Episode 2 - Children that will only poo in a nappy This is a 16 minute listen. Resources signposted in this episode ERIC's Guide to Children's Bowel Problems Children that will only poo in a nappy and other toilet avoiders Here is the transcript of Alina and Bethan's discussion. Today we're talking about children that will only poo in their nappy. It's a really common issue that parents contact our Helpline about. Alina is going to be offering some really good advice and tips about how to work through this issue. Here’s an email we received from a parent. My daughter started toilet training at two and a half, and not long after had a tummy bug. Since then she won't use the toilet or the potty for a poo. She turned for a few months ago and will start school this September. She poos every day, but will only do it wearing a nappy when we're at home. It's got so bad that last week she wore knickers to nursery and didn't do a wee for seven hours and waited until she got home. She'll tell us when she's been and her nappy needs changing, we've tried so hard to persuade her that it will be easier for her to go on the toilet, but she point blank refuses. I get so worried when she holds her wee for that long that it's going to cause long term damage. What can we do? Well, Alina, over to you. I've got lots of different tricks up my sleeve for this one. We get asked this a lot but the first thing to do is to try and reassure you that it is really common. It's just a phase for a lot of children. It's something that they go through, particularly after potty training has begun when they just do this refusal. But they will come through it with your help. Why does it happen? It depends on the child. With this girl it's quite likely that the tummy bug she had gave her trouble doing poos - the diarrhoea that frightened her or that it hurt her. And that's what triggered it. For some children, they don't like the flush in the toilet, they go straight to the toilet, and we're pulling away from home they're okay at home just about. But when they're away from home they find that too daunting. For some children it's around liking the comfort and security of a nappy. They have spent those early months of their lives wearing a nappy and potty training is quite a big thing for them to get used to. Some children just find it really hard to not have that nappy there. So what can parents do to break this habit? It can be caused by a physical problem that starts a really strong fear. It's a bit like having a fear of a spider - like a phobia. We get parents that say, well, they don't have a problem weeing and pooing, but they just will not do it in the place that we want to. What's borne out by the calls that we get, is that for a lot of children, it's because they've had a painful poo. Perhaps they were a little bit constipated. And then that memory, that fear of pushing the poo out, means that they just don't want to go anywhere near the place where they're expected to do it. So they would rather have that nappy on. You find that children will often disappear behind the sofa or in their bedrooms and hide and to stand up to do that poo because they've worked out that actually that is the most comfortable place for them to do that. Clinging on to the nappy is that sort of comfort and security. It can be incredibly upsetting for everybody. And it and it can be quite easy to get into a real battle over it. Get that constipation checked out. We would recommend looking at the ERIC website where we've got a whole section on children's bowel problems, and then booking an appointment with your doctor GP. They can check your child for constipation and prescribe some laxatives if that's what's needed. I would also really strongly recommend that you get the child checked for a urinary tract infection. Holding on of a wee for that long, it's very unlikely to cause long term damage. I mean, if you were doing that over months and years, then yes, your bladder muscles are going to get over stretched, but doing this for short period is very unlikely to cause long term damage. But what it can do holding on to it like that is it can cause a UTI. What you need to do is sort those physical things out to give yourself the best chance of of helping them on the behavioural side. What are they drinking during the day? This is important because it doesn't take much for even quite young children to work out that the more they drink, the more they're going to need to go and do wee so they also avoid drinking as well. So drinking plenty is really important and it's just a really nice thing that you can reward a child for. This issue makes kids feel pretty miserable. It can cause a lot of stress and angst but using drinking as a nice achievable goal for them, which we know is going to help soften that poo and is also going to help with their bladder signalling and avoid infections and constipation. How do you tackle the behavioural side of this issue? All the things that I'm going to say are covered in a document we've got on the website called “children who will only poo in a nappy and other toilet avoiders”. The first thing I would say is, if your child insists on wearing a nappy to poo or wee, don't say “no” as it's not going to help the problem. They're just going to simply just avoid doing it even more and then that withholding is going to cause more and more problems. What you need to do is let them have that nappy on and then work on gradually changing their behaviour. Tiny steps approach So it's all about using a tiny steps approach. And being absolutely consistent in sticking to the programme that you decide to do. So what we would say is, talk to your child and explain what's happening and what you're planning to do to try to avoid being in nappies the whole time. Perhaps you can make it a part of the negotiation and agree with your child a new sort of regime that you're going to have, which is that its fine for them to do their wee or the poo in the nappy, but the nappies are going to be kept in the bathroom toilet area, and they just need to let you know when they want to go. Keeping them in the bathroom area, reinforces where weeing and pooing should happen. Some children are happy to start sitting on the potty or the toilet, perhaps in the bathroom, perhaps not, wearing a nappy and over time, you can just loosen it at the side or even cut a hole in. Other children might choose to go to their bedroom and do it there. Begin there and then come to an agreement with your child that they're going to move closer towards the bathroom with the potty. You might find you've got to be really patient because it might take days to get them to the place you want to be. But follow this approach because it really does work. Routine and rewards Children love routine, they also like rewards as well. The key point is that they need to feel that they're achieving something. So make all of these goals achievable for them. Alongside doing this its worth having just toilet time, they can be fully clothed, you're not expecting them to do anything on the potty or toilet. But just for even, you know, less than a minute, they're going to sit on that toilet once a day or the potty once a day just to get used to being there. Fear of the bathroom In terms of the other achievable goals, it's things like them helping you to clean up after they've done the wee or poo, tipping the poo from the nappy into the toilet can be a really good trick because again, it starts breaking down that fear. For lots of children, it's the flush. So you may like to get them used to pushing the flush so they get used to it. Also things like splashing and noise, showing them how to put a layer of paper in the toilet. Lots of children don't like the thought that the poo might splash. You're trying to reduce the fear and increase their interaction with the toilet because unfortunately it is something they're going to have to do and you're just trying to make it manageable for them. Try to make it a nice friendly place whether that's putting posters up and having a little basket of toys next to the potty or the toilet they that they wouldn't normally see. That can be really helpful because it works as a distraction. I remember talking to one family and they got the child involved in making cutouts of feet with brightly coloured paper. And they would come to an agreement with their child that the feet were going to move. So after she'd done her poo in the nappy in the bedroom, then they just came to the bedroom door. And then it was onto the landing. And then it was a toilet door. And so then she got right next to the toilet. It is about knowing your child and thinking what how would they like to approach here? What are their kind of things that they like doing? What about outside the home, at nursery and school? It is absolutely vital that everybody's singing from the same hymn sheet on this because otherwise a child will just get confused. That so there's a couple of things we'd, we'd suggest doing. And so this in the case of this family, you know, this this little girl is about to start school. So we would say before she starts for the parents to ask for a meeting with the class teacher, and any assistants that are going to be working with their child, the special educational needs coordinator of the school and a school nurse ideally as well. Agree a plan with nursery or school We have a really good template healthcare plan form on the website in the help at school section, to download. We try to make it easy as easy for schools and families as possible. This helps you to run through what that girl's routine is, what the issue is and how it's being managed at home. So it can be agreed with the school what they're going to do and how they are going to try and keep it as consistent as possible. It's all about open lines of communication with the staff. Really trying to make sure the staff aren't making a big deal of it. Children, even if they don't share it, will be feeling anxious and sad that this is happening to them and this sort of denial and things are just their way of dealing with it and sort of blocking out of the problem. They need to be treated with plenty of kindness. You've got to be really sensitive to their feelings. There’s lots of resources in the Help at School section of our website. It's also just good idea to point the school in the direction of the bowel problems section just so they understand how much struggling with constipation and withholding for example can affect a child. I think there is a tendency for family members and perhaps nursery and school staff to think well, your child really should be out of nappies by now, that they're just being a bit lazy, they can't be bothered. It's not that at all it really needs to be recognised as what can be quite a quite an overwhelming problem. A common problem shared by many families This affects so many parents and families and but maybe people aren't wanting to talk about it so families end up feeling a bit like you're the only one battling with this problem. There’s no magic wand like a lot of things to do children's wee and poo problems. There is no overnight fix. It's very rare that you will get a child that will happily ditch that nappy, particularly when this has become a bit entrenched. But sticking to these approaches, which is all based on what the work that we've done with families and is what they tell us has worked. We have got a HealthUnlocked community page where parents and carers can get the peer to peer support, so you can actually talk to other families going through it. But it's a tiny steps approach needed to move forward and there's lots of lots of patience, lots of praise, and you'll get there in the end.