keep in mind that 3 year olds are very concrete and can not reason the way older children do. So, what you interpret as “resistance” may be lack readiness. Part of the reason this situation is becoming stressful is your expectations are out of synch with your granddaughter’s developmental phase. “Smarts” have little to do with success.

So, your best bet right now is to back off. Allow her to continue to use Pull-ups and reward her when she recognizes she has a bowel movement and continue to encourage her to use the potty but let this be on her time frame and not yours. I view this is as “potty guiding”. I’ve always felt it a misnomer to call this potty “training”!

If at any time in the process, you have any concerns about her ability to have a bowel movement even in a Pull up, consult her pediatrician for advice on stool softeners. In the meantime, keep her diet high in fluids, fruits and vegetables and watch binding foods like bananas to help keep the stools soft and regular.

Dr. Gwenn

Disclosure:

I have partnered with Pull-Ups® to serve as a Pull-Ups® Potty Training Partner. I have been compensated for my time commitment to the program, which includes writing articles for Pull-Ups.com, offering tips and advice on the Pull-Ups® Facebook page. However, my opinions are entirely my own and I have not been paid to publish positive comments or endorse the product.

Q)
Dear Dr. Gwenn:

My daughter is 3 ½ years old. I just spent the last year raising her alone while my husband was in Korea. Since we are a military family, our lives change every so often when it has to. Lately our daughter takes up to 3 hours to go to sleep, we have left her by herself and we have to take her back into her room at least 6 times. We’ve tried reading stories in her bed and staying in her room until she falls asleep. On occasion, she has lain in our bed for hours before falling asleep.

During the evening struggles, she often throws fits and kicks and screams. I need help!!! This is affecting my marriage and now I have become one of those mothers that I didn’t want to become with a spoiled child. Please help!!!

Thank you,
Rebecca

A)
Dear Rebecca:

Please know you are not alone in your frustration – we’ve all been there with toddler struggles but you have the additional burden of having a husband who is only intermittently in the picture due to his military obligations. This is not small challenge for so many families today.

Toddlers become easily disrupted when their schedule and sense of security change, and in today’s world deployment of a parent is one of the biggest stressors facing families and kids.

Deployment and separation are very difficult on a family and it is not uncommon for couples and kids to feel enormous stress even on the welcome and happy occassion of a home coming.
The military often has excellent family services which I’d encourage you to explore since part of this situation is an adjustment for all of you to your husband’s tour of duty and his return. I found some very useful resources online that may help you at least start to understand your child’s view of her Daddy’s comings and goings. She is old enough that she may also have some fears about his job. Here are some links that may help you out:

Militarybaby.com: helping a preschooler when daddy is deployed.

Talking to my friends whose husbands have been in the Armed Services, I learned that there are many services available to military families. From what I understand, all military families are connected to a FRG – family readiness group. Those groups form the foundation for support groups, play groups, etc. That group would be a good starting point for you. There really is power in knowing you are not alone.

You could also talk to your husband’s command’s wife who is often in charge of help out the spouses. My friends who have had husbands in the army tell me that different units have different levels of cohesiveness but all these services do exist in one form or another. Finally, keep in mind that all posts have medical units with therapist. From what you described, I’d start there while you are pulling together more social supports.

In the mean time, you and your husband should try and be consistent with your daughter and present a united front. She may be toying with limits now that two parents are actively involved. While I understand how frustrating it must be for your husband to have to deal with a child so out of control, help him see this through her eyes and he may feel less helpless. He’s likely feeling a bit guilty and that is not an easy feeling. This will get better but will take a bit of work from all of you, a great deal of patience and understanding, and some support and help from the outside.

Dr. Gwenn

Q) Dear Dr. Gwenn,

Thanks,
YP

A) Dear YP:

Vomiting in toddlers is always alarming. Although your child is well appearing, it is still possible he has a mild stomach virus. Food poisoning is a consideration with acute vomiting although this has gone on for a while. Other considerations in this setting are reflux or even allergies. I’ve seen a number of children who have such significant post-nasal drip they throw up due to the amount of mucous they swallow.

The first step is to help your son feel better and make sure he doesn’t get dehydrated. Push clear fluids and reintroduce solids slowly following theso-called BRAT diet – breads, rices, applesause and toast…essentially, very bland foods! Also, touch base with your pediatrician to get not only more guidance but to start discussing what may be the actual underlying cause of this situation. An office visit will likely be needed to accomplish that. And, since your pediatrician knows your child well by know and your child’s history, he or she can better advise you on what may be occurring. Once an office evaluation is done, your pediatrician can advise you if any further testing is needed. Often wtih children the diagnosis of vomiting is apparant from the history and physical but because the GI tract is a plumbing system, sometimes we need xrays to peer inside.

For all vomiting situations, seek medical care immediately if your child can not keep anything down, especially fluids. Children can become dehydrated quickly. Sometimes we have to give the children bowel rest and use intravenous fluids to keep them hydrated and safe while we let the work up progress. Other symptoms to call for with vomiting include vomiting green material or blood, fever, or abdomial pain.

Dr. Gwenn

Q)

Hi  Dr.Gwenn,

Our daughter is 3 years old and fell on her knee recently. She will stand on it but is refusing to walk. We personally think there is nothing wrong apart from the graze on the knee.

Could you please shine some light on this situation? This is the 2nd time we have had this problem after a fall on both knees.

Yours gratefully,

Mr.G

A)

Dear Mr. G,

This is not an uncommon situation with toddlers. Toddlers stop toddling quickly after a fall and our job as parents and providers is to sort out the times it is a matter of low “boo-boo” tolerance from something more serious going on beneath the surface where we can not see well without xrays and other radiographic tests.

It’s always helpful to hunt for reassuring characteristics of an injury first and to do a double check of how your daughter is acting now compared with how she normally acts when not injured.

What we all have to keep in mind is falls hurt, especially when on weight bearing parts of our bodies. If she fell square on her knee, that knee is sore. That much we can say with certainly. You and I would know that and realize that a little soreness doesn’t mean anything serious in our knee and walk on it. A toddler freezes.

The second issue to consider is that true injuries that are serious requiring further investigation hurt at rest and with motion. If your child is happy, playful and otherwise herself, no need to worry.

Third, even minor injuries have some element of swelling and tendon, ligament and muscle pulling and tugging which amounts to a minor sprain. That also contributes to the discomfort. Ice helps a great deal. Rest, which your daughter is doing by refusing to walk. If she will allow you to prop up her leg while reading a story or watching a DVD, elevation helps. And, ibuprofen can be very beneficial for its anti-inflammatory qualities and to combat the pain. Ibuprofen is dosed by weight. This link should help.

Finally, the injuries we tend to worry about have swelling, bruising, deformity and more behavioral changes of pain such as crying, whincing, grimaces, holding the knee.

We often try giving a dose of ibuprofen and watching how the few days after an injury unfolds. If, however,your toddler truly refuses to restart her toddling in a reasonable amount of time, call your pediatrician.

Best,

Dr. Gwenn

(Originally posted October 2008; Updated December 2009)

Q) Dear Dr. Gwenn:

Our 23 month old daughter apparently fell down while playing.  My wife and I did not see her fall nor did our other three daughters but we knew something happened because we heard her cry and found her sitting on the floor near her play kitchen. We didn’t think anything of it until the next day when she absolutely refused to walk or even stand on it, but is otherwise fine if she is sitting.

We went to our doctor and she took X-rays of foot and ankle and said there was no break so it was a sprain, check back in a few days.  We checked back after doing our own research and asked if it could be a toddler fracture. The doctor did not seem to want our input, rechecked the same xrays and said there is no break, check back in a week if she is not walking.

I am concerned about waiting too long.  We are going on our third day and still there is no change in her refusal to walk or stand.  I guess what I am wondering is should we wait and is there something else we should do?

Much thanks.

J&A

A) Dear J&A:

This is a very common problem in toddlers given how frequently they fall while mastering their new skills of standing, walking, and running. The biggest issue for me is the tempo of improvement after the initial fall. If a child falls, has negative xrays, but slowly improves with rest and motrin taking more steps and using the leg more, likely the injury is a sprain. But, if the child is not using the leg at all and refusing to bear weight, that is suspicious for a toddler’s fracture.

Toddler bones are very unique compared to ours – they bend similar to a new branch to a significant degree before they break. So, negative xrays are not always the end of the story.

I’d suggest you ask for a referral to a pediatric orthopedist who may be able to give you a more definite answer based just on the history you emailed to me. Many times in this setting, an orthopedist will assume there is a fracture, or break, and recommend a cast for 3-6 weeks.

Your pediatrician was not technically wrong in telling you to wait it out a week. Sprains are actual small tears in the soft tissues of a body part, in this case the lower leg. That hurts – a good deal in fact. Your daughter will not be harmed by waiting that long – she’s essentially splinting the injury by not using it.

A trial of motrin and ice can be really helpful here. If after a good 1-2 days of ice and motrin your daughter is still not bearing weight at all, I’d suspect a fracture more than a sprain.

This becomes a balancing act between following advice and following your gut.

Best,

Dr. Gwenn

(Originally posted April 2007; Updated December 2009)

Q) Dear Dr. Gwenn:

My 3 yr old had an injury to her left foot. It is still has some swelling and she limps pretty bad in the morning, when it’s cold, or she has to run. We have taken her to her pediatrician 2 times. The first time and X-ray was done and no fracture could be detected. The second time was because 6 weeks had passed and no improvement. I would say it is getting worse now and we are on the 9th week.

What do you suggest? I’m a very tired mom from having her beg to be carried all the time. We have it wrapped and on Motrin (i.e. generic ibuprofen), but it’s just not improving.

Thank you for your help.
LK

A) Dear LK:

Thank you for asking this very important question.

At any age, whenever a medical situation doesn’t resolve as expected or is getting worse, that situation needs to be re-evaluated by your original physician, in this case your child’s pediatrician. The re-evaluation is essential to not only see what may have changed from the initial visit but look for new diagnoses that may not have been able to be diagnosed at the original visit. This visit is also an important touch point to help decide if it’s time to consult a specialist at one of the major medical centers.

You are most definitely at the point of needing a full re-evaluation but likely the input of a specialist. Call your pediatrician to arrange an in-office evaluation with a repeat examination. During that visit, discuss what labs and x-rays have been done in the past and whether those should be repeated. Also discuss whether a pediatric rheumatologist or orthopedist would be helpful to see at this stage as both specialize in swollen joints. Your pediatrician can guide you best as to which specialist would be best for your child based on your child’s actual exam and lab test results.

In the mean time, keep doing what you are doing. It may not look as if the Motrin is working but very likely your daughter would feel a lot worse if you stopped it.

I hope your daughter feels better soon.

Dr. Gwenn

Q) Dear Dr. Gwenn:

My 3 year old boy has been limping for a little over 6 months. At first we saw an orthopedic doctor who thought it was growing pains and put him on naproxen twice a day. That did help as long as he took it but he still had a slight limp. If we missed a dose, the pain came back horribly.

Over the past month, his limp and pain worsened. We were sent to a rheumatologist and an ophthalmologist to be tested for arthritis. The tests came back negative. The rheumatologist put him on prednisolone with the naproxen. I was just wondering what the next step should be. I do not want to keep giving my 3 year old medicine unless it is necessary. What else could be causing this limp?

Thanks.

A

A) Dear A:

Limp in a small child is always a challenge to sort out partly because the child is too young to accurately explain how he feels. Since your son has had limp for son long, referals to specialists such as orthopedists and rheumatologists are the next steps once your pediatrician has done the first stage of the office work up.

Since your son’s limp and pain are getting worse, it is necessary that something be done for him to be more comfortable. As much as we would love to give every child a diagnosis for their specific symptoms, that just isn’t always possible. Sometimes the best we can do is rule out the big diagnoses and then treat the symptoms, in this case the pain. In my mind, that is always necessary when it comes to a child with naming the diagnosis very much secondary.

For you to feel more comfortable about treating your son, ask your rheumatologist for a consult session to review the work up and the reasoning behind the prednisolone with the naproxen. Ask about what the working diagnosis seems to be and what the next steps will be if your son is not better in a reasonable amount of time. One important issue you need to consider is that this has been going on for a very long period of time and will likely take some time to calm down.

In addition to traditional medication treatments, ask your rheumatologist about physical therapy and even treatment modalities like accupuncture. Sometimes with chronic pain, these “nonmedical” therapies go a long way in helping people of all ages feel better.

Dr. Gwenn

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