A 4-year-old who won't join the potty people

Q. I am a pediatrician in Birmingham, Ala. I have a patient who is now 4 years old. She has been potty trained since the age of 2. By that she has urinated in a toilet since then. She has pooped in the potty twice that her parents know of, but since about two weeks after she quit wearing diapers, she has requested a pull-up or diaper to poop in.

She simply refuses to poop in a potty. She will sit on the potty with her pull-up on and poop, but she will not go without the diaper/pull-up. Her parents have tried every type of potty/toilet seat available. They have put benches under her feet. They have cut holes in the pull-up, but she will not go with those "broken" pull-ups. They own every potty book they could find and read them to her constantly. They watch videos, sing songs, and do potty dances. They have promised elaborate gifts without success, and have tried sticker calendars on several occasions. They withhold her favorite things, and tearfully she allows it if she can just have her diaper. They tried the cold-turkey/tough-love method, and the child held onto her stool for at least fourteen hours amid lots of tears.

Whenever the family talks about the situation a lot, the little girl becomes more quiet and reserved. When left alone to get a pull-up on her own she never makes mistakes, and is a happy girl who is pretty mild-mannered given her age.

Mary Doyle, MD

A. By 4 years of age, parents become increasingly anxious about kindergarten if their child is not fully toilet trained. It is at this point we often hear elaborate behavior modification efforts, with sticker charts and a Lamborghini waiting, if only "it all gets put in the toilet."

However, in this case we suspect there were episodes where the passage of stool was uncomfortable, if not painful, which conditioned this child to be anxious and to avoid the toilet. She also noticed that it is easier and less painful to push a stool out if she stands, so she now is afraid to give it up.

Children need to have bowel movements every day or every other day, or the stool becomes too dry and hard to push out comfortably. If this little girl has a history of constipation, until she knows her "poops" aren't going to hurt, no treatment has a chance.

Her stools need to be painless to pass, evacuated in under five minutes, and soft (like paste) or smooth and formed (like a snake.) Small balls that cluster together to make the "snake" are more difficult to expel, and closer on the stool spectrum to the painful and anxiety-provoking "bunny poop" (small hard fecal balls).

Stools can be softened through medication such as polyethylene glycol (Miralax). Ideally, the dose should be titrated up by the teaspoon (starting with 1 or 2 teaspoons a day) every three to four days until the child stools daily. If the stools become liquid and the child has accidents, the dose is too high. After weeks of experiencing painless, uneventful bowel movements (in a diaper), the child's fear and anxiety will gradually extinguish.

It may take eight to 12 weeks before she will sit on the toilet to have a bowel movement. At this point, the parents can introduce a behavioral plan that provides a small reward for sitting on the toilet, and a larger prize for producing a stool in the toilet. Each prize should be small, but motivating. After a number of stools in a row, a larger prize can be earned. Behavioral plans only work if the prizes are big enough to motivate, but small enough so the child is left wanting more. In addition, the parents need to be consistent, as follow-through with the rewards is critical. Otherwise the child may not have enough motivation to change her current behavior.

Medication should continue under the pediatrician's guidance until the new stooling patterns are routine. Then, taper the Miralax, and substitute high-fiber foods. For children who are picky eaters, Miralax can be continued if constipation continues to be an issue.

Bruce Masek, PhD and Suzanne Bender, MD