Holding on for dear life… A kids way of showing you they are constipated

Author             Jóh-Ann Gouws BPhysT (UP) (NZRP)

Designation     Registered physiotherapist with a special interest in pelvic function

We’ve all witnessed the familiar antics of children when they need to use the restroom but are reluctant to go. In fact, many of us have experienced similar feelings ourselves. Picture this: you’re in line at the grocery store, still several carts away from the checkout, when an overwhelming urge to go strikes. The discomfort is real! So, what do you do in that situation?

Most people instinctively contract their pelvic floor muscles when they feel the urge to poo but want to postpone it. This action sends a signal to the brain that it's not a convenient time, causing the poo pressing against the anus to move back into the rectum until a more appropriate moment arises. In typical circumstances, this process occurs without any special effort, and no one else is aware that the body is signalling the need for a bowel movement.

However, this dynamic changes significantly for those who experience chronic constipation and develop withholding behaviours. Especially in kids who have bodies that are still developing and limited cognitive insight into the consequences of their behaviours.

Why Does Withholding Occur?

Withholding behaviours can emerge for various reasons, especially in children. Often, these behaviours arise during changes in routine. For example, consider three-year-old Jimmy, who recently became a big brother. Previously, his mother had time to prepare healthy meals and ensure he spent adequate time on his potty. With the new baby demanding her attention, Jimmy's potty time becomes rushed, and he may not have such a variable diet as food prep time may be limited.

Similarly, Tayla has started attending a new school where restroom access is limited to designated break times, unlike her previous school where she could go whenever necessary.

In these scenarios, parents may interpret the changes in their children’s bowel habits as emotional responses to new stressors. However, these changes reflect a significant disruption in routine—something that our bowels thrive on. Long-distance runners often emphasize the importance of routine for maintaining regular bowel movements. Most people can identify their own bowel habits, including the time of day and frequency, and many feel uncomfortable if they cannot adhere to their usual schedule.

Another factor contributing to withholding behaviours is pain. A single painful bowel movement can lead a child to withhold future stools, as the brain retains that memory. If a child experiences straining during a bowel movement, they may become more cautious in subsequent attempts. Painful experiences can be traumatic for children, making them hesitant to repeat the ordeal.

Fear of the toilet or the sounds it makes can also contribute to withholding. Additionally, some children may have an aversion to the sensation of passing stool, which could be related to sensory processing issues. An occupational therapist can provide assistance for these concerns.

Chronic withholding can alter how a child perceives the urge to poo and their response to it. In such cases, simply contracting the pelvic floor muscles is often insufficient. It's important to note that children do not withhold stool out of spite, and punitive measures are never appropriate.

Signs of Withholding in Children

Look for these signs that a child may be withholding:

• Tensing the buttocks and tucking the pelvis, similar to a dog tucking its tail

• Walking on their toes

• Crossing their legs

• Sitting with one leg tucked under them

If withholding behaviours are not addressed, they can lead to worsening constipation, abdominal pain, urinary and faecal leakage, and even bedwetting. If a child withholds for an extended period, they may become gassy, and the gas can have a particularly foul odour.

Medical Considerations

It’s essential to rule out any underlying medical conditions that could be causing constipation, such as Hirschsprung's disease, celiac disease, thyroid issues, or cystic fibrosis. A general practitioner is a good starting point for obtaining the necessary tests. If specific concerns arise, a referral to a paediatrician or paediatric gastroenterologist may be warranted.

Addressing Withholding Behaviour

It is crucial to tackle withholding behaviours promptly. Children need reassurance and positive reinforcement to encourage pain-free bowel movements. When you observe signs of withholding, ask if they need to use the restroom and guide them there. Create positive associations with the toilet by engaging in activities such as playing games, singing songs, or using rewards. Celebrate their efforts to sit on the toilet or potty, regardless of whether they have a bowel movement.

Additionally, it’s vital to ensure that their poos are soft and easy to pass, which can be achieved through adequate hydration and a balanced diet for most kids. In some cases, medication may be necessary, which should be discussed with a healthcare provider. Ideally, stools should be soft and mushy before focusing on behavioural modifications related to withholding. The important thing to know is that it can be detrimental to allow this behaviour to continue over long periods and in many cases easy but consistent changes can help your kid have happy and healthy frequent poos.