My three-year-old is unaware that he's soiling his pants

Potty training problems

Question

My three-year-old boy used to open his bowels only once per week.

We have tried various things, including orange juice, increasing fibre intake and Lactulose. He now opens his bowels more frequently without relying on the above and has a fairly varied diet.

The problem now is that in between times he frequently 'leaks' into his pants with very soft stools.

He does not seem to be aware when this is happening, but he finds it upsetting. We try to reassure him but it has not improved.

We are now not sure how to deal with this as we are uncertain whether it is a behavioural or physical problem.

Answer

Children generally learn to control their bladder and bowels at vastly different ages.

Bowel function is usually mastered first, delay in bladder control being much more common. There's a lot to be said for allowing the child to develop these skills at their own pace, although using nappies can be very costly, time-consuming and parents may well wish to do away with them as soon as possible.

The best developmental stage to start potty training is probably when the child has learnt to recognise when he actually needs to go.

Attempts to potty train too early are frustrating to the parents and put undue pressure on the child, all of which makes the situation worse.

It is possible that your son, because of his recent constipation and dietary adjustments has never really understood the signals that tell him he needs to go.

Failure to recognise these signals would certainly cause leaking, but as you say this may be a behavioural or a physical problem.

One physical problem that needs to be considered is Hirschsprung's disease, a congenital disorder where a segment of the intestine lacks the ganglion cells that control the intestines' rhythmic contractions.

Symptoms often appear in infancy or early childhood and they include constipation and bloating. Often the child has a poor appetite and may fail to grow properly too.

It's possible that the dietary changes that you have given your son have softened the stool to the extent that he leaks involuntarily. Tests required to investigate this would include a barium enema and a biopsy.

If proven, surgery to remove the segment would be needed. Hirschsprung's disease is, however, unlikely in this case.

A more credible explanation being that the previous constipation caused him to ignore repeated calls of nature in order to avoid discomfort and he's now developed a distended lazy bowel with chronic constipation and overflow leakage.

Take your son to the GP who can gently examine him with a surgical glove and refer him to a paediatrician if there is anything untoward.

Yours sincerely

The Medical Team

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