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Holding stool.

Q My toddler uses the potty for urine, but he is reluctant have a bowel movement there. Sometimes it seems like he deliberately holds his stool until nighttime, when we use a pull-up. How can I make him stop holding his stool?

A While there is no quick fix here, there are things parents can do to help their child through this phase. First, you have to appreciate what's going on medically and psychologically. Stool holding often starts with one or more large or painful stools that may frighten the child. After that, Junior becomes (understandably) a little hesitant to allow stool to pass, because he's afraid it will hurt. So he holds, and waits, and the stool mass gets bigger and harder. So when it finally does pass, it hurts more. Then next time, Junior is going to try to hold in the stool even more. It's a self-perpetuating cycle, and one that can lead to a lot of discomfort. To stop this cycle, parents need to do several things at once.

Don't add to the discomfort of passing stool. Don't try to force it, and don't punish any behavior that's involved with stool. Don't belittle the child or insult him. Avoid saying things like "don't act like a baby" or "you're making me mad." Don't show even with body language that you're disappointed or upset, even with a stool accident-all of that just feels even more negative to the child, and will reinforce his holding habit.

Make stools more comfortable by using a daily stool softener. You can get exact doses and instructions from your pediatrician. The key here is to use a consistent daily dose to keep stools soft and painless, and to not stop using the stool softener until all memories of the painful stools have disappeared. This usually requires months of therapy. That may sound discouraging, but it's much better than going on and off medications for years.

Encourage healthy eating, though don't harp on it or make it a big deal. More fruits and vegetables, and drinking more water, can help. More dairy can make things worse. But, again, don't harp on diet or punish your child because of food issues. That will lead to even bigger problems.

Set aside a "potty time" every day to sit on the pot, to wait to see what happens. Don't let Junior just sit there a few seconds and have a little tiny BM--encourage him to sit a long time, read a story, play with your phone, or do whatever keeps him happy. This should not come across as a punishment. The idea here is to stop relying on whether Junior says he does or doesn't have to "go"--just tell him it's time to go, once a day, and don't rush.

With time and patience, stool holding will stop. Often, though, parents will need input from their pediatrician or a gastroenterology specialist to take care of this. The approach needs to be gentle, non judgmental, and consistent--and even with that, it takes time to develop new habits. While there's no quick fix, there are things parents can do to help their children make it through the holding phase, as it too, shall pass (pun intended).

Telephone Diagnosis: Belly Rain

Giving advice over the phone is always tricky. I can't see your child, I can't see her medical chart, and I can't get a detailed history or any physical exam at all. After-hours calls aren't really to make diagnoses or give detailed medical advice--they're really just for me to try to make sure your child is safe to wait until the next day to see us in the office. If not, it's off to the Emergency Department. Believe me, as long as it's safe, I'd really like to keep you away from there.

One of the most common "do I need to go to the ED?" calls are about belly pain. Kids get a lot of bellyaches, from all kinds of things, and obviously most of them don't require emergency care. Except those that do: appendicitis tops the list, but also bowel obstructions, ovarian torsion ora handful of other things that really can't wait until the next day. So how can I know, over the phone, if you really do need to take your child to the emergency department?

These are the questions I ask parents who call; information I've found can help distinguish which belly aches need immediate evaluation at an ED:

How does your child look, overall? A child who's very pale or grey or barely moving needs to go to the ED. If he says it hurts but he's walking around and looks pretty good, it can probably wait.

Is the belly actually tender? Tender means "hurts to touch." I'll ask parents over the phone to gently squeeze the belly here and there. Don't ask your child if it hurts as you squeeze, just watch his face. If he grimaces in pain or pushes your hand away, the belly is tender. That means: to the ED.

What other symptoms are there? Frequent or forceful vomiting is concerning, especially if there's yellow or green tint from bile. Really, any combination of serious symptoms along with belly pain are likely to lead to an ED referral.

How long has this been going on? Bellyaches that have been going on for many days or weeks or months are much less likely to be an emergency than belly aches that just started, or are intensely worsening over a few hours.

Where does it hurt? Bellyaches in the center of the abdomen, near the belly button, are less likely to be caused by something that needs urgent attention than belly pain in the corners, away from the center.

There's obviously more to phone medicine than these questions, but these are a pretty good start. Again, if you're worried, call your own doctor for specific advice about your own child. Most bellyaches can be safely managed at home, but every once in a while there's a serious emergency brewing. Give your doc a call with the answers in mind to these questions, and you'll be able to get better advice to make sure your child is okay.

Disclaimer: I haven't talked to you, I'm not your kid's doctor, and I'm not giving you specific medical advice in this article. If you're thinking your child has a bad bellyache, call your own doctor for specific medical advice. Stop looking things up on the Internet--there are too many weirdos out there giving out poor information, and you're wasting your time.
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Title Annotation:Pediatric Insider
Author:Benaroch, Roy
Publication:Pediatrics for Parents
Date:Jan 1, 2014
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