Mother Requesting Referral for 3-year-old Not Potty Trained — Free SCA Practice Case
Mother requesting referral for 3-year-old not potty trained
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Lisa King
Age
3 years
Consultation Type
VideoAge
3 years 4 months
Mother's Name
Lisa King
Situation
Video Consultation.
Reason for Encounter
"Lucas is still in nappies. Nursery are putting pressure on us. Requesting a referral to a paediatrician."
Medical Records
- ●PMH: Eczema (mild, treated with emollients).
- ●Development: Met all milestones (walking, talking) on time. 8-week and 1-year checks normal.
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●1 Year Ago: Mother mentioned he was a "fussy eater." Advice given on diet.
Patient Script
For the friend playing the patient role
Character Overview: You are Lisa, Lucas's mother. You are visibly stressed and embarrassed. You feel like a "failure" because your friends' children are all dry. You are angry at the nursery for threatening to keep him in the "baby room" until he is toilet trained. You believe Lucas is being "lazy" or "stubborn."
Opening Sentence: "Hi Doctor, I need a referral for Lucas. He's nearly three and a half and he still isn't potty trained. The nursery manager told me yesterday that he can't move up to the pre-school room next term if he's still in nappies. I've tried everything; he just won't do it."
History if Asked (Data Gathering Phase)
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The Behaviour: "He knows when he needs to go. I see him hiding behind the sofa or doing a little dance, crossing his legs. But if I put him on the potty, he screams and arches his back. He'd rather do it in his nappy."
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The "Soiling" (Key Clinical Clue): "He does poo in his nappy, but it's often just these little hard pellets, or sometimes it's really messy and loose, like he can't control it. I think he's doing it on purpose to annoy me." (This describes overflow diarrhea and constipation, not laziness).
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Urinary Symptoms: "He is wet all the time. He doesn't seem to care if he's wet. He has a good stream when he does go, no pain when weeing."
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Diet/Fluids: "He's fussy. He mainly eats chicken nuggets, toast, and pasta. He hates vegetables. He drinks loads of milk—maybe 3 or 4 beakers a day."
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Red Flags (Neurology): "No, he walks and runs fine. No back problems."
ICE — Ideas, Concerns, Expectations
(The patient's mother does not volunteer these unprompted — these surface only when the candidate directly explores her perspective.)
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Ideas: Lisa thinks Lucas is being deliberately difficult or lazy. She does not suspect a medical cause — she sees it as a behavioural problem. "I just think he's being stubborn. He knows when he needs to go — he just refuses to use the potty. I don't understand why he won't just do it like the other kids."
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Concerns: Lisa is worried about the social consequences — Lucas being held back at nursery, being judged by other parents and nursery staff, and what this means about her as a mother. "Honestly, I'm terrified he's going to be the only one still in nappies when they all move up. The other mums don't say anything but I can see them looking. And the nursery making it official just makes me feel like I'm doing something wrong."
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Expectations: Lisa wants a referral to a paediatrician — she believes this needs a specialist. She also wants a letter for the nursery confirming a medical reason so Lucas isn't penalised. "I just want someone to take this seriously and tell the nursery it's not my fault. If there's something medical going on, I need it in writing so they can't hold him back."
If Asked — Medical History and Medications
(Cross-referenced from the Candidate Brief. Only items with plausible relevance to the presenting complaint are included.)
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Eczema / Emollients: "He's got a bit of eczema — just dry patches really, mainly on his arms. I put cream on it when it flares up but it's not been bad lately. It's not bothering him at all at the moment."
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Previous GP visit about fussy eating (approximately 1 year ago): "Yes, I did speak to a doctor about his eating before — maybe a year ago? They said to keep offering different things and not to make a big deal out of it. But honestly, nothing's really changed. He still won't eat fruit or veg. He basically lives on beige food."
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Developmental checks: "He had all his checks done — the 8-week one and the one-year one — and they said everything was fine. He walked on time, he talks well for his age. No one's ever raised any concerns about his development."
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Medications and allergies: "He's not on any medicines. No allergies that we know of."
Social History and Lifestyle Impact
(Volunteered naturally in conversation when the candidate explores Lisa's situation and how the problem is affecting the family.)
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Occupation / daily life context: Lisa works part-time as a teaching assistant at a primary school. Lucas attends nursery three days a week while she works. Her partner works full-time and is less involved in the toilet training. Lisa's mother helps with childcare but is critical of her approach. "I work at a school three days a week, so he's at nursery those days. My mum has him one day but she keeps telling me I should just leave him without a nappy and let him learn the hard way — she doesn't get that I've tried that and it was a disaster."
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Lifestyle impact of the condition: "It's affecting everything. I can't send him to birthday parties without packing spare nappies and feeling mortified. Last week he had an accident at soft play and another mum made a comment. I dread pick-up at nursery because I know they're going to tell me he's had another soiling episode. And at home, the potty battles are ruining our evenings — he screams, I shout, and then I feel terrible. My partner thinks I'm making too big a deal of it but he's not the one getting the phone calls from nursery."
If Asked — Associated Symptoms
(The patient's mother responds only when the candidate directly asks about these symptoms. Informed by NICE CKS Constipation in Children and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) guidance.)
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If asked about abdominal pain or tummy aches: "Now you mention it, yes — he does sometimes hold his tummy and say it hurts, but then it passes. I thought he was just putting it on to get out of eating his dinner."
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If asked about blood in the stool or when wiping: "No, I've never noticed any blood."
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If asked about pain when passing a stool: "He does seem to strain sometimes, and occasionally he cries when he's doing a poo. I assumed that was normal for his age."
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If asked about appetite or whether it has changed: "His appetite is up and down. Some days he barely eats anything, other days he's fine. But he's always been a fussy eater so I didn't think much of it."
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If asked about nausea or vomiting: "No, he's not been sick."
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If asked about weight loss or poor weight gain: "No, he seems to be growing fine. He's not skinny or anything."
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If asked about abdominal distension or bloating: "Actually, his tummy does look a bit round sometimes — I just thought that was normal for a toddler."
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If asked about perianal soreness, fissures, or redness: "He does get a bit red around his bottom sometimes, especially after the loose ones. I put some Sudocrem on it."
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If asked about soiling his pants (as opposed to nappy): "If he's not wearing a nappy, yes — he does sometimes have marks in his pants. Like he doesn't even know it's happened."
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If asked about any urinary tract infections or urine infections: "No, he's never had a urine infection."
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If asked about how much water he drinks (as opposed to milk): "Honestly, not much. He mainly drinks milk. I do offer water but he pushes it away."
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If asked about any family history of constipation or bowel problems: "My partner had problems with constipation as a child, actually. His mum mentioned it once — said he was on something for it for years."
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If asked about any behavioural or developmental concerns beyond toileting: "No, he's a bright little boy — he talks well, plays nicely with other children. The nursery have never raised anything else. It's just this one thing."
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If asked about when toilet training was first attempted: "We first tried at about two and a half. It was a complete disaster — he'd hold everything in all day and then have a massive accident. We stopped and tried again a few months later but it was the same."
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If asked about stool withholding behaviour: "Yes, actually — he does that thing where he goes stiff and stands on his tiptoes and goes red in the face. I thought he was trying to push, but maybe he's trying to hold it in? I'm not sure."
Responses to Management (The Negotiation Phase)
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If the Doctor says 'he will grow out of it': "But the nursery won't wait for him to grow out of it! They said he needs to be dry by September. Can't you write a letter saying there's a medical reason?"
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If the Doctor diagnoses Constipation: "Constipation? But I told you, sometimes it's runny! How can he be constipated if he's having accidents in his pants?" (Tests ability to explain overflow).
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If the Doctor prescribes Laxatives (Movicol/Laxido): "I don't want him to get addicted to laxatives. My mum said if you use them too young, the bowel gets lazy." (Address the myth).
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If the Doctor mentions 'School Readiness': "I know he needs to be ready, that's why I'm asking for help! I feel like everyone is judging me."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Toilet Training Readiness — Normal Range and When to Suspect Pathology
Understanding developmental norms allows the GP to reassure appropriately while identifying children in whom a medical barrier is driving the delay.
- ●Physiological readiness for toilet training typically emerges between 18–30 months, but there is significant individual variation — the interquartile range for individual continence skills spans 7–15 months.
- ●Daytime dryness is achieved at a median age of approximately 32–35 months; night-time dryness at a median of 4 years. A child not reliably dry by age 3–4 is within the normal range if no other features are present.
- ●At 3 years 4 months, Lucas is within the normal range for age — but his symptoms (withholding postures, overflow soiling, stool-related pain) indicate a medical barrier rather than developmental immaturity. The distinction matters: reassuring without treating will not resolve the problem.
Recognising Functional Constipation in a Toddler
Functional constipation in this age group frequently presents as toilet training failure and is widely under-recognised in primary care.
- ●Rome IV diagnostic criteria for functional constipation in a child aged <4 years include: two or fewer defaecations per week, history of retentive posturing, history of painful or hard bowel movements, large-diameter stools, or presence of a large faecal mass in the rectum — with symptoms present for at least one month.
- ●Retentive posturing — the child standing stiff, going on tiptoes, crossing legs, hiding behind furniture, or arching the back on the potty — is a key diagnostic feature. It represents the child attempting to withhold stool to avoid pain, not voluntary refusal to use the toilet.
- ●Pain-retention cycle: hard stool causes pain → pain leads to withholding → withholding leads to more impaction → stools become harder → more pain. Breaking this cycle is the central aim of treatment.
- ●Associated features that support the diagnosis and should be actively elicited: abdominal pain or distension, straining or crying on defaecation, perianal soreness or fissuring, and soiling in pants without awareness.
Overflow Soiling — The Key Diagnostic Distinction
The single most commonly missed clinical point in this presentation type.
- ●Overflow soiling (also called overflow diarrhoea or encopresis) occurs when liquid stool leaks around a faecal mass that has become impacted in the rectum. It produces loose or watery stool, which parents — and sometimes clinicians — mistake for diarrhoea.
- ●A child with constipation can therefore simultaneously pass hard pellets and have loose, uncontrolled soiling episodes. These are not contradictory findings — they are the same pathological process.
- ●The clinical hallmarks that distinguish overflow from true diarrhoea: the child is unaware the soiling is happening (passive leakage rather than urgency), there is no systemic illness, and there is a background history of infrequent or difficult defaecation.
- ●Accepting the parent's description of "runny poo" at face value, without exploring the alternating pattern, leads directly to a missed or delayed diagnosis of constipation.
Red Flags — When to Consider Organic Pathology
Functional constipation is a diagnosis of exclusion. The following features should prompt consideration of organic causes and specialist referral.
- ●Hirschsprung disease: delayed passage of meconium (>48 hours after birth), failure to thrive, marked abdominal distension, ribbon stools, and absence of faecal soiling (because the aganglionic segment prevents overflow). Most cases present in infancy but milder short-segment disease can present later.
- ●Spinal cord pathology (tethered cord, sacral agenesis): lower limb weakness, gait abnormality, saddle anaesthesia, or abnormal lower limb reflexes alongside constipation and urinary symptoms. An abnormal lumbosacral inspection is the key physical finding.
- ●Anal stenosis: ribbon stools from birth; identified on inspection.
- ●Hypothyroidism and hypercalcaemia: consider if there are systemic features — fatigue, poor growth, or polyuria alongside constipation.
- ●In Lucas's case, normal gait, normal development, no meconium history concern, and no systemic features make organic pathology unlikely. Functional constipation is the working diagnosis.
Management — Disimpaction First
NICE CKS is explicit: disimpaction must precede maintenance therapy. Treating constipation with a low-dose maintenance laxative without first clearing faecal loading is a common primary care error that results in treatment failure.
- ●First-line agent: macrogol (polyethylene glycol 3350 with electrolytes) — Movicol Paediatric Plain or Laxido. Macrogols work by drawing water into the bowel lumen (osmotic mechanism), softening the stool without stimulating bowel muscle.
- ●Disimpaction regimen (NICE CKS): start at 2 sachets daily and increase by 2 sachets every 2 days, up to a maximum of 8 sachets per day in children aged 2–5, until watery stool is produced. This indicates the faecal mass has been cleared.
- ●Warn the parent that the process will appear to worsen initially — more soiling and accidents will occur as the impacted mass starts to move. If this expectation is not set, parents often stop treatment prematurely, assuming it is making things worse.
- ●If macrogol alone is insufficient, a stimulant laxative (sodium picosulfate or senna) may be added as second line. Lactulose is no longer recommended as first-line for constipation in children.
Management — Maintenance Therapy and Duration
- ●Once disimpaction is confirmed (soft or watery stool passing freely), step down to a maintenance dose of macrogol — typically 1–2 sachets daily, adjusted to produce 1–2 soft stools per day.
- ●Duration of maintenance therapy should be at least 3–6 months from the point of successful disimpaction, and often longer. Premature cessation — particularly once stools appear normal — is the most common cause of relapse in primary care.
- ●The bowel needs time to return to its normal calibre and sensation. The child also needs time to lose the fear of defaecation before reliable toileting can be expected.
- ●Do not attempt toilet training during or immediately after disimpaction. Reintroduce the potty or toilet only once stools are consistently soft and painless, using a gradual, pressure-free approach with positive reinforcement.
Dietary and Lifestyle Modification
Dietary factors in this case are significant contributors and should be addressed alongside pharmacological treatment.
- ●Cow's milk intake: excessive milk consumption (>350–400ml/day in toddlers) is a recognised risk factor for constipation. Milk is low in fibre, high in casein (which slows gut motility), and displaces more fibre-rich foods from the diet. Lucas's intake of 3–4 beakers per day significantly exceeds this threshold.
- ●Advise reducing milk intake to no more than 350ml per day and replacing displaced volume with water. This is consistent with NHS and NICE guidance for children aged 1–4.
- ●Fibre: advise gradual introduction of fibre-rich foods. Acknowledge the challenge of dietary change in a fussy toddler — small, repeated exposure is more effective than pressure. A dietitian referral may be appropriate if fussy eating is severe.
- ●Fluid intake: adequate water intake is essential alongside macrogol therapy. A child who drinks minimal water will derive less benefit from osmotic laxatives.
- ●Family history of childhood constipation (paternal in this case) is worth noting as a predisposing factor — it helps normalise the problem for the family and reduces parental guilt.
Behavioural Approach to Toileting
Pharmacological treatment alone is insufficient. A structured behavioural approach must run alongside it.
- ●Stop pressured toilet training until the constipation is treated and stools are soft and painless. Attempting to toilet train a child who is in pain when defaecating entrenches the negative association and perpetuates withholding.
- ●Once stools are soft, reintroduce toileting gradually using positive reinforcement — sticker charts, praise, small rewards. Punishment, pressure, and expressions of frustration worsen withholding behaviour.
- ●Advise regular toilet sits (2–3 times daily after meals, exploiting the gastrocolic reflex) with correct positioning — feet supported on a step, knees above hip level, leaning slightly forward.
- ●Avoid making toileting a battleground. The aim is to rebuild a positive association with the potty or toilet.
Referral Criteria
Functional constipation in children is managed in primary care in the first instance. Referral to paediatrics is appropriate in the following circumstances:
- ●Failure to respond to adequate doses of macrogol for 3–6 months (i.e., treatment-resistant constipation, not undertreated constipation)
- ●Presence of red flag features suggesting organic pathology (Hirschsprung disease, spinal pathology — see above)
- ●Significant rectal loading that does not respond to oral disimpaction and may require rectal intervention (phosphate enema or manual evacuation under sedation — hospital setting only)
- ●Severe psychological impact on the child or family requiring input from paediatric psychology
- ●At initial presentation, a request for referral from a parent whose child has responded to primary care treatment is not an indication for referral — explain this clearly and compassionately, with a clear plan for when referral would be made.
Safety Netting and Follow-Up
- ●Review in 1–2 weeks to assess response to disimpaction — check whether watery stool has been passed and adjust dose accordingly.
- ●Return sooner if: vomiting develops, no stool is passed despite escalating doses after 7–10 days, the child develops abdominal pain that is severe or worsening, or the parent is struggling with the regimen.
- ●Subsequent follow-up at 4–6 weeks to assess readiness to step down from disimpaction to maintenance dosing, and to review dietary progress.
- ●Long-term: the maintenance phase requires regular review — typically every 3 months — to adjust dosing and plan gradual weaning. Avoid setting a fixed end date for treatment; wean only when stools have been consistently soft for several months.
Nursery Advocacy and the GP's Role
- ●Under the Equality Act 2010, schools and nurseries have a duty to make reasonable adjustments for children with medical conditions. A child with functional constipation or overflow soiling has a recognised medical condition — penalising them for toileting difficulties is not lawful.
- ●The GP can support the family by providing a brief medical letter confirming that Lucas is under treatment for a bowel condition, that his toileting difficulties are medically caused, and requesting that the nursery make appropriate adjustments during treatment.
- ●The letter does not need to be lengthy. A factual one-paragraph summary — diagnosis, treatment, expected timeline, and request for support — is sufficient.
- ●Signpost the family to ERIC (The Children's Bowel & Bladder Charity) — ericcharity.co.uk — which provides parent guides, nursery information sheets, and a helpline. ERIC also provides template letters for nurseries that families can use directly.
Addressing the Laxative Myth
A specific, commonly encountered barrier to treatment adherence in this presentation.
- ●The belief that laxatives cause "bowel laziness" or dependence is widespread among parents and grandparents, and is directly relevant to this case.
- ●Macrogols are osmotic agents — they work by retaining water in the bowel lumen to soften stool. They are not absorbed systemically and do not stimulate bowel muscle or nerve endings. They cannot cause dependence, tolerance, or a "lazy bowel."
- ●Stimulant laxatives (senna, sodium picosulfate) act on bowel muscle, but there is no good evidence of long-term dependence at therapeutic doses in children.
- ●The risk of not treating is far greater than any theoretical risk of treatment: untreated constipation becomes more entrenched, the pain-retention cycle worsens, and the psychological impact on the child and family escalates.
- ●Address this concern directly and respectfully — do not dismiss it, but correct it clearly with an explanation of mechanism. Unaddressed, it will result in the parent stopping treatment as soon as stools improve.
Mapped to the RCGP curriculum topic: Patient < 19 years old.
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