Dr. Greene's Answer
As a result of stool holding, a child’s appetite will drop. Kids can withhold stool for a variety of reasons, but one reason is something I call the D3 Cycle–Discomfort-Dread-Delay. Kids have an uncomfortable stool, they get afraid of the next one, hold it for a while, the next one hurts worse, and the cycle continues–and gets worse. It can start at any point, often with delay (if they are busy playing, for instance). They can also do it from anger or fear–as with the arrival of a new baby in the home, parental divorce, a stressful move, or other life changes.
If the DDD cycle is the problem, the best way to break the cycle is often with medicine that will soften the stool and make it impossible to hold in. The dose is gradually adjusted until kids have a soft stool daily, and then left at that level for about two weeks while they learn that stooling doesn’t hurt and while the intestines shrink back to normal size. (Often kids who have withheld for a while are so stretched out that they can no longer feel the urge to go until it is too late.) Taper off after another two weeks. The starting dose of Miralax (one option) for a 4-year-old is usually about 2 to 4 teaspoons per day, but sometimes people need to go quite a bit higher before seeing the results. Have the parents check with their pediatrician to see if this might be a good approach for their boy.
Kids with this problem should also be encouraged to have a high fiber diet as well. This is something that you can help with! Ideally, lots of fruits and vegetables should be part of the diet. Any cereals or breads are best as high fiber cereals, whole-grain breads, and whole wheat pastas. Avoid constipating foods such as white rice, white breads, and junk food. In addition, papayas, beets, or daily prune or pear juice can help keep the stools soft once the DDD cycle has been broken.