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Pediatrics/toddle tigh anal sphincter


My granddaughter is 4 1/2 yrs old.. her bowel movements are hugh and very painful..and when she finally does have a bowel movement it is very large..  we have given her miralax but all that does is cause smears in her under wear... she seems to fight a bowel movement by holding it in.. we have given her enemas ,, that is very traumatic.. is there something else we can do.. she is to start kindergarten in the fall,, but until we can get this worked out.. she will not be allowed in public school or any school for the fact.... is there a surgical procedure that can be done.. and how long will that take to heal... ??  HELP !!!!

Hi Joann,

There is no "quick-fix" type of solution to this problem. We have to work on it for quite some time to tackle this. The first step is to get her thoroughly evaluated by her pediatrician. The pediatrician might get some tests done to look for/rule out a structural defect as the cause of this problem. If that is so, then a surgery might be needed. However, please note that in vast vast majority of such cases, there is no such defect, and the problem usually lies in faulty toilet training and/ or toilet training resistance and needs to be managed accordingly.

After ruling out structural cause, we have to work on toilet training/ habits. In many cases is than one episode of constipation (hard stools) instills fear of Painful defecation in the child. And once he starts holding stools (for fear of pain or any other reason), the colon keeps on absorbing water from it and stools become harder: more difficult to pass and fear of painful defecation encourages the child to hold stools further. Hence, a vicious cycle is set in and constipation begets constipation. To break this cycle laxatives like Miralax are required...The purpose of the laxative is to make the stools a little loose so that colon is cleared, the child is able to pass stools without pain. The dose is adjusted according to the need so as to avoid very loose stools (and avoid staining). Once this is done, dose is reduced and this low dose is maintained for a few weeks so that the child passes soft stools and his fear of painful defecation goes away.

Simultaneously, we have a re-look at her diet: diet should be rich in fiber (plenty of veggies and fruits), lot of water and restricted milk (not more than 450 mL/ 24 hours).

And in case, your granddaughter is  voluntarily holding stools (toilet training resistance, something not uncommon in this age group) the most crucial step in management of constipation is tactful handling of the issue, that is largely a behavioral issue: Just explain her one last time (and it has to be the last time) clearly that it is essential for all of us to let the undigested "dirty things" out of the body daily. Explain to her that it is expected of her that she goes to toilet daily herself and you are not going to tell her about it from now on. She is a big girl now and doesn't need any daily instructions on that count. And after this, just stop all discussions on the topic. Pretend that you are not at all bothered about it. Do not even mention the topic again. And expect improvement in next 2-4 weeks...

Please feel free to ask for any further clarification.

Best wishes,
Dr. Puneet Kumar,
Kumar Child Clinic, Dwarka,
New Delhi, India


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Dr. Puneet Kumar


I would be happy to answer general queries on prevention and treatment of ailments in newborn, infant, toddler, child or an adolescent. Needless to say, it will not be possible to answer any query requiring specific diagnosis of a particular subject.


I have worked in various capacities (medical officer, resident, senior resident, consultant) in public as well as private sector in Pediatrics and Neonatology. Today, I have over 15 years of experience in the field.

Currently, I am running my own clinic (Kumar Child Clinic) in Dwarka, New Delhi and am attached to Lifeline Hospital, Dwarka as consultant pediatrics and neonatology. I am also developing my clinic website into a comprehensive child health/ parenting website (

(a) Chapter "National Immunization Schedule" in Frontiers of Social Pediatrics, Jaypee Publishers: 2nd edition, 2016. (b) Article, "All about Pertussis vaccines" in special issue of Indian Journal of Practical Pediatrics, October 2015 (c) Three chapters (DTP vaccines, Pneumococcal vaccines and Poliovirus vaccines) in "Textbook of Pediatrics for Post-graduates" First edition: 2015. (c) Chapter: "Alternative delivery methods of vaccines" in IAP textbook of Vaccines, First edition, 2014 (published by IAP/ Jaypee Brothers) (d) Special Article: "50 years of Immunization in India: Progress and Future" in January 2013 issue of Indian Pediatrics (e) Four chapters in "FAQ: Book on Vaccines and Immunization Practices" First edition, 2011 AND 2nd edition, 2015 published by Jaypee Brothers. (f) Three articles in special issue of Journal of Pediatric Sciences on “Controversies and Challenges in Pediatric Vaccination Today" in Sept, 2010. Co-edited the series also. (f) Regular column, “How do I treat” in Pediascene ( (g) Review article, “Role of Anti-Poliovirus Agents in Polio eradication and beyond” in Polio Pulse, April, 2008. (h) Chapter on “Acute Infectious Diarrhea” in Textbook of Infectious Diseases in Children. (An IAP Publication), 2007. 2nd edition in 2011. (i) Book-Review (IAP Pediatric Drug Formulary, 2004) in Pediascene, March 2005 ( ) (j) Case-report on Osteopetrosis. Jharkhand Journal of Pediatrics, Dec-2002.

After MBBS, I have done DNB residency in Pediatrics.

Awards and Honors
Winner of IAP practising pediatrician's quiz in 2001.

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