Dr. MJ Bazos MD, Patient Handout

Stool Soiling or Refusal:

When Your Toddler Won't Use the Toilet

Why do some children who are already potty-trained still have bowel movements in their pants?

Sometimes children who have already been potty-trained accidentally "soil," or have a bowel movement, in their pants. Soiling is usually caused by constipation (can't have a bowel movement easily). Children who are constipated may have one or more of these signs:

• Very small, hard, dry or rock-like stools
• Blood-streaked stools
• Pain or crying during bowel movements
• Stomach pains
• Crankiness or restlessness during the day
• Loss of appetite

If your child is soiling and shows signs of constipation, call your family doctor.

But some children who've already learned to use the toilet to urinate during the day still soil their pants. These children aren't constipated and don't seem to have any medical problems. They haven't yet learned about using the toilet for bowel movements. They usually soil their diapers or pants almost every day and have normal bowel movements.

Why does my child seem to have trouble using the toilet for bowel movements?

A child who gets constipated often or has bowel movements that hurt may resist toilet training. Your child could be scared of being alone in the bathroom, or scared of the toilet. Some children use soiling as a way to control things or to get extra attention. Others just don't want to stop playing.

Is this just a phase?

It's possible that your child is going through "a phase." Your child may not have the skills yet to use the toilet. But, if your child keeps soiling after about three months of being able to use the toilet to urinate, it's probably time for him or her to learn to use the toilet for bowel movements. If other daily routines, such as getting dressed, picking up toys or going to bed are a problem, it may be best to get help for those problems before you try toilet training. Your doctor can offer advice and tell you who to call for help.

How should I start toilet training my child for bowel movements?

Here are 6 steps to help you teach your child:

1. Make a toilet diary.
Keep a "diary" showing when, where and what kind of bowel movements your child has. It will help you and your doctor see patterns in your child's bathroom habits. Try to keep a toilet diary for at least one week before going on to step 2. If your child is in day care, ask the teacher to help you look for patterns in your child's toilet behavior. At the end of this handout there's a sample toilet diary you can use to help you.

2. Teach your child to sit on the toilet.
At first, you and your child can play in the bathroom to show that the bathroom is not a bad place. After a few weeks, your child should start sitting on the toilet (with pants on) for a few minutes at a time. Your child may need a foot stool and favorite books, dolls or small toys during bathroom time.

Read, talk to and play with your child when you're in the bathroom together. Don't expect--or ask--your child to have a bowel movement on the toilet yet. Remember, he or she is still getting used to the idea of sitting on a toilet. Start with a very short amount of time (about 30 seconds) and slowly work up to 5 minutes. A kitchen timer can be the signal for the end of "bathroom fun." Move to step 3 once your child is sitting on the toilet 3 to 5 times a day, for 5 minutes each time.

3. Make sure your child's bowel movements are soft and well-formed.
Your child may decide to stop having bowel movements for a while after "graduating" from diapers (see step 4). To avoid this problem, make sure your child is having soft, well-formed bowel movements. It helps if you give your child less dairy food and more high-fiber foods. If your doctor says it's OK, you may be able to give your child fiber supplements or laxatives for a short time. Ask your family doctor about diet changes.

At first, your child may have more soiling accidents. Have your child help clean up messes, but don't yell or punish your child for soiling. Being angry with your child when he or she soils only makes toilet training harder. Try to stay calm and relaxed when your child soils, so he or she won't feel bad.

4. 'Graduate' your child from diapers.
Have a small family "graduation" party. Tell your child that he or she is now a "big boy" or a "big girl" and won't be wearing diapers anymore in the daytime. It's OK to use diapers at night for a while if your child still wets the bed. Don't use diapers for special times like shopping trips. This sends the wrong message. Choose a low-stress time to start this step of toilet training.

5. Have set times for sitting on the toilet.
Once your child is having healthy bowel movements and is used to sitting on the toilet, start having him or her sit on the toilet at regular times during the day. Time the sits to start about 10 to 20 minutes after each meal and during times when your child usually has a bowel movement. You'll be able to tell these times from the toileting diary. Your child should sit on the toilet at least 3 to 5 times per day, for about 5 minutes each time.

6. Reward bowel movements in the toilet.
The first time your child has a bowel movement in the toilet, give him or her a reward. Good rewards are stars on a chart or fun activities. At first, give a reward after every bowel movement in the toilet. Later, give the reward after every few bowel movements. Pretty soon your child will be trained. Then you can stop giving rewards.

Next, teach your child to know when it's time to go to the toilet. Teach your child to tell you, instead of waiting for you to ask. Young children should tell a parent before they use the bathroom, in case they need help.

When should I call my doctor?

If your child doesn't have a bowel movement for 3 or 4 days in a row, you should call your doctor. He or she will suggest something to give your child to prevent constipation. After you've done this, you should go right back to the step you were on before and keep trying.

Toileting Diary Child's name: Day/date Time Time Time Time Time Time Time Time Mon/22 9 a.m. BMB, UB 12 noon PS, UT 2 p.m. BMP, UP                                                                                                                 BMT=bowel movement in toilet BMP=bowel movement in pants BMB=bowel movement in bed PS=practice sits UT=urinates in toilet UP=urinates in pants UB=urinates in bed Directions: When your child has a bowel movement or urinates: Put day of week and date in the first column. Put time of day in "Time" column. Add the code to the "Time" column. Continue each day.