Potty training and constipation:
Causes and ways to treat

Potty training and constipation are often tied together. For some (perhaps many) children, making the “passage” between pooping-in-the-diaper to pooping-in-the-potty/toilet is a big challenge, one that can be associated with defecation troubles, like stool withholding and constipation.

Dr. Samuel Nurko defines constipation as: “a delay or difficulty in defecation that has been present for longer than two weeks and is causing significant distress.” (Ref. #1: Managing constipation: Evidence put to practice)

According to Dr. Nurko's article, children’s constipation in most cases is diagnosed as functional constipation, i.e. not caused by a specific organic disorder or diseases.

This page discusses functional constipation only, and more specifically -- the relation between potty training and constipation. As such, it does not refer to chronic constipation, i.e. constipation that has been present long before potty training.

To distinguish functional constipation from organic constipation with full certainty, a thorough medical diagnosis is required.

Speaking as a mom though, and with respect to the issue of potty training and constipation: if my child doesn’t normally have troubles passing stool, and only started to experience difficulties once we started potty training -- I’d make the connection.

Possible causes for functional constipation, and the relation between potty training and constipation

Functional constipation can be led by:

• Changes in diet and fluid intake

• Deviation from usual toileting routines: toilet training is an example for such deviation.

• Voluntary withholding of stool to avoid unpleasant defecation: Children that experience hard bowel movements might intentionally avoid them by holding the stool in. This behavior can lead to constipation, and escalate it, if it was already present.
  On the same note, and with regard to potty training: Children who experience fear or some sort of “emotional blockage” around defecating in the toilet may also withhold stool and develop constipation.

• Changes in daily routine, stressful events, can also influence bowel movements.

• Children who postpone using the toilet when feeling the urge to defecate can also develop constipation (if they do so consistently). This is similar to stool-withholding (bullet #3 above), but can be driven by a different motive, such as not willing to stop activity in order to sit on the toilet.
  “Not willing to stop activity” is actually quite relevant to potty training, which is about dropping the habit of “defecting anywhere” and learning new, socially appropriate toilet habits.

  Toilet training requires kids to manage their urge-to-defecate, stop any activity they're currently doing, and go sit on the toilet or potty. Some kids may try to postpone the urge as it would seem more easy, perhaps.

• Is there a relation between potty training and constipation, to kids’ “Stubbornness”?
  A study from 2006 by Burket et al (Ref. #2) finds a connection between constipation and Stubbornness: According to the study, constipated children were perceived by their parents to be much more stubborn, especially with regard to toileting, than study's control children were perceived by their parents.

  How is this helping? ... Perhaps it can imply something about the way parents should respond to this problem.

• Constipation and stool toileting refusal behavior (STR):

  Stool toileting refusal is not the same as stool withholding, but it can be associated with it in the sense that "toilet refusers" may start to withhold stool at some point (Bruce Taubman, Ref. #5).

  [--- Sidebar ---
  
  A study from 2004 by Blum et al (Ref. #4) finds constipation to be a contributing-factor in stool toileting refusal, rather than a result of it. The study says:

  For children who experience hard bowel movements / painful defecation along with stool toileting refusal (STR), the first episode of constipation usually occurs before the STR. This suggests that for many of these children the tendency-for-constipation was already there, and didn’t start as a result of the STR behavior.

  The conclusion from Blum's study (Ref. #4) along with Taubman's (Ref. #5) can be interpreted as saying that: * Hard bowel movements (or tendency to constipate) can contribute to STR behavior. * STR can become associated with stool withholding. * Stool withholding causes constipation or increases its severity.

  It seems there is a "cyclic relation" between those 3 factors.
  
  --- end of Sidebar ---]

What are the recommended ways to treat functional constipation?

Dr. Samuel Nurko's article (Ref. #1: Managing constipation: Evidence put to practice) suggests that treatment for functional constipation should include the following:

• Guiding the parents: Parents should be encouraged to be patient, positive, well organized, and respond carefully to any presence of fecal soiling (Encopresis), which is an involuntary side-effect of constipation in children.

• Dietary changes: Parents should try to apply (but not to force) a balanced diet for their kids, such that includes whole grains, fruits and vegetables. Carbohydrates such as Sorbitol can be found in certain juices like Prune-juice, and can help soften the stool.

• Behavioral modification: Parents should educate/guide their child to apply regular toilet habits, for example sitting for 5-10 minutes after meals. Dr. Nurko also suggests using incentives to support toilet routine, such as: keeping a stool-chart, combined with a reward system.

• Oral medication: The combination of behavioral management with oral medications has been shown to benefit children with functional constipation: Oral laxatives (which are not invasive and therefore allow the child to maintain a sense of control) are beneficial in enabling regular toilet habits, until the child achieves to maintain those habits without this support.
  
  PEG-based solutions which are more recently introduced (such as MiraLax), can provide a good alternative for the more traditional laxatives (like Sorbitol).

  According to the article, laxatives can be given as maintenance treatment until the child is able to pass stool regularly and without difficulty. Close follow-up by pediatrician is required.

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References and Sources used in Potty Training and Constipation page

1) Samuel Nurko, MD, MPH, Susan S. Baker, MD, PhD, Richard B. Colletti, MD, Joseph M. Croffie, MD, MPH, Carlo Di Lorenzo, MD, Walton Ector, MD, and Gregory S. Liptak, MD, MPH. CME: Managing constipation: Evidence put to practice. Contemporary Pediatrics.Dec 2001;12:56

2) BURKET ROGER C. MD, COX DANIEL J. PhD, TAM ANITA P. MA, RITTERBAND LEE PhD, BOROWITZ STEVE MD, SUTPHEN JIM MD, STEIN CHARLES A. MD, KOVATCHEV BORIS PhD. Does "Stubbornness" Have a Role in Pediatric Constipation?. Journal of Developmental & Behavioral Pediatrics.April 2006;Volume 27;Issue 2;pp 106-111.

3) IFFGD: Internal foundation for Functional Gastrointestinal Disorders [http://www.aboutkidsgi.org/site/about-gi-health-in-kids/functional-gi-and-motility-disorders/constipation]

4) Nathan J. Blum MD, Bruce Taubman MD, Nicole Nemeth MD. During toilet training, constipation occurs before stool toileting refusal. Pediatrics.June 2004;113(6)

5) Bruce Taubman MD. Toilet Training and Toileting Refusal for Stool Only: A Prospective Study. Pediatrics.January 1997;Volume 99;No. 1;pp 54-58.