The D3 Cycle

The "D3 cycle" (discomfort, dread, delay) is more common than most people think. It results a painful belly that has filled up with stool. Here's how to stop the D3 Cycle.


Hello, my 8-year-old daughter has been suffering from upper abdominal pain for 3 months. She says the pain is right above the navel and to the right about an inch. What worries me is that she also has a bulge where the pain is to the right of her navel. We have had an ultrasound and 2 x-rays. The 2nd x-ray was done by a gastroenterologist and he found that she was full of stool. She has been on a cleaning regimen and has been on Miralax for 3 weeks. The pain is still there not as bad except when she runs or jumps. She is an active little girl and its very frustrating to her to be giving up the things she loves to do. She was in cheerleading/gymnastics class when this pain first began. She has since had to give up gymnastics as she wasn't able to perform because it was to painful. Is there something else the doctors should be looking for or is it possible that there is something that for some reason did not show up on the ultrasound? I would appreciate any information you could give me. Her pediatrician says this may be something she will just have to learn to live with. I feel that more tests should be done. Should I keep pushing for more?

Dr. Greene's Answer

Having the belly fill up with stool is more common than most people think. The scenario is so common that I created my own name for the downward spiral that leads to it. I call it the “D3 cycle” (discomfort, dread, delay).

How Does the D3 Cycle Start?

Children can enter the D3 cycle at any point. Sometimes it begins with an uncomfortable experience passing a hard stool created by a change in diet or a brief illness. Sometimes the starting point is simply the fear of sitting over the gaping hole in the potty to poop. Sometimes children are engaged in playing and choose to ignore the urge to poop, holding the stool in just to delay interrupting a vitally important game.

Whatever the starting point, they end up having a painful experience. When the next urge arrives, the child decides to delay going to the bathroom in order to avert what happened last time. The longer she delays, the firmer the next stool becomes. When she finally does poop, the event is even more uncomfortable-confirming her fears. What she dreaded was true!

She vividly learns from this experiment, but it’s the wrong lesson. So next time she is even more determined to hold in the stool. Discomfort leads to dread; dread leads to delay; delay leads to discomfort. The rectum stretches internally so that more stool can be held, and soon urges to defecate are not often felt. The D3 cycle becomes a powerful trap.

How to Stop the D3 Cycle

But this trap can be undone. Kids should not have to learn to live backed up with stool.

You said that she has been on a program to reverse this for 3 weeks. That sounds like the right place to begin. It can take a while to get the bowels regular. Once kids are having daily soft stools, it takes another 2 weeks for the intestines to shrink back to normal.

Cramping pain during this process is not unusual. If the pain persists after the stool problem is resolved, a long list of other possible causes should be considered. Food intolerances, celiac disease, inflammatory bowel disease, parasites, or other infections could cause it-to name a few possibilities. Further workup may be indicated to find out what else is going on. Children with these conditions deserve to have them identified and treated.

Last medical review on: February 10, 2009
About the Author
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Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
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Recent Comments

My 3 year old daughter refused to poop in the potty. Even the small potty that sits on the ground. She comes to me and asks for a diaper and that is the only way she will go. when she stays anywhere else but home for more than a couple days, she wont poop at all. How can I get her to use the potty?

In another article, Dr. Greene answered a parent who’s little boy refused to poop in the potty:

“Often the quickest way to success is to make steady, little steps forward, rather than just trying again to get him to go straight from diapers back to the fearsome potty.

First, encourage him to do his pooping in the bathroom — like you. He can keep his diaper on, he can be across the room from the potty, but he’s in the right room. Usually this step isn’t too tough. If it is, figure out why (difficulty getting cooperation in many areas, difficulty breaking away from play, defiance, etc.) and address the underlying issue. Once he has comfortably pooped in the right room for 3 days or more, he can take another little step when he seems ready.

Next, have him poop sitting down — like you. He can sit on the floor, on the potty with the lid down, on the potty with the lid up, or wherever he wants in the room. He still gets his diaper (or pull-up or underpants as the case may be). Again, once sitting has become comfortable, he can try another little step.

If he has been sitting on the floor, he moves to the potty or toilet. If the lid has been down on the potty or toilet, now lift the lid. He still gets to wear the diaper (or whatever). This step is usually surprisingly easy. Wait until he is comfortable with each stage before he takes another tiny step.

The next step may be to simply remove the diaper and have him go on the potty — like you. Many kids will move from the last level to this one with unexpected ease. If you gauge that this will not be the case for your son, you can instead cut a little hole in the bottom of the diaper. He can go as before, and the poop may or may not fall into the potty. As the days go by, make the hole larger and larger. I’ve known some kids who just wore a waistband for a bit! Before long, he will want to be free of the diaper altogether, now that he is free from the fear.

Your son wants to use the potty even more than you want for him to –he just doesn’t know it yet. His practical experiments have proven to him his hypothesis that this achievement is unattainable for him. He is discouraged and afraid, and doesn’t want to have to face pain, failure, and fear.

By loosening him from the chains of the D3 cycle, and then by taking this huge task that had inspired dread, breaking it down into small achievable steps, and getting him going again, you can set him free to enjoy the growth he is longing for.”

We hope that’s helpful,
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Hi Dr. Greene,
I have a 4 year old boy who has been stuck in the D3 cycle for a year or so maybe longer. When he has to poop he holds it of course. When put on the potty he cries and says he can’t do this he is scared, that he never wants to poop. We have tried culturelle, miralax, prune juice, and now we have put him back in diapers and are using mineral oil to help. But he still with holds for as long as he can up to a week at a time in between bowel movements. We don’t know what to do. Please help my poor boy. Any advice is very appreciated