Check Out Our New Website: bedwettingandaccidents.com

Our free "K-!2 Teacher's Fact Sheet on Childhood Toileting Troubles" is now available at bedwettingandaccidents.com.

Our free “K-!2 Teacher’s Fact Sheet on Childhood Toileting Troubles” is now available at bedwettingandaccidents.com.

By Steve Hodges, M.D., and Suzanne Schlosberg

We are excited to announce that we have a new website: bedwettingandaccidents.com.

Go check it out. Right now!

For a short while both sites will be up and running, but then itsnoaccident.net will be redirected to bedwettingandaccidents.com.

In the meantime, check out the new content and features at bedwettingandaccidents.com. We’ve reorganized the site, so spend some time exploring.

Here’s what we’ve added:

•A private discussion forum. Many folks, uncomfortable discussing these topics on Facebook, have asked for a private forum. There you go! You’ll find it under the Getting Help nav bar. Channels include: enemas and laxatives, bedwetting, pee accidents (enuresis), poop accidents (encopresis), UTIs, potty training, working with your doctor, schools, and healthy eating. Feel free to suggest others!

•Free downloads for school nurses and teachers. The School Nurse’s Guide to Childhood Toileting Troubles and the K-12 Teacher’s Fact Sheet on Childhood Toileting Troubles are now available! These are useful not only for school staff but also for parents want to explain to teachers why a student needs extra bathroom passes.

Here's " !2 Signs Your Child is Constipated"  in Spanish.

Here’s ” !2 Signs Your Child is Constipated” in Spanish.

Infographics in Spanish. 12 Señales De Que Su Niño Está Estreñido, Mi Tabla del Popó, and El Estreñimiento es la Causa #1 de Accidentes
y Orinarse en la Cama, are now available for free in Spanish. We are most grateful to our translator, Belén Velásquez, whose granddaughter, Sophia Rousse-Bermudez, is featured on our new Success Stories page.

Infographics for the UK. The folks at ERIC, a British charity devoted to continence issues, have “translated” our three infographics into British English. Across the pond it’s “wee” and “poo” instead of “pee” and “poop.” ERIC is now the UK distributor for our children’s book, Bedwetting and Accidents Aren’t Your Fault.

•An expanded Find a Provider page. Please continue to send us contact information for medical providers on board with our approach.

Keep checking back for more new content! And subscribe to our new site for additional news and updates.

We’re just getting our new site going, so feel free to post comments on our Facebook page or email us directly.

Steve Hodges: shodges@wakehealth.edu
Suzanne Schlosberg: Suzanne@bedwettingandaccidents.com

Elimination Communication: Bad Idea

Just because other cultures train their babies to use the toilet doesn't mean it's fine for us. Infant toilet training often leads to toileting problems

Just because other cultures train their babies to use the toilet doesn’t mean it’s fine for us. Infant potty training often leads to toileting problems

By Steve Hodges, M.D.

Oh boy, here we go again: another mom extolling the virtues of placing her infant on the potty.

“My son was just 3 weeks old the first time he pooped in a toilet,” writes Katy Chatel in the Washington Post. “Now, when many his age are just being introduced to a baby toilet, my 19-month-old uses the adult one on his own.”

Kim Kardashian has been bragging all over town about her own 19-month-old’s “insane” feat of being “halfway potty trained.” But Chatel, adapting the “elimination communication” (EC) approach favored by Mayim Bialik and Alicia Silverstone, has one-upped her.

Or so it would seem.

I’d love to check back in with Chatel — and Kardashian, for that matter — a few years from now, because that’s when the repercussions of early toilet training tend to surface.

Early toilet training, whether facilitated via EC, potty bootcamp, or any other method, is risky business.

The arguments Chatel offers up in favor of EC — cutting down on “diaper waste, expenses and rashes” and improving “baby bonding” — sound reasonable but are far outweighed by the health risks to children who toilet train so early.

Early in my career I wasn’t aware of these risks, but after a few years, the pattern became clear to me: the earlier children toilet train, the more likely they are to develop toileting problems. Eventually, my published research confirmed this association, finding that children trained to use the toilet before age 2 have triple the risk of later developing daytime wetting problems compared to children trained between 2 and 3.

(This doesn’t mean 24 to 36 months is the “magic window” for problem-free training. I personally advocate waiting until around age 3.)

Why Early Toilet Training is Bad News

Problems arise because babies and toddlers haven’t developed the judgment to respond to their bodies’ urges in a timely manner. Compared to children who train later, early trainers are far more likely to delay pooping and peeing.

These are dicey habits. When a child chronically withholds poop, stool piles up in the rectum, forming a large, hard mass that presses against and irritates the bladder. It’s a vicious cycle: pooping becomes more painful, so kids delay even more.

Holding pee compounds the problems, thickening and further irritating the bladder. Eventually the bladder can get so irritable that it empties without any input from the child.

Katy Chatel mentions that her son, Jessey, is often “dry in underwear for hours.” I don’t know whether she means he toddles over to the potty and pees on his own or whether he simply does not pee for hours. But if Jessey is holding his pee for more than about two hours at a stretch, he may be headed for trouble.

Parents tend to view potty training as a process, like learning to ride a bike, that has a finite ending: Once the kid catches on, there’s no going back. You’re all home free.

But this is a misconception. The holding habit can catch up with children years down the road. These potty prodigies may be kindergarteners, or older, when they show up at my clinic with the sudden onset of pee and poop accidents, urinary tract infections, or bedwetting. Their parents are stunned.

They’re also unhappy when I explain that only enema or laxative therapy will fix the problem.

The most significant risk factors associated with dysfunctional elimination are not emptying on time and not emptying completely. So, it only makes sense to remove the barriers to timely and complete peeing and pooping, especially during the years when the bladder is growing rapidly.

The only way to ensure kids pee and poop whenever and wherever they need to — and to keep pooping pain free — is for children to wear diapers well past age 2.

27.4 Billion Diapers a Year

Katy Chatel expresses understandable concern about the damage that billions of diapers do to the environment. But she also disses cloth diapers because of the “amount of water used to launder them.”

Look, I’m all for saving the planet. But as a pediatric urologist, my priority is saving kids from the pain, stress, embarrassment, even abuse that can define life when you’re a 6th grader who pees in his pants.

Many children trained early via EC or other methods end up fine; others end up in my urology clinic. I routinely see 9-year-olds who have poop accidents, 8th graders who have monthly UTIs, and high-school juniors who wet the bed.

These problems almost always stem from habits these kids developed in or before preschool.

Arguing in favor of EC, Chatel also mentions that the diaper-free lifestyle is commonly practiced in other cultures. True enough. But as I explain in It’s No Accident, being a toddler in rural Botswana typically doesn’t involve snacking on mac-and-cheese-flavored goldfish and going to daycare. You can’t simply say: It works for them, so therefore it works for us.

Chatel concludes with a hope that more parents will practice elimination communication so we can “cut down on diapers and improve baby bonding.”

My hope: parents will stop putting their babies on the toilet. (It would be excellent if they stopped bragging about it, too.)

There are countless ways to bond with your infant and help the environment without raising your child’s risk of developing bladder problems.

Why So Many Kids Are Pooping In Their Pants

11-year-old Eliza Medina was asked to drop her pants for a "poop inspection." But that's not the only outrage in Gustine.

11-year-old Eliza Medina was asked to drop her pants for a “poop inspection.” But that’s not all that we should outraged about.

By Steve Hodges, M.D.

OK, let’s stipulate that asking fifth-graders to pull down their pants for a “poop inspection” is outrageous.

I’m surprised administrators at the Gustine Independent School District thought that was a remotely OK way of deducing the source of the poop teachers were “regularly finding” on the gym floor.

But what doesn’t surprise me is that there’s poop on the gym floor.

We have a children’s health crisis in Westernized countries that is being totally ignored: an epidemic of toileting troubles, aka dysfunctional elimination.

Not long ago, teachers in Spokane, Washington, complained that too many kindergarteners were “not potty trained.” A popular UK play center was just shut down because children were having “too many accidents.”

My clinic is booked solid with kids who have toileting problems — 1st-graders who wet their pants, 5th-graders who can’t even feel poop dropping out of their bottoms, 10th graders who wet the bed every night.

None of this is a “normal part of childhood” or an indication of behavior problems.

It’s happening because our kids have alarmingly high rates of constipation. Probably one-third of kids have rectums clogged with stool, and a good many of them are having accidents because of it.

In Gustine, Texas, the signs of constipation seem to have gone unrecognized. This chart can help educators and families.

In Gustine, Texas, the signs of constipation seem to have gone unrecognized. This chart can help educators and families.

When kids delay pooping, stool piles up in and stretches the rectum. A stretched-out rectum is like a stretched-out sock: it loses elasticity. So, poop just falls out.

A rectum that’s been enlarged by a mass of poop also loses sensation. That child in Gustine whose poop landed on the gym floor probably didn’t even feel it come out of his bottom.

Rectal poop masses in children can grow quite large — imagine a grapefruit or a Nerf basketball — stretching the rectum to five times its normal diameter. The big mass presses on and irritates the nearby bladder, triggering daytime and nighttime pee accidents.

As with our country’s childhood obesity epidemic, the worst cases of dysfunctional elimination are getting worse. Some children’s colons have been so stretched by giant stool masses for so long that in addition to having severe urinary problems, these kids need surgery to remove the segments of their colons that won’t shrink back to size.

Sadly, these kids’ problems go untreated for years because doctors don’t recognize the link between constipation and accidents. I just treated a 17-year-old boy whose pediatrician had told him, year after year, that he’d “outgrow” his bedwetting. Um, when exactly was that going to happen?

Thanks to enema therapy, the boy’s bedwetting has resolved, but he may need surgery to fix his chronically stretched colon.

Kids Often Shoulder the Blame for Potty Accidents

Yes, those students in Gustine were treated poorly, but their humiliation pales compared to the shame and abuse heaped upon many children who have chronic accidents.

Almost daily I read news reports of school-age children scalded, beaten, or humiliated for having accidents. Recently a Florida mom, fed up with her 10-year-old’s bedwetting, forced the boy to parade around in a princess gown — and then posted the pictures on Facebook. This week a Maui woman went on trial for allegedly abusing a child enrolled in her potty bootcamp.

Many of my patients have been referred to psychiatrists for their wetting problems, on the (completely faulty) assumption that they must be pooping in their pants on purpose.

Even prominent universities recommend that children who wet the bed be “rewarded” for having dry nights, sending the damaging message that these kids are somehow in control of their bladder or bowels. This is a travesty (and it’s why I wrote the children’s book “Bedwetting And Accidents Aren’t Your Fault.”).

All toileting problems are treatable, often in a matter of weeks. First, the large, hardened lump of stool must be cleared out so the rectum can shrink back to size, regaining tone and sensation. Second, the stool must be softened so that pooping no longer hurts.

Shaming children in no way helps this process.

Constipation Nation

Our free "K-!2 Teacher's Fact Sheet on Childhood Toileting Troubles" can help teachers spot problems before they escalate. Contact me for a copy.

Our free “K-!2 Teacher’s Fact Sheet on Childhood Toileting Troubles” can help teachers spot problems before they escalate. Contact me for a copy.

It’s well documented in the research that constipation causes toileting accidents and that clearing up constipation resolves these accidents. But what’s causing such widespread constipation?

•Our kids eat way too much processed food and aren’t active enough.

•Parents toilet train children too early, largely due to preschool deadlines and the notion that it’s somehow awesome to have a potty-trained toddler.

•Dismal public school bathroom conditions and misguided restroom policies prompt children to steer clear of the toilet.

I discuss each of these issues at great length in It’s No Accident.

Some kids, because of their temperaments or genetic make-ups, are less affected than their peers by these factors and manage to avoid potty problems. However, enough forces in our culture conspire against healthy toileting behaviors that more kids than you can imagine end up pooping or peeing in their pants.

Educating Parents, Teachers, and Students About The Signs of Constipation

In response to the outcry from Gustine parents, school district superintendent Ken Baugh conceded the school crossed a line. “Maybe we can find a much better way to solve this,” he said.

Here are some ideas for starters.

Here's " !2 Signs Your Child is Constipated"  in Spanish.

Here’s ” !2 Signs Your Child is Constipated” in Spanish.

•Educate parents and teachers on the signs of constipation. I suggest everyone involved in the Gustine debacle read our free download, “12 Signs Your Child is Constipated.” Our Spanish version will be available for download next week on our new website, but anyone interested can email me for a copy. Teachers are on the front lines of this epidemic and are in a good position to catch these problems before poop ends up on the school gym floor.

•Educate teachers and school nurses on the causes of and treatments for dysfunctional elimination. We offer two free downloads: “The School Nurse’s Guide to Childhood Toileting Troubles” and “The K-12 Teacher’s Fact Sheet on Childhood Toileting Troubles.” Contact me for either of these. They’ll be published next week, too.

•Teach students about healthy elimination. Schools promote Obesity Awareness Week, Drug Awareness Week, and Sleep Awareness Week. Some public schools even have Rabies Awareness Week. But certainly more children develop medical problems from holding poop than get bitten by rabid dogs!

My dream is for school nurses to spearhead Toileting Awareness Week, but I’d settle for an annual assembly on what happens if you hold your poop. Exhibit A: the gym floor in Gustine.

Dysfunctional elimination is a serious and expensive problem that is completely preventable. We must all join forces to resolve this epidemic.

From a Urologist to Kim Kardashian: Stop Potty Training North

North

By Steve Hodges, M.D.

So Kim Kardashian is bursting with pride that her 19-month-old daughter, North, appears to be a potty prodigy. North is “so smart,” Kardashian told People. “She is halfway potty trained, which is insane for her age.”

As a pediatric urologist, I can tell you Kardashian is right about one thing: It is insane for a 19-month-old to be potty training.

Well, if not insane, then at least totally ill advised.

Little North, her brilliance notwithstanding, will be at high risk for developing wetting problems down the road.

As our research at Wake Forest University suggests, children toilet trained before age 2 have triple the risk of later developing wetting problems, compared to kids trained between 2 and 3.

Of course, not every child trained as a toddler will later develop dysfunctional elimination, but in our study, published in Research and Reports in Urology, 60 percent of the children trained before age 2 did present with accidents well after mastering the toilet.

Parents who train their children early — to meet preschool deadlines, to save landfills from diapers, or because they think it’s awesome to have a potty-trained toddler — should know there can be serious repercussions.

Why Early Potty Training is Risky Business

Our research found that children toilet trained before age 2 had triple the risk of the later developing wetting problems. This is because toddlers are more prone to holding their poop. This infographic illustrates how constipation directly causes accidents.

Our research found that children toilet trained before age 2 had triple the risk of the later developing wetting problems. This is because toddlers are more prone to holding their poop. This infographic illustrates how constipation directly causes accidents.

It’s not that toddlers can’t be trained to use the toilet. For sure they can. Exhibit A: Little North!

The problem is that toddlers don’t have the judgment to respond to their bodies’ urges in a timely manner. Compared to children who train later, they are far more likely to delay pooping and peeing.

These are risky habits. When a child chronically withholds poop, stool piles up and forms a large, hard mass. This mass can stretch the rectum — imagine a rat in a snake’s belly — from about 2 cm in diameter to 10 cm or more. I have plenty of patients harboring grapefruit-sized rectal lumps of poop.

There’s limited real estate in the pelvis, so the bladder gets crowded out by the poop mass. In addition, the nerves controlling the bladder, which run between the bladder and colon, become irritated. The upshot: unexpected bladder contractions – in other words, mad dashes to the toilet and accidents.

Poop accidents are a risk, too. An overstretched rectum loses tone and sensation, so poop may simply fall out — without the child even noticing.

Holding pee compounds the problems, thickening and further irritating the bladder. Eventually the bladder can get so irritable that it empties without any input from the child.

That’s when these potty prodigies show up at my clinic, with the sudden onset of pee and poop accidents, urinary tract infections (UTIs), or bedwetting.

“It doesn’t make sense,” a mom will tell me. “I didn’t push her – she basically trained herself.”

I believe these parents — and it doesn’t sound like Kim Kardashian is pushing North — but in my clinic the kids who develop the most serious problems are typically those who trained earliest and most easily.

In other words, they have been deciding for the longest amount time when they should pee or poop. It’s a disaster.

Early Potty Training Can Backfire

Parents of all stripes, celebrities and regular folks alike, take pride when their children toilet train early, in the same way they beam when their kids walk, talk, or read before their peers.

But you should not think of early toilet training with pride. You should think of it the same way you would if your 19-month-old made any other major life decision on her own: with trepidation.

I don’t want to be dogmatic about the appropriate age to start toilet training, but I’ve rarely met a child younger than 3 who truly has the judgment to make good toileting decisions.

My co-author, Suzanne Schlosberg, toilet trained her twins at 24 months. How’d that turn out? Check out her video, “How I (Royally) Screwed Up By Potty Training My Twins Too Soon.”

Based on my experience and our research findings, I encourage parents to delay potty training, to temper their expectations of toddlers, and to have more patience when children have accidents.

“Failed toilet training” is one of the leading triggers of child abuse, according to the Child Abuse Prevention Center. Every week brings news reports of toddlers beaten, scalded, or killed by adults frustrated over toilet training. Often the reason toilet training “failed” is that the children were trained at too young an age.

I also urge parents to stay far, far away from potty bootcamps. Just this week a potty bootcamp owner in Hawaii went on trial for allegedly abusing a 17-month-old enrolled in her program.

I also hope our findings will encourage preschools to ease up on deadlines requiring children to be potty trained by age 3. These deadlines often prompt parents to train their toddlers extra early so that the children will be completely trained and accident-free by the time school starts.

What preschools fail to realize is that early training can backfire.

I understand that for multiple reasons, many parents will toilet train children under age 3, and I think the most important point to glean from our study is that constipation status — rather than age — is the critical factor that will influence whether a child develops wetting problems. In our study, virtually every child who had chronic accidents was stuffed with poop.

No matter what age you introduce your children to the toilet, make sure your child is ready — that is, interested and not constipated — and is leading the way.

The signs of constipation often go unrecognized, so stool piles up quickly in a child's rectum.

The signs of constipation often go unrecognized, so stool piles up quickly in a child’s rectum.

Make sure your child pees every two to three hours, and remain vigilant about monitoring for signs of constipation, which are often subtle and not widely known. A child can poop daily and still be constipated. The top two signs are extra-large poops and hard poops, shaped like pellets or logs.

Kim Kardashian says North is “halfway” potty trained. If that means she’s peeing on the potty but not pooping, North is very likely constipated, and her parents should dial back potty training.

I hope Kardashian and Kanye West can find something to feel proud about besides little North’s accomplishments on the potty.

Is Miralax Toxic for Children?

I prescribe Miralax daily, but I don’t love this stuff.

I prescribe Miralax daily, but I don’t love this stuff.

By Steve Hodges, M.D.

My phone has been ringing nonstop since the New York Times published an article raising questions about the safety of Miralax in children.

Many, many of my patients take Miralax (PEG 3350) daily and, following my advice, have been doing so for months, even years.

So when the Times mentions “ingredients in antifreeze” and “psychiatric illness” in reference to the laxative their children are taking, naturally parents want to know: Is the medicine you prescribed poisoning my child?

The short answer: probably not, based on the available evidence. More than 100 studies have found PEG 3350 is safe to use in children, and I have found no published studies linking Miralax to severe or harmful side effects. (I discuss this research in It’s No Accident.)

Nonetheless, I welcome all inquiries into the safety of this ubiquitous laxative, and I look forward to the results of the government-funded study that will examine whether PEG 3350 may trigger psychiatric problems in children.

Still, the Times article misses the forest for the trees. While it is of course important to know whether Miralax contains trace amounts of toxins, no one is asking a more salient question: Why are so many American children constipated in the first place?

Constipation Nation

Constipation is an extremely common — I would say epidemic — problem among children in Western countries.

In a small minority of cases, constipation has a medical explanation — a child may have Hirschsprung’s disease or other rare, congenital conditions. But in 95 percent of cases, children withhold stool simply to avoid the pain of pooping. Stool piles up in the rectum, making bowel movements even larger, harder, and more painful. And the cycle continues.

This is no way a benign process. Failing to eliminate on time often leads children to develop painful, distressing, and embarrassing medical complications that needlessly cost the health-care system millions.

What’s the most common cause of abdominal pain among children seen in the emergency department? Constipation.

The most common cause of bladder and kidney infections in children? Constipation.

The most common cause of enuresis, both daytime accidents and bedwetting, in children? Constipation.

Virtually the only cause of encopresis (poop accidents) in children? Constipation.

Children are often subjected to expensive, uncomfortable tests and even surgeries that could have been prevented had the child defecated on time and completely. Unbelievably, children also shoulder the blame for their “accidents,” because few adults realize that “rebellion” and “behavior problems” play no role here. This is a travesty. (And it’s why I wrote Bedwetting and Accidents Aren’t Your Fault.)

As I explain in It’s No Accident, the reasons children withhold stool are multiple but not complex:

•Our kids eat way too much processed food.
•Parents toilet train children too early (and without adequate follow-up), largely due to preschool deadlines.
•Dismal public school bathroom conditions and misguided restroom policies prompt children to steer clear of the toilet.

Compounding these problems, we as a society, we ignore the early signs of constipation. No one bats an eye if a child has enormous or hard bowel movements (the top two signs of a clogged colon) or doesn’t poop at least every other day. We’re happy as long as a child goes at some point and doesn’t seem to complain.

But children need to poop every day — soft, mushy poops. When constipation goes unrecognized, stool piles up rapidly, at which point simple, drug-free therapies such as fiber and dietary changes are too little, too late.

The signs of constipation often go unrecognized, so stool piles up quickly in a child's rectum.

The signs of constipation often go unrecognized, so stool piles up quickly in a child’s rectum.

The Benefits — And Limits — of Miralax

We can argue about how to fix these cultural problems until the cows come home, but a child who already is constipated needs help now, which is why Miralax is so often prescribed.

Families with Miralax on the counter are often judged harshly — “Water bottles were the tool of choice for constipation when I was a kid. Prunes also help,” wrote one Times commenter. But the reality is, no amount of water, fiber, or prune juice will dislodge a large, hard rectal clog. (Another reality: many kids who are excellent eaters end up constipated.)

So doctors typically turn to PEG 3350, which is not habit-forming and is easy to give to kids because it has no taste or odor. You can mix it in their beverages, and they typically won’t complain.

Miralax also is generally effective — more so, according to a 2014 meta-analysis, than magnesium hydroxide (Milk of Magnesia), lactulose, mineral oil, psyllium fiber, and fructose. The authors of that study concluded that is also safe, with minor side effects such as diarrhea, nausea, bloating, and vomiting.

For these reasons, I prescribe Miralax daily, but I don’t love this stuff.

While it’s effective at softening stool, PEG 3350 often does not fully clean out a child’s rectum. The rectum remains stretched and floppy, like a worn-out sock, and therefore doesn’t have the tone needed to fully evacuate or the sensation to signal to the child that it’s time to poop.

Nope, enemas aren't habit forming! Quite the opposite — they are important for shrinking a stretched-out rectum back to size.

Nope, enemas aren’t habit forming! Quite the opposite — they are important for shrinking a stretched-out rectum back to size.

Only a completely cleaned-out rectum can bounce back sufficiently, which is why I typically prescribe enemas for my severely constipated patients. Enemas have been proven in rigorous studies to resolve enuresis and encopresis, and yes, enemas are safe for children. On the whole, my patients who receive enemas get far better results than those who use Miralax.

The problem: Most parents simply won’t give their constipated children enemas, insisting the child will refuse. (My experience demonstrates otherwise; it’s parents who project their fears on their kids.) Even many pediatricians won’t go near enemas. One doctor told a patient of mine that enemas are “cruel and unusual punishment.” That’s a travesty, too.

So, I end up prescribing Miralax all the time. And while it’s not as effective as enemas, it does an OK job.

“But Miralax Isn’t Natural”

Many folks object to Miralax on the grounds that it’s “not natural.” That’s absolutely true, and I wish I never had to prescribe it. However, carrying around a rectum full of poop throughout an entire childhood, a common scenario these days, is not natural either and can have serious, long-term consequences.

Also not natural: walking around with a tube inserted through your abdomen into your colon so you can flush out poop with liquid laxatives. Yet that scenario, known as a cecostomy, is becoming more common in children whose severe constipation has gone untreated for years.

Getting a constipated child cleaned out is critical, and laxatives can be an effective approach. As one of my colleagues, a pediatric gastroenterologist, told me, “Parents are terrified of the consequences of giving their kids laxatives, but what about the consequences of taking out part of a 6-year-old’s colon? Many people don’t realize how severe the cost of undermanagement can be.”

This doctor has performed more than 100 cecostomies in children whose stretched-out colons are permanently damaged from constipation and has sent more than a handful handful of his worst-case patients to surgeons for colostomies.

I do not think that parents should stop giving their children Miralax just because small amounts of toxins were discovered in eight samples in 2008. At the same time, I urge parents and pediatricians to give enemas a second look.

Ultimately, it doesn’t matter what method is used to empty a child’s clogged rectum (as long as that method doesn’t harm the child, of course). What does matter is that the child’s bowels empty completely on daily basis, so the kid don’t show up at the ER with painful urinary tract infections or opt out of sleep-away camp because she wets the bed.

I hope the harsh light shined on Miralax will help illuminate our nation’s epidemic of pediatric constipation, leading to preventive strategies, more rapid diagnoses, and more effective treatment for these kids.

Perhaps then we’ll all need less Miralax.

“What If My Doctor Doesn’t Believe Constipation Causes Bedwetting?”

If your doctor dismisses your concerns about bedwetting or constipation, you may need to find a new doctor.

If your doctor dismisses your concerns about bedwetting or constipation, you may need to find a new doctor.

By Steve Hodges, M.D.

We doctors are a stubborn lot. We’ve spent about a hundred years in school and treated more patients than we can count, and we spend weekends reading long-winded journal articles.

So, we tend to think we’ve seen it all and know it all.

But, of course, we haven’t and we don’t.

I mention this because literally every day I hear from parents frustrated by one of two scenarios: Their child’s doctor 1.) has stubbornly dismissed their concerns about bedwetting or accidents or 2.) refuses to consider our approach to diagnosing and treating constipation.

Parents ask me: Can we follow your program without our doctor on board?

Here are a few excerpts from emails parents have written me:

•”Our 7-year-old has never had a dry night, yet our pediatrician continues to insist bedwetting is normal and she’ll grow out of it.”

•”I liked It’s No Accident, and our GP found it interesting and sent us to a specialist to discuss our son’s constipation. The specialist’s response was ‘Oh, you read a book, good for you.’ Refused to even talk about it.”

•”Our doctor told us that giving our son enemas would be ‘cruel and unusual punishment’ and would turn our 4-year-old into a ‘psycho.’ “

•Our 10-year-old son has had encopresis for 6 years. We have been seeing a pediatric GI for 6 months, and his only solution is MiraLAX and more MiraLAX. We’ve gotten nowhere.”

•”Our 6-year-old-son has been having accidents despite being potty-trained early for preschool requirements. Our pediatrician dismissed the accidents. When we pushed for an X-ray, he put up a big fight (“no need”) but finally caved. The radiologist confirmed constipation, but the pediatrician wouldn’t give us any details.”

In that last case, the mom sent me the child’s X-ray, and let me tell you, her son was stuffed with poop.

If your doctor responds like these doctors did, can you dismiss their dismissals and simply follow the instructions in our book?

Well, you can — and many families have done so successfully — but I don’t advise it.

Why It Helps to Have a Doctor in Your Court

Sure, MiraLAX and pediatric enemas are sold over the counter, so you don’t actually need a doctor to follow our program. Still, every child’s case is unique, and a pediatrician may have insight into your child’s health that could influence how you approach our regimen.

Also, a doctor who’s on board can help you adjust MiraLAX dosages, prescribe alternatives (such as lactulose) for various reasons, prescribe stimulant laxatives (such as Ex-Lax) when necessary, and answer questions about giving enemas. Of course, you need a doctor to get baseline and/or follow-up X-rays.

So, how can you get a skeptical or stubborn physician in your court?

Honestly, sometimes you can’t. Many doctors don’t want to hear new ideas, especially if they come from patients who’ve done research online. They may get annoyed or defensive and dig in.

To some extent, I can understand a doctor’s reluctance to treat constipation aggressively. In many med schools, doctors are taught that bedwetting up to age 7 is normal and at that point, the best therapies are a bedwetting alarm or bladder-calming medications. Doctors may not realize alarms and medication don’t get to the root of the problem and that medication, as a long-term solution, doesn’t even work.

To a large extent, the medical community just isn’t up on the research.

So if your doctor won’t budge, you may simply need to find a new doctor, awkward and time-consuming as that may be. It is, after all, a lot easier to work with your doctor than against him or her.

On the other hand, if you like your current doctor, disagreements over wetting notwithstanding, don’t jump ship right away. Some skeptical docs, when presented with a compelling case, will eventually come around.

The Patient Who Changed My Career

That’s what happened to me. Early in my career, I didn’t grasp that constipation is the primary cause of bedwetting, accidents, and UTIs. I knew a clogged rectum could contribute to urinary problems but didn’t realize constipation alone could wreak such havoc on a child’s bladder.

But then I had a patient, a precocious 6-year-old girl with a history of UTIs, who made me rethink everything I’d been taught.

In “It’s No Accident,” I describe this patient’s story in detail, but here’s the short version.

This patient, whom I call “Ella” in the book, had urinary reflux, a condition that causes some urine to flow back up into the kidneys when the child pees. Constipation is known to exacerbate urinary reflux, so I watched Ella closely for signs of constipation and took several preventive measures. Ella showed no signs of constipation.

After much therapy, she didn’t improve, so I ended up doing surgery to reposition her ureters. I was shocked: When I cut open Ella’s abdomen, I discovered a grapefruit-size mass of poop sitting right behind her bladder and squishing it into a position likely to cause reflux.

That surgery changed my career. Suddenly, I saw how easy it is to miss constipation in a child and just how much damage a mass of stool can cause.

Thanks to Ella, I’m a much more open-minded doctor.

So press your doctor for that X-ray and for aggressive treatment. Perhaps if you keep at it, he or she will come around.

“My Child is Terrified of Pooping on the Potty”

By Steve Hodges, M.D.

The following question was posed during a free webinar on bedwetting and accidents that Dr. Hodges presented with Amy McCready of Positive Parenting Solutions. You can post-register for the webinar here.

A child who seems afraid to poop in the potty is likely constipated and more fearful of pain than of the toilet itself.

A child who seems afraid to poop in the potty is likely constipated and more fearful of pain than of the toilet itself.

Q: My 4-year-old child is terrified of pooping in the potty — she will only poop in a pull-up. What can I do?

A: Chances are, your child fears the pain she associates with pooping, not the toilet itself.
Children who hide to poop or request pull-ups to poop typically are constipated, as we indicate in our 12 Signs Your Child is Constipated infographic. Because pooping is painful for them, they naturally want to avoid it as long as possible. The process has become an ordeal and a struggle, and they are more comfortable pooping in pull-ups because that’s what they’re used to.

For the time being, use MiraLAX or enemas to make sure your daughter has soft, mushy poops daily — poops that resemble numbers 4 and 5 on My Poop Chart, our version of the Bristol Stool Scale. Don’t worry about where she poops. Once she regularly has soft poops and makes the connection that pooping doesn’t hurt anymore, you can help her make the switch to pooping on the toilet.

No, Waking Your Child to Pee Won’t Stop Bedwetting

The following question was posed during a free webinar on bedwetting and accidents that Dr. Hodges presented with Amy McCready of Positive Parenting Solutions. You can post-register for the webinar here.

It's tempting to wake up a child in the middle of the night to pee, but this approach doesn't get to the root of the problem.

It’s tempting to wake up a child in the middle of the night to pee, but this approach doesn’t get to the root of the problem.

By Steve Hodges, M.D.

Q: My 6-year-old and 8-year-old still wet the bed a few times a week. We usually wake them up to pee before we go to bed, which seems to help, but only a little. Should we stick with this strategy?

A: Most parents of children who wet the bed try this approach. But I advise against it for two reasons:

•It’s hard to time the wake-up exactly right. So, kids are often escorted down the hallway half-asleep — and they end up wetting the bed, anyway. This can compromise both the parent and the child’s sleep.

•Even if you can keep your children dry overnight this way, you haven’t solved anything except a laundry problem. You’ve simply adapted their sleeping patterns to their poor bladder capacity.

Ultimately, it’s a mug’s game (one of my favorite British expressions, meaning “a futile endeavor”).

It’s highly likely that your children are constipated. If you’re skeptical, I advise having them X-rayed for constipation (yes, X-rays for this purpose are safe and warranted!). Then, do the MiraLAX cleanout or, better yet, the enema protocol, and follow up with a maintenance regimen for at least six months.

Don’t wait around for your children to “outgrow” the bedwetting. They may — or may not. I treat many tween and teen patients whose families were told to “wait it out.”

Yes, A Child Who Poops Three Times a Day Can Be Constipated

By Steve Hodges, M.D.

The following question was posed during a free webinar on bedwetting and accidents that Dr. Hodges presented with Amy McCready of Positive Parenting Solutions. You can post-register for the webinar here.

When poop piles up in a child's rectum, the rectum gets stretched out and loses the oomph to empty completely. That's why a child who poops three times a day can be constipated.

When poop piles up in a child’s rectum, the rectum gets stretched out and loses the oomph to empty completely. That’s why a child who poops three times a day can be constipated.

Q: My 6-year-old son consistently has two or three BMs a day, so he hardly seems constipated. Is there any other factor that could cause him to wet the bed every night?

A: I can pretty much guarantee you he’s constipated! Most folks define constipation as “infrequent pooping, but pooping more than twice a day can actually be a sign of constipation — in fact, it’s listed on our 12 Signs of Constipation infographic.

Excessive pooping can signal that the rectum is full and is not emptying completely with each BM. Incomplete rectal emptying is the main cause of toileting problems in kids.

In children who are chronically constipated, the rectum becomes so stretched it loses its tone and strength, like when a t-shirt gets stretched out if a child repeatedly pulls it over his bent knees. That’s an analogy kids can relate to — we’ve used it in our children’s book, as you can see.

A stretched-out rectum simply can’t muster the oomph to evacuate all the poop. So, the poop piles up, hardens, and presses against and irritates the bladder. Sometimes the poop mass can get so big that it literally flattens the child’s bladder. In this case, the child has zero chance of staying dry all night because his bladder capacity is so compromised.

Parents and pediatricians often look everywhere under the sun for bedwetting explanations, but when it almost always comes down to constipation.

No, Your Child Won’t Become Dependent On Enemas

By Steve Hodges, M.D.

The following question was posed during a free webinar on bedwetting and accidents that Dr. Hodges presented with Amy McCready of Positive Parenting Solutions. You can post-register for the webinar here.

Nope, enemas aren't habit forming! Quite the opposite — they are important for shrinking a stretched-out rectum back to size.

Nope, enemas aren’t habit forming! Quite the opposite — they are important for shrinking a stretched-out rectum back to size.

Q: Can a child’s body become dependent on enemas for pooping? I’m afraid if we start my son on enemas, we won’t be able to stop.

A: Don’t worry — your child won’t become dependent on enemas! But he may well end up with more severe problems if you avoid enemas. If your child’s rectum is stretched out and not emptying well, and you never treat the problem, your child may be at risk for life-long bowel problems. Our enema regimen (detailed in It’s No Accident) will enable your son’s rectum to shrink back to normal size. Your son will then be able to better sense when his rectum is full, and his rectum will have the tone and strength to empty more completely. A body can only become dependent on laxatives if they are used when the body doesn’t need them. But a child who is chronically constipated needs them!

If you worry about the safety of enemas or whether your child will agree to the regimen, read our blog posts “Don’t Be Afraid to Give Your Child an Enema” and “Yes, Enemas Are Safe for Children — And They Work Better Than MiraLAX.”