How to Cure Bedwetting in Three Months in Any Child

Don’t Be Afraid to Give Your Child an Enema

When I first realized that bedwetting and toileting accidents are almost always caused by a poop-stuffed rectum, I started giving MiraLAX out like crazy. I was on a mission to defeat pediatric potty problems, and I had just the tool to do it. Years later I can say that while I still like MiraLAX as a way to clean out a child’s colon, I don’t love it anymore. I love enemas.

MiraLAX is an excellent, safe and easy-to-use laxative, but for reasons we detail in It’s No Accident, it often doesn’t do the job. Here’s what I’ve learned from treating thousands of children and reading their X-rays: Enemas are the single best way to empty out the rectum and keep it empty.

Yet parents hate them.

When I prescribe enemas to help a child who wets the bed or has daytime accidents or recurrent urinary tract infections, I often get a two-word response from Mom or Dad: “No way.”

I find this frustrating because it suggests that folks still don’t see toileting problems as real medical problems. I can tell you this: If enemas were found to fix any other pediatric medical condition, like asthma or a peanut allergy, parents wouldn’t refuse to use them.

Here are the anti-enema arguments I hear most frequently from parents, along with my responses.

Argument #1: “But my child will never allow it.”

I’m a firm believer that the cure should never be worse than the disease, but if children suffer with chronic bedwetting, encopresis or infections, at some point you have to take charge and say, “So here’s what we’re going to do.”

You may not get as much resistance as you expect. Children are more embarrassed by toileting problems than many parents realize and often gladly cooperate with a treatment, however not-fun it may be, that will fix their problem. I’ve had countless parents report that their child actually said, “Thank you, that wasn’t so bad, and I’m so happy I’m not wet anymore!”

Argument #2: “But my child will become addicted.”

Untrue! This is addressed in our book in detail, but briefly: If the rectum is stretched out and empties poorly, chronic enemas will help it shrink back to size. There is no downside. Only if you continued to use enemas in the presence of normal bowel function (Lord knows why anyone would) could you cause dependency.

Argument #3: “The enemas will disrupt my child’s electrolytes.”

Doctors often propagate this myth, but I can assure you they are unfounded. Yes, Fleet enemas contain phosphorous, an electrolyte that gets absorbed into the body. But if you use no more than one enema a day (the most we prescribe), the increase is negligible. The regimen we use for enema therapy has been used in countless children for decades. If children have normal renal function (and virtually all do), they will simply pee out the extra electrolytes. If your child doesn’t have normal renal function, talk to a doctor first. If your child’s renal function is normal but you can’t help but worry, you could always use saline enemas, but they are a bit less effective.

So there you go: You have no reason not to use enemas. In my experience, all the toileting problems we cover in our book are solved with this simple tool.

Watch Out! The Start of School May Mean Toileting Problems for Your Child

To some folks, the start of school means buying pencils and backpacks and back-to-school clothes. To me, it means seeing frantic parents and stressed-out kids suddenly dealing with accidents, bedwetting and urinary tract infections.

For many kids, school creates toileting problems. For others, it’s a big hurdle to resolving problems that already exist. We explain all this in great detail in It’s No Accident, but with school starting, let’s recap the five ways schools contribute to toileting problems. By being proactive you can do a lot to limit or prevent these stressful, messy issues.

1. Preschools forcing toilet training on kids who aren’t quite ready
A great way to guarantee toileting issues in kids is to push toilet training in a kid who’s not ready. Kids have to be ready, willing and able to go to the bathroom anywhere they need to, whenever they need to, and have to be free of constipation to stay problem-free. Not all three-year-olds fit that description. Schools that force a diaper-fee policy are hurting kids, and we are trying to work with them to create more reasonable policies.

2. Limiting bathroom access
Now this is a tough one. I don’t believe teachers mean any harm here. It has to be difficult enough to keep a classroom orderly without kids running in and out of the restroom all day, and surely some kids are just running around the halls. But to punish kids for going to the restroom or limit access isn’t the solution. Not all kids go during designated school bathroom breaks (though they should be encouraged to try). Then, when they really need to go, they aren’t allowed. That’s how problems start!

3. Dirty, smelly, or unsafe restrooms
Hand in hand with #2 is the issue of clean and safe restrooms. Even if a child has free access to the restrooms, he or she won’t go if the restrooms are disgusting or scary. Many of my patients never use the bathroom at school, and some of them don’t routinely poop when they wake up in the morning. In other words, they’re withholding for huge stretches of time. And I’ve never met a kid who feels comfortable pooping at school. We can do better.

4. Low-fiber, processed food
Despite efforts to improve the quality and nutritional value of school meals, we have a long way to go to create an environment where children are regularly eating the kind of high-fiber, whole-food meals that keeps poop soft. School-age children are not known for their stellar eating habits in general; junked-out school lunches just compound the problem.

5. No education regarding the dangers of holding
Remember all the health talks you had when you were in school? They taught you about dental health and screened you for scoliosis, but no one ever talked about the dangers of holding your pee and poop. This is a glaring deficiency in the health education of our children, and it’s a main reason why children are so willing to hold. They see no downside to doing so. Spreading the word about these problems is critical.

“The biggest mass of poop I’ve ever felt.”

By Dr. Hodges

The other day I saw a 7-year-old boy who’s still in diapers because he has both pee and poop accidents. The first time I saw him, months ago, I ordered an x-ray, which showed his rectum was absolutely stuffed with stool. I referred him to a gastroenterologist for therapy to get the boy cleaned out.

A few months later, he returned to my clinic. He’d had two urinary tract infections, such a rarity in boys that I got worried I may have missed a congenital problem, like a blockage of his urethra. I asked his mother to continue giving him Miralax so that his stools would be borderline diarrhea, and I set him up to be evaluated in the operating room with a cystoscope, a tube that goes through the urethra into the bladder.

But I could barely get the scope in his bladder because of a big mound behind the bladder neck. I pulled out the scope and put a finger in the boy’s bottom — and found the biggest mass of poop I have ever felt.

This poor kid had been wetting for four years because nobody ever bothered to check for rectal stool.

How Can A Child Poop Daily and Be Constipated? Why Doesn’t Miralax Always Work?

Grab some ping-pong balls and a tube sock for a demo explaining how a kid can poop daily and still be constipated.

By Dr. Hodges

The main message of It’s No Accident can seem simplistic at first glance: Constipation causes wetting — got it. But there’s more to the story.

Among parents and physicians, there are varying levels of ignorance about potty problems and wetting in general, and I am exposed daily to all of them. Some misconceptions are harmless, but others can lead to suboptimal care or even damage to children.

The most common mistake is the assumption that toileting problems are a normal part of growing up. I’ve tried to stress that they aren’t, and I think folks can get behind that point without much misunderstanding.

Second, I’ve emphasized that the root cause of wetting and urinary tract infections is almost always constipation. Now here’s where things get tricky. I use the term constipation only because it’s a familiar term to parents. But what I really mean is what in medical terminology is megarectum or terminal reservoir syndrome (See why I prefer constipation?). In other words, problem has nothing to do with the frequency of consistency of and everything to do with how much poop a child is carrying around in her rectum. (In our book we cover in detail the signs of this sort of constipation; study these carefully!)

To understand the consequences of carrying around a load of poop, imagine a demonstration using a sock (the colon) and ping-pong balls (the poop). Now, cut a bit off the toe of the sock. Make the opening small enough that the balls have to be forced out. Place a ping-pong ball at the top of the sock, work it down and pop it out the bottom.

That’s how most adults poop: The pop passes through the intestine, gets to the end and you let it out.

Now let’s see how kids poop. This time, don’t let the ping-pong ball out the end when it gets there. Instead, delay the exit a bit. Put some more ping-pong balls through, and delay their exit, too. Kids do this repeatedly, and eventually, since you have more coming in than out, the entire sock fills with ping-pong balls. It becomes so full and stretched that every time you force a ping-pong ball through the top, one pops out the bottom.

See how we now have achieved a new baseline with daily pooping, despite a very different looking sock (or intestine)? Nonetheless, based on what comes out the bottom, an observer wouldn’t be able to tell the difference.

Meantime, the stretched-out intestine drives the bladder crazy.

Now let’s looks at the same kid on MiraLAX. There are two ways folks fail using MiraLAX. First, parents give the child just enough to make the kid’s poop soft but not enough to get the child’s intestine cleaned out, so it never shrinks to normal size. It’s easy to imaging that by flushing water down our metaphorical sock that (in addition to getting a wet sock) you could easily get water out the bottom without forcing any ping-pong balls out. Many parents quit MiraLAX to soon because the child appears to have diarrhea; they think the pooping problem has been resolved when in fact the intestine is still full of poop. Trust me, you can’t know with out an X-ray.

This is also the main mistake most pediatricians make, other than ignoring the problem in general. They put a kid on MiraLAX and see that the child has soft stools but fail to check on the progress with X-rays.

If you read the book you’ll learn that Dr. Sean O’Regan, the Irish doctor who demonstrated the constipation-wetting link back in the 1980s, didn’t like using osmotic laxatives like MiraLAX because they could cause the poop to turn mushy without always restoring the rectal tone or causing the intestine to empty fully enough or for long enough for it to return to normal size. (Think of how a stretched-out sock recovers after washing and drying).

The second way many parents fail MiraLAX therapy is that they don’t maintain it long enough. So, the floppy, stretched-out colon fills again and the problem recurs. That’s why Dr. O’Regan recommended three months of enemas. (I know this makes parents cringe, but stay with me.) He wanted to keep the intestine chronically empty so that its tone would be restored and kids could actually begin to sense more quickly when they needed to poop and therefore would go more regularly.

Remember, the goal is to restore rectal tone in these kids, not make them poop soft poops daily, although that is also important.

School Bathrooms in the USA

By Tom Keating

Thilo Panzerbieter and his girlfriend at the time, Martina, now his wife, came to San Francisco in 2007, and I trained him on how to review school restrooms. Now Thilo, the executive director of the German Toilet Organization, has worked with Project CLEAN to improve more than 20 Berlin schools.

Imagine he were asking you these questions about your own school bathrooms. How would you respond? Project CLEAN would certainly like to have a joint project in the States and in Germany, and these last two blog posts may lead the way.

Thilo: At no other school is the gap in the level of maturity – from the youngest to the oldest students – as big as at elementary schools. How does this affect the work that must be carried out to improve school restrooms at elementary schools?

Tom: The bigger problem is that students in primary grades follow instructions quite well, while those in the upper elementary grades, fourth and fifth, start being more independent. And when these older students “cross over” to middle school, it is like they cross a psychological/biological railroad tracks. We need much more orientation at the end of the fifth grade, which is then stated in a new way in the first weeks of sixth grade. Transitions are the key to having elementary grade students continue good habits in the middle years.

Thilo: Would you talk about shifting responsibilities from elementary to middle to high school along the continuum of from soap to citizenship?

Tom: Grades K-3 are the instruction years. Kids learn to eliminate in school, wash hands, and keep restrooms tidy. Often these lessons slack off in upper elementary. Then unfortunately middle school often becomes destruction years with mischievous and outright vandalism in some cases. High school years are nonchalant or careless years unless someone reaches out to young adolescents and establishes relationships around restroom issues including the GTO approach of introducing young citizens to worldwide concerns over sanitation.

Thilo: From your experience in working at German and US American schools, where is the toilet taboo greater? Is it tougher to address such issues in Germany or in the United States? Or is the taboo actually an advantage when addressing the issue?

Tom: I feel the taboo is greater in the USA, though because of my limited German language I would like to test that thought. The taboo can be an advantage if restroom improvement in schools is approached from many angles – facilities, curriculum, clubs, custodial, maintenance, organizations, wellness, health, and leadership by the building leaders.

Thilo: Do you believe that school partnerships between schools in Germany and in the United States could help to improve the respective school restrooms? If so, how can we initiate such a partnership? What can students from these different countries learn from each other?

Tom: Partnerships might help with a minimum of a two-year commitment, enough funding, and stable leadership. To begin a partnership with GTO and Project CLEAN and say one middle or high school in each country, we need a Letter of Agreement with three or four agreed upon activities, and a modest amount of euros and dollars. Students can learn better ways to deal with sanitation, wellness, school restroom issues, and worldwide toilet conditions. I believe any exchange of cultural and educational experiences would benefit all the students.

If interested, please contact Thilo at thilo.panzerbieter@germantoilet.org.

School Bathrooms in Berlin

By Tom Keating

When your family takes a trip, you probably tour museums, hike beautiful trails or check out famous monuments. When I travel, I visit school bathrooms. As an advocate of cleaner school restrooms, I’m always looking to learn how other countries operate in this realm.

This post is an exchange between me — coordinator of Project CLEAN in Decatur, Georgia — and Thilo Panzerbieter, head of the GTO. That’s the German Toilet Organization, in case you didn’t know.

The GTO invited Project CLEAN to assist in its first Toiletized World projects in 2009 and again invited me to help Berlin schools in January 2012.

In this post, I ask and Thilo answers. The next post will be the reverse.

Tom: Do younger kids in Berlin come from home to elementary school prepared to handle restroom issues well?

Thilo: A lot of schools assume that students should be taught at home how to behave in a school restroom. This is only partially true. Many underestimate the specifics of the situation.

Students and adults go separate ways in school restrooms. Hence, students – for the first time in their lives – are in a situation where they are using public space without adult supervision. Many of them end up challenging the boundaries of authority in this environment – very much like small children challenge their parents’ authority at home. If parents and school staff are more sensitive to this, students can be led from “soap to citizenship.”

Tom: When students in middle school are taken on an inspection of their school restrooms, during a “toilet walk,” (Schulklobegehung), what kid of reaction do these adolescents have?

Thilo: At first they all find it absurd: They laugh, giggle and horseplay. When they realize that we are serious about wanting to understand their situation, they begin to answer questions sincerely. As we go through the exercises, which are part of what we call, “Toiletized World” (Klobalisierte Welt), more and more students begin to feel that they are not alone in their desire for better school restrooms. We thereby create group dynamics that help to empower the students.

Through an open discussion with the school administration and “Hausmeister” (house technician/maintenance personnel), the students understand who to see if there is a problem. If these adults care, we have a chance of improving the situation.

Tom: What is the restroom related work of the Hausmeister? How does a working relationship among students and the Hausmeister handle such issues as graffiti, vandalism, and mischievous actions by students disrespecting restrooms?

Thilo: The Hausmeister is a school’s grounds keeper and house technician in one. In a lot of schools he actually lives in the building. He locks and unlocks doors, does small repairs and maintenance work. It is not his task to clean the restrooms – external cleaning personnel does this. But a lot of times he is the one who deals with clogged sinks and toilet bowls.

He is the one who removes graffiti or repairs stall doors. In Germany, the motivation of this person and his relationship to the students is essential in solving school restroom issues. It states a lot about a school, whether the students know the Hausmeister’s name or not.

A good relationship between the students and maintenance staff creates respect for that person’s work and thereby also for the state of the restrooms.

Tom: What might Berlin middle and high school students advise American youth as to how to better grasp the world-wide humanitarian and cooperative development aspects of sanitation issues?

Thilo: Most Berlin students are also not aware of this issue, unless they have gone through our “Toiletized World” project. Our concept teaches the students about the international work of the German Toilet Organization and similar aid organizations working abroad.

By giving the students an insight into the living conditions of people in Africa and Asia, they learn that the privilege of a toilet cannot be taken for granted. About 40 percent of the world’s population currently lives without access to sanitation facilities.

This unhygienic situation causes over 4,000 child deaths under the age of five per day. Sick children cannot go to school and girls often times drop out of school when they reach the menstrual age, due to a lack of privacy.

Understanding these facts helps German students and their teachers see their own situation in a different light: How would my life be without water, soap, stall walls or a toilet? I am sure that our approach would also work in the United States – I would love to try it.

To contact Thilo Panzerbieter, email him at thilo.panzerbieter@germantoilet.org. I can be reached at keating.projectclean@gmail.com.

We’ve Come a Long Way in Two Years

By Betsy Rosso

Celebrating Zoe’s fifth birthday takes me back two years ago to when our potty saga began.

We had planned to begin potty training in earnest when Zoe turned three, and I attended a workshop taught by a local developmental psychologist to get tips on how to make the process as painless as possible. One tip she offered was to space potty training six to eight weeks away from major life events, like moving or starting a new school or anything traumatic in the family. Zoe was scheduled to have eye surgery two weeks after her birthday, which seemed like a major event, so we postponed training until June.

If I had known then what I know now, we could have saved ourselves a lot of heartache and many loads of laundry. But I think it all turned out OK. We ended up back at our wonderful co-op preschool, we got to know a terrific doctor and delightful physical therapist, and we learned a lot about the digestive system. I’m also thankful that our experience has been able to help others.

I got an email today from an acquaintance—someone I recently met professionally. After we met we became Facebook friends and she started reading my posts about It’s No Accident and bought the book. Here’s what she wrote: “My daughter usually pees in bed and we have been having her go to the bathroom every two hours [during the day] like the book says to do and she has been dry for three nights. I know this is just a start and things can take an odd turn. But I just wanted to thank you for publicizing and sharing your story.”

It makes me happy that our sharing our story, which is not always easy to share, is making a difference for other kids and other families and that they might find relief from their problems sooner rather than later and with less heartache.

It also makes me happy that I took Zoe on a field trip today for her birthday. We were in the car for more than an hour and a half each way. A year ago, I would have put her in a pull-up for the drive or expect that she’d ask to stop almost as soon as we started driving. Instead, she drew pictures in the car and read me a story. She did ask a couple or 20 times if we were almost there, but she didn’t need to use the bathroom. When we arrived she was eager to start playing, and I made us take a pit stop in the restroom. But she was fine. I am so proud of her and how far she’s come. And proud of us for getting there with her.

Is Your Child’s Pelvis Full of Poop?

Here's a 4-year-old

By Dr. Hodges

I have been flooded with emails from concerned parents since the publication of It’s No Accident, especially in response to the recent articles on Slate.com and Babble.com. Most of the emails have been from parents asking how to figure out if their child is constipated and what they should do about it. Many parents have asked whether I can recommendation a physician in their area.

Unfortunately, I’ve heard from some of these parents that while they love their pediatrician, they have been disappointed in their doctor’s lack of interest or willingness to listen to the concepts presented in the book.

Here’s a typical example:

A mom emailed me about her 4-year-old daughter, Jane, who had been having accidents during the day and wetting the bed at night after potty training easily at age 2.

Jane’s mom reported that Jane had an excellent diet, eating plenty of fiber (fruits and vegetables) and little in the way of processed foods. Constipation did not appear to be an issue, but after reading my book, Jane’s mom raised the concept with their pediatrician.

Her pediatrician assured her that her daughter was not constipated, but this persistent mother was able to persuade the doctor to go and order the X-ray, just in case.

After looking at the X-ray, the pediatrician commented that while there was more stool than he expected, it definitely wasn’t causing the child’s wetting. I had the mom send me the X-ray, and I can tell you this: Every bit of space in that child’s pelvis is crammed full of poop!

Where exactly did her pediatrician think the child’s bladder wear going to fit in that pelvis? How could anyone think that that mass of stool would not affect the bladder?

Nobody had a clue this child was constipated. Fortunately, we can now get this girl cleaned out, and I feel certain her wetting problems will stop.

Help us get the word out to pediatricians and urologists! We are compiling a referral list of pediatricians, family doctors and urologists who are on board with the notions in our book and are experienced at treating bedwetting and accidents in the ways recommended in the book.

If you have a good experience with a doctor, please let us know so we can contact him or her for possible inclusion in our registry. Help us build the list and inform the world!

7th Graders and Me

By Tom Keating

I recently taught Life Science to five classes of seventh graders at a middle school in suburban Atlanta. The three-grade school has 700 sixth-through-eighth-grade students, and each of my classes had about 22 boys and girls.

I planned to “cover” aspects of wellness, disease, sanitation, and epidemiology as they related to toilets and especially school restrooms.

Normally a guest speaker will make one lesson plan and repeat it for each class and each day. I decided to have five different lessons, each separate, yet interrelated. The anecdotes and compressed descriptions that follow are intended to provoke thought and discussion, which I welcome.

Class One: I have long believed that the most important number is one. In deciding on policy and political issues, one child must be thought of, imagined, considered. So when I wanted to teach these five classes of science students, I began with Theresa Clash, an eighth-grade girl who in 2004 wrote me an email about her restrooms at Eliza Miller Junior High. To quote her directly:

“You need to come to our junior high school because of our restroom supplies, our restroom stalls, and our restroom toilet seats…. Our restrooms don’t have enough tissue, no towels, and no soap…. Our restroom stalls are to hideous that they lean over….some of our [toilet seats] are covered with feces.”

Two of my classes discussed what we could have done to help her. Send me an email, and I’ll tell you what happened to her and to the restrooms.

Class Two. From the “one,” we focused on the middle school where I was speaking and similar middle schools in neighboring Atlanta counties. Examples of door-less stalls, tin cans for sanitary products, and broken sinks were shared. I showed “The Making of the Skit True Dat.” This excellent video and the accompanying article can be found at projectclean.us. We talked about the 3.8 hours of hand washing that would take place if all 700 students took 20 seconds to clean their hands. We also measured the “cleanliness” of a lab table.

Class Three. From the “one,” and schools at hand and nearby, we ventured out to a middle school in Delaware and mentioned other schools in California and Pittsburgh. The Delaware location had a principal who cared, a student who designed outstanding artwork, custodians who got behind some of the restroom issues, and a district building manager who allowed Project CLEAN to innovate. Nevertheless, rusted toilet partitions were so bad, stripping from them could have been twisted into a weapon, and the building staff might have been charged with a “known peril,” tort violation.

Class Four. We grew more in our attempt to discuss the civic ecology of the excretory system in public school restrooms. We went to Addis Ababa and Berlin for a discussion of a developing and a developed country. Latrine conditions in the urban school in Ethiopia were outrageous. Student interest in local, national, and international aspects of sanitation is dignity was played out in almost every school I visited in Germany’s now-united capital. The leadership of the German Toilet Organization supplemented by the school and adolescent experience of Project CLEAN have made my two visits to Berlin worthy of my next two blogs.

Class Five. The fifth class explored the tragic deaths of children every 15 seconds from diarrhea-related illnesses throughout the world. No matter how the metric was presented to the students and me, it remains difficult to comprehend the annual loss of life of 2,102,400 children. We also tried to understand that a gram of feces could contain 10 million viruses, 1 million bacteria.

The format of a stone tossed into a calm pond rippling out from the initial splash allowed me to move from the “one” to over two million, yet the most important number in your school is your child, just as a child dying in sub-Sahara Africa is to his mother.

If you have an issue at your school, start small, build as you can, do not get overwhelmed, and contact me if you wish.

404.694.2905
keating.projectclean@gmail.com