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I have a very smart and very very sweet three year old. I feel very guilty for not potty training him early but we had a stressful situation in the family and it was difficult to devote the time even though our son was largely with us. He only goes to school 2 days a week for a few hours. He will go #1 but I have to send him in a pullup because he won't do #2 anywhere but his diaper and he stains. Laxatives help but there are two problems- how can you train a child who has loose stool? The chocolate laxative gives him terrible burns, the powder I sometimes can't get in him because if he gets at all backed up, he barely eats. If I manage to keep any laxative going, it tends to give him very loose movements, even when I adjust for dose (either it works or doesn't) I've also tried enemas which he hates. I know he's had painful movements but alot of it is because he held it in to begin with. And when he stains it often gives him a rash. I don't know how to defuse his fear of doing #2. I try very hard to feed him fiber but he's very difficult. I can get protein into him with a song and dance but he complains that all the fruit has 'stuff on it.'  What that stuff is I'll never know.

Answer
Hi Reema,

We need to work on three-pronged strategy (diet, medicines and toilet training) with lots and lots of patience to solve this.

In diet, as you know, fiber is very crucial here. Fruits and veggies are a must: Try different fruits and veggies in different forms: Even smoothies would do. Papaya, banana, oranges, carrots and Prunes are especially good, but keep giving any and every fruit and vegetables. Prefer whole-grain cereals to further boost up fiber intake. Avoid fruit juices. Another component in diet that needs consideration is milk intake. Milk (including curd, milk used in milk cereal, cheese, etc.) should not exceed 450 mL in 24 hours. Milk has lots of calcium that can't be absorbed from the gut and promotes constipation. Secondly, it indirectly reduces fiber intake.

When he withholds, the large gut keeps absorbing water from the stool that is there, making it harder, and thus more painful to pass. When he has pain in passing, he would withhold more: Thus a vicious cycle is initiated wherein constipation begets constipation. We need medicines to break this cycle and take his fear off. In India, we commonly use Lactulose (available here as Livoluk, Duphalac, Smulax, Cadilose, Looz, etc.) for this purpose. In US, they use Peglec more commonly (Available there as Miralax). The dose is titrated such so that after the stool initially becomes a little loose, then it is maintained at a dose so as to maintain the stools in semi-formed to soft consistency (not loose). This low dose is continued for at least 4-6 weeks (sometimes 12 weeks) so that the child's fear of hard stools is totally gone. Discuss about the dose with your doctor.

The third crucial component in our strategy is toilet training. He is passing in diaper is used to it and relates diaper with passing and we can't solve the problem without addressing this behavioral issue (I had a patient who used to pass only on a page of newspaper spread on the floor: as he was first trained to pass that way!). So, you have to first make him sit on the appropriate place twice daily for 5 minutes each: gradually extending to 15 minutes each WITHOUT expecting him to pass. Just he first has to be comfortable and used to sitting there as such. Please ensure to make it a sort of a game, and should not appear to him "rigorous routine"/ "Punishment". Let him take his time to get to it. Gradually, he would start passing appropriately.

And expect good results in a few weeks (not Days!!)

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

www.KumarChildClinic.com

+91-9818356846

Pediatrics

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Dr. Puneet Kumar

Expertise

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.

Experience

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.

Organizations
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 (http://www.kumarchildclinic.com)

Publications
(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, July-Sept 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. http://www.pediatricsciences.com/issue/view/1050000010 (f) Regular column, “How do I treat” in Pediascene (www.pediascene.com) (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 (http://www.pediascene.com/page.php?cid=6&catid=9&id=132 ) (j) Case-report on Osteopetrosis. Jharkhand Journal of Pediatrics, Dec-2002.

Education/Credentials
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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