A Colleague Agrees: Constipation Causes 90% to 100% of Potty Problems

By Steve Hodges, M.D.

The revered Rome III criteria for diagnosing constipation are a bunch of hooey. (And BTW, they weren't developed in Rome, Italy.)

The revered Rome III criteria for diagnosing constipation are a bunch of hooey. (And BTW, they weren’t developed in Rome, Italy.)

One of my great frustrations as a doctor is that so few of my medical colleagues recognize constipation as the root cause of toileting problems.

They dismiss accidents in 5-year-olds as “normal” and tell 7-year-olds who wet the bed “You’ll grow out of it” and “Your bladder hasn’t caught up to your brain.”

Just yesterday I received this message from a mom via Facebook:

Our son is 8 and has wet his bed his whole life, with plenty of daytime accidents as well. We’d been told for years by our pediatrician that he would grow out of it, but he wasn’t and we were frustrated. Only after reading your book did I truly understand what was going on. Last week we started the weekend bowel clean-out and by Sunday my son had his first dry night!!

The boy has been dry for seven out of eight nights since.

But many families don’t get the right advice, and meanwhile, kids suffer, embarrassed to go on sleepovers or to sleepaway camp. Their parents feel frustrated, helpless, and exhausted from all the laundry and middle-of-the-night wake-ups. This is nuts.

In my experience, most pediatricians and even most pediatric urologists and GI doctors don’t grasp that constipation underlies not just some but virtually all childhood toileting problems. The mom I quoted above had sent her child to a pediatric urologist who did acknowledge the link between constipation and bedwetting but did not prescribe an aggressive enough treatment regimen.

Also this week I received an email from a distraught mom of a 15-year-old who still wets the bed. She wrote:

We have tried every thing and nothing has worked. My son is now getting depressed and hopeless. We have tried many doctors, getting him up at night, pills, and a chiropractor and don’t know where to go next.

I receive letters like this on a regular basis, so I was thrilled when I read an editorial comment published in the Journal of Urology and written by a medical professional who completely understands the issue, Angelique Champeau. Angelique is a pediatric nurse practitioner at University of California San Francisco Benioff Children’s Hospital, and she started UCSF’s Pediatric Continence Clinic.

After I read her letter, I contacted her simply to say, “Thank you!”

Angelique Champeau of UCSF Benioff Children's Hospital knows what the heck she's talking about when it comes to bedwetting and accidents.

Angelique Champeau of UCSF Benioff Children’s Hospital knows what the heck she’s talking about when it comes to bedwetting and accidents.

Angelique’s letter was prompted by an article written by an international group of pediatric gastroenterologists representing the International Children’s Continence Society (ICCS).

Angelique knows what the heck she is talking about. Unfortunately, the ICCS remains pretty well entrenched in the dark ages.

I’d like to share key points that Angelique made in her response to the JOU article. (Some of these points were edited out of the published letter.) Perhaps with two of us trying to get the word out, our colleagues who treat toileting problems in children will be more inclined to take our perspective and treatment approach seriously.

Following are excerpts from Angelique’s letter, along with my own comments. By the way, LUTD stands for “lower urinary tract dysfunction” and refers to bedwetting, accidents, UTIs, and other toileting problems.

•Prevalence of constipation in kids with toileting problems
Angelique: This article claims that “urologists frequently report symptoms of constipation in up to 50% of children seen for LUTD.” While urologists frequently do report this number, following the references listed, and in my own review of the literature, I was never able to uncover a study where this was demonstrated. After 16 years of managing LUTD in children, I would hypothesize that this number is closer to 90-100%. Using a prevalence of 50% can cause gross under treatment.
My two cents: She’s absolutely right. There’s literally no support for that 50% figure. The problem here is the definition of “constipation.” Most docs determine whether a child is constipated simply by asking parents whether the child has a history of infrequent or hard bowel movements. But we know these criteria fall way short, missing most cases of constipation. That’s why we created our 12 Signs of Constipation chart and why I X-ray my patients.

•Defining constipation
Angelique: While childhood constipation is defined in the literature as “infrequent, hard, often painful defecation and the involuntary of loss feces in the underwear,” as it is in this paper, I find it unreliable. In my practice, I discover very constipated children who report having “daily, soft stools.” Whether these kids are truly constipated while having “daily soft stools” or the history is merely inaccurate remains to be seen.

Additionally, the paper states “parent report of stool symptoms are not reliable,” yet the offered Rome III criteria to diagnose constipation depends on an accurate history by the family. According to the Rome III criteria, one must have at least 2 of 6 criteria; however, 5 of the 6 criteria are based on history alone. Using the Rome III criteria, constipation will be underdiagnosed. Personally, I question child report as well, especially when in the presence of their parent.

My two cents: Yes to all of it! Though “Rome III criteria” sounds highly scientific and loaded with gravitas, in reality this list of criteria is a bunch of hooey. And by the way, the criteria don’t come from Rome, Italy; they come from a foundation in North Carolina. As I mention in It’s No Accident, in our clinic, X-rays confirm 90 percent of potty-trained children with wetting problems or recurrent urinary tract infections are severely constipated. Yet only 5 percent of parents even had an inkling their child was backed up. Parents are clueless! I myself had painful poops as a kid, and did I go running to tell my parents? No I did not!

•Environmental and behavioral influences on constipation
Angelique: The paper states that “various environmental and social circumstances are associated with a higher prevalence of constipation in children, including low consumption of fiber, low physical activity level, and low parental education level.”

We need to be very careful when looking at the research with regards to constipation in children. Many of the studies quoted were adult studies, including the studies on fiber, activity and education level. The cause of constipation in children, withholding, is different than the cause in adults, and so should be the treatment. There is no evidence in the literature to suggest that increasing dietary fiber in childhood constipation has any effect on childhood constipation. Additionally, children are rarely sedentary. Anecdotally, I find many constipated children who come from highly educated families.

My two cents: Many, many of my patients come from highly educated families with very concerned, borderline abnormally amazing parents! No TV allowed, no sugar allowed — and yet their children are still backed up! I agree with Angelique that a high-fiber diet isn’t going to dislodge a giant lump of poop stuck in the colon.

Nonetheless, every day I see patients whose junked-out diets are making their potty problems worse or preventing a full recovery. I believe that keeping a child’s insides clear, with high-fiber foods and plenty of water, is important, especially over the long-term. And as I wrote here in the Huffington Post, I believe our highly processed diet is an important contributing factor to our epidemic of potty problems.

It is my mission to make parents, teachers, and health professionals aware that constipation is what’s behind our epidemic of toileting problem. I’m glad Angelique Champeau is helping the cause. I have included her on our Find a Doctor page and am always in search of other medical professionals to add to our growing list.

Yes, Enemas are Safe for Children — And They Work Better Than MiraLAX

Enemas are perfectly safe, as long as you limit them to once daily and your child is otherwise healthy.

Enemas are perfectly safe, as long as you limit them to once daily and your child is otherwise healthy.

By Steve Hodges, M.D.

If there’s one word parents at my clinic don’t want to hear, it’s “enema.”

When I explain that enemas are the express route to solving bedwetting, accidents, and UTIs — more effective than MiraLAX and Ex-Lax and infinitely better than fiber gummies (which don’t work at all) — I get three responses:

1.) But aren’t enemas dangerous for a child?
2.) But can’t we try MiraLAX first?
3.) But my kid will never allow enemas!

Here are the short answers (see below for detail):

1.) No, enemas are not dangerous — as long as you limit them to once daily and your child is otherwise healthy.
2.) Sure, you can try MiraLAX first, but it won’t work as well and may not work at all.
3.) You’d be surprised; kids want the wetting to stop, and will generally do what it takes.

Parents are particularly horrified when I spell out the enema regimen that works best to unclog a rectum: nightly for a month, every other night for another month, and twice a week for a third month.

But you know which of my patients get better fastest? Those who follow this regimen!

Do you know which of my patients end up the happiest, freed from belly pain and the stress, embarrassment, and hassle of wetting their pants? Those who follow this regimen.

This is the protocol tested by Dr. Sean O’Regan, the Irish doc whose irrefutable published studies are the basis of It’s No Accident and basically my entire medical practice and mission in life.

How We Know Enemas Fix Toileting Problems

Many constipated children lose so much sensation in their stretched-out rectums that they cannot detect an air balloon the size of a tangerine.

Many constipated children lose so much sensation in their stretched-out rectums that they cannot detect an air balloon the size of a tangerine.

Back in the 1980s, while I was watching “Back to the Future” with my 8th-grade buddies, Dr. O’Regan was making a breakthrough contribution to the scientific literature.

He first tested this regimen on his 5-year-old son, who was wetting the bed multiple times a night. The child’s rectum was so stretched out from a rectal clog that the boy could not even detect the presence of a tangerine-sized air balloon in his bottom. (Want to find out for sure how stretched-out your child’s colon is? That’s the test to request! It’s called anal manometry.)

After one week of nightly enemas, the boy’s wetting diminished. After three months on the step-down regimen, the boy had stopped wetting the bed completely and Dr. O’Regan had stopped getting grief from his wife. Dr. O’Regan then tried the regimen with his own patients and had so much success he conducted formal studies.

In one investigation, Dr. O’Regan tracked 47 girls with recurrent UTIs and severe constipation and toileting problems. By the end of the regimen, 44 of the girls stopped having UTIs. Among the 21 patients with encopresis (poop accidents), 20 stopped having accidents. Of the 32 patients with enuresis (pee accidents), 22 stopped wetting. What about the girls who didn’t improve? Their parents admitted to not following the enema regimen fully.

It’s hard to argue with those results, yet pediatricians have never embraced the regimen. Most have never even heard of it.

How to Ensure Safety of Enemas in Children

Just this week a patient’s mom reported to me that three different pediatricians told her “no way” when she asked about giving enemas to her son. The boy is 13 years old and has wet the bed his entire life. (These are the same doctors who told her that her son would “outgrow” the bedwetting. Um, when?)

The most common safety concern is that phosphate enemas, the kind typically sold in pharmacies, will elevate certain electrolytes to dangerously high or dangerously low levels. Phosphate is used in enema solutions because it helps draw water into the colon, allowing you to use a much smaller volume of fluid than enemas than with enemas that use pure saline solutions. (Saline enemas are 100 percent safe but need to be administered in large volumes, from a height of two feet above the child, and require cumbersome tubing.)

Are concerns about the safety of phosphate enemas warranted?

Well, if you look hard enough in the medical literature, you will indeed find cases of electrolyte imbalances in children. A review of 39 studies that looked at complications from phosphate enemas over 50 years — from 1957 through 2007 — found a total of 15 cases of electrolyte imbalance in children ages 3 through 18. Over 50 years.

In nearly every case, the child had kidney disease or another chronic disease, was severely dehydrated, received multiple enemas in one day, or retained the enema fluid in their bodies — or a combination of those factors. Retained enema fluid is extremely rare healthy children; it almost always happens in children with chronic medical conditions.

In reality, phosphate solution spends very little time in the colon and thus has little influence on the body’s electrolyte levels.

Here’s how to follow Dr. O’Regan’s protocol safely:
1.) Never perform enemas on a child with kidney disease.
2.) If your child has another chronic disease, seek the guidance of your physician before performing enemas.
3.) Never do more than one enema a day.
4.) Make sure your child empties after the enema is given. If the child doesn’t, just wait; it’ll happen. If, somehow, the child does not poop, DO NOT administer another enema until you’ve run it by your pediatrician. A child who’s that clogged up can have a serious issue going on.

Why Miralax Doesn’t Always Work

One reason Dr. O’Regan’s original protocol involved enemas instead of MiraLAX is simple: Miralax didn’t exist back then. It was not approved by the FDA until 1999. But even when it did become an option, Dr. O’Regan continued to recommend enemas because they work better.

I explain why in this post.

The fact is, “new” does not always mean “improved.” Remember the New Coke debacle? OK, terrible analogy. For the record, I am not in favor of soda of any kind. But you get the idea.

Sure, it’s much easier to hand a child a glass of water mixed with a powder than it is to insert a tube up his bottom. No argument there!

But MiraLAX often does not fully clean out the child’s rectum. So, the rectum may never shrink back to normal size, regain the tone necessary to fully evacuate, or regain the sensation necessary to signal to the child that it’s time to poop.

Don’t Project Your Fear of Enemas Onto Your Child

Dr. O'Regan's son would read Winnie the Pooh while waiting for the enemas to work.

Dr. O’Regan’s son would read Winnie the Pooh while waiting for the enemas to work.

Most parents I work with assume their child will absolutely refuse enemas. But often they are, pardon the pun, pulling this assumption out of their own bottoms!

In my experience, when you explain to a child, even to a teenager, that this regimen is the ticket to dryness, they are plenty willing to give it a try. It’s typically when parents convey squeamishness or fear that kids pick up on it and become reluctant themselves.

When I asked Dr. O’Regan how his son reacted to the regimen, he told me: “He didn’t mind at all. He was a real bookworm and used to read Winnie the Pooh while waiting for the enemas to work.”

Dr. O’Regan recalled that prior to the regimen, his son was “a cranky kid.” But when he got cleaned out and stopped having bellyaches and wetting the bed, he became noticeably more cheerful. Says Dr. O’Regan: “Years later, he told me, ‘Dad, I thought bellyaches were normal.’”

And what about the hundreds of patients Dr. O’Regan prescribed his regimen to? “None of them ever complained,” he said.

At the time of his discovery, Dr. O’Regan told me, he felt pleased he was able to help so many children who’d been blamed by their parents and brushed off by their doctors. “These kids were told that it was all in their heads, that they were psychologically disturbed,” he recalled.

Dr. O’Regan noted that he and his colleagues devoted an immense amount of time to their research and that the one hundred or so children tracked for his studies were just a small fraction of the patients he successfully treated with the same methods. “When you find something new that actually works, that makes a difference, it’s quite spectacular.”

Nonetheless, within a decade of the publication of his studies, as I document in It’s No Accident, Dr. O’Regan’s research had been buried.

I continue on my mission to resurrect Dr. O’Regan’s protocol. I prescribe it every day in my clinic, and it works.

“My 15-year-old still wets the bed”: A Cautionary Tale

Parents: Don't wait for your child to "outgrow" bedwetting because you may well end up with a 10th grader who wets the bed.

Parents: Don’t wait for your child to “outgrow” bedwetting because you may well end up with a 10th grader who wets the bed.

By Steve Hodges, M.D.

Pediatricians are constantly telling parents of bedwetters, “Don’t worry — he’ll grow out of it.”

Other favorite responses: “Bedwetting is normal,” “He’s just a deep sleeper,” “Don’t make a big deal out of it,” and “His bladder hasn’t caught up to his brain.”

While all this may be reassuring to hear, at least for a while, it’s sadly misleading. Actually, it’s flat-out wrong.

Ask yourself this: If your shower drain were clogged, how many years would you wait for your drain to “grow out of it”?

I’m guessing the answer is zero years. You would use one of those snake things or (if you were me), you would call the plumber.

Bedwetting is almost always caused by severe constipation, and no amount of waiting around is going to get that big, hard lump of poop out of your child’s rectum. And until that clog stops pressing on your child’s bladder and messing with the nerves feeding the bladder, the bedwetting is almost certain to continue.

In this post, I discussed three patients who were told by their pediatricians to “wait it out,” just a sampling of the cases I saw in my clinic that week.

Now I’d like to share an email I received this week from a mom of a 15-year-old who has wet the bed his whole life. She wrote:

I have taken him to our pediatrician numerous times and even got a referral to a urologist. Neither doctor suggested my son was constipated and just said, “He’ll grow out of it” and “He shouldn’t drink after 8 p.m.” One doctor gave him a nasal spray and some pills, neither of which worked.

I came across your book and took it to the pediatrician. I asked for an X-ray to determine whether my son is constipated (I’m sure he is). The doctor dismissed me, and actually told, “Other countries have bigger holes in the toilets because of the larger stools they produce.”

I am so tired of watching my son be controlled by this! He is a straight-A student active in school, football, JROTC, volunteering, and student government. But has this big secret dark cloud over him all the time. He would love to be able to spend the night with his friends and go to summer camps, but he always has to stay behind.

I really feel constipation is my son’s problem and don’t understand why no one has said so when for years I have talked to the doctors about him stopping up toilets. I would appreciate any advice you can give us.

I called his mom, and the boy just has begun a nightly enema regimen. In the last week, he has only wet his bet ONE TIME. Believe me, he is not complaining about enemas. He is thrilled to be dry for the first time in his life.

In my clinic I see a significant number of teenagers, most of them told by their pediatricians that they’d “outgrow” the bedwetting. These are teenagers, for heaven’s sake! How long do their doctors expect them to suffer the embarrassment and frustration of being left out of overnight activities?

How long does it take to cure a teenager who wets the bed? The teens I see tend to fall into two groups: About half are cured quickly, often within a few weeks, especially if they use enemas. Removing the clog does the trick.

The other half are more resistant to therapy. In some cases, I believe, it’s because they won’t do enemas, and Miralax just isn’t enough to do the job. Other teens may have trouble because their bladders have been overactive for too long.

It’s also possible that the kids who wind up at my clinic are among the worst of the worst cases, so they’re going to be harder to fix no matter what.

If you have a child who is age 4 or older and is wetting the bed — especially if the child also shows any of the other constipation red flags shown in our infographic, 12 SIGNS YOUR CHILD IS CONSTIPATED — do not wait for him or her to “grow out of it.” Many, if not most, pediatricians won’t express the slightest concern about bedwetting until a child is at least 7, but that’s unfair to younger children and their families. Many cases of bedwetting that appear to be normal and not worth treating actually have underlying causes that can be dealt with fairly easily, almost always without medication. Rarely have I treated a 4-year-old bedwetter who was not constipated.

If you want to make sure your child does not become at 10th grader who wets the bed, take action today!

The Worst Potty-Training Advice I’ve Read

Despite what the "guru" says, you cannot compare potty training a child to potty training a puppy!

Despite what the “guru” says, you cannot compare potty training a child to potty training a puppy!

By Steve Hodges, M.D.

I continue to be astounded by the seriously bad potty-training advice spewing out of the Internet.

Let’s take this Q&A, published in the Gaston Gazette of North Carolina, my home state.

A mom has toilet trained her 16-month-old and is dismayed that, at 19 months, the toddler removes her nighttime diaper and then wakes up in a pool of pee crying for her parents.

The “guru” who answers the question — a psychologist — advises the mom to put her daughter to bed wearing nothing from the waist down. He insists “there is no better motivator” for staying dry overnight “than waking up on cold, wet sheets.”

Wow. This is wrong on so many levels that I don’t even know where to begin. But let’s try this: Staying dry overnight has nothing whatsoever to do with “motivation.” The use of this term reeks of the blame that so many of my young patients are subjected to. Children do not wet the bed because they are not “motivated.” Dryness is not within their control.

Toddlers wet the bed because, well, they are toddlers! The vast, vast majority of them simply haven’t reached the point of brain/bladder development that allows them to stay dry overnight. Letting them soak in cold, wet sheets will not change that.

And when older children wet the bed, it is almost always because they are severely constipated. The poop clog in their colon presses against the bladder, squishing it to the point where staying dry is simply impossible — no matter how “motivated” or wet and cold these kids are.

I’m so tired of hearing children get blamed for potty problems that I’ve co-written, with Suzanne Schlosberg, a children’s book called Accidents and Bedwetting Aren’t Your Fault! It’ll be out this fall.

But I digress. Let’s return to the “guru.”

He congratulates her for “ignoring the babble coming from the professional community” that urges parents to wait for “readiness signs.” He claims that the reason toilet training has gone from “being no big deal” in the 1950s to “the single biggest parenting hurdle of the early years today” is that parents are waiting too long to begin the process.

People, this isn’t the 1950s! Moms are working, and kids are in daycare or preschool. Toilet training requires constant monitoring to make sure the child is not holding pee or poop and diligent follow-through well after the process is “completed.”

Toddlers simply don’t have the good judgment to pee or poop in a timely manner. Symptoms may not surface for two or three years, but the holding behavior so common among potty-trained 2-year-olds often catches up with these kids. That’s when they show up at my clinic, with the sudden onset of accidents, UTIs, and urinary frequency.

Research in my clinic, soon to be published in the journal Research and Reports in Urology, found that kids toilet trained before age 2 had triple the incidence of toileting problems as kids trained later. (Stay tuned for details.)

The guru’s puppy analogy is ludicrous. Period. (As he’d say.)

Look, I’m not a chef, so I don’t advise people on how to pan sear their scallops. I’m not an auto mechanic, so I’m not going to tell you when your rear wheel bearings need replacing.

I really wish psychologists and celebrities would stop advising people on when to toilet train their children.

Free Download: 12 Surprising Signs Your Child is Constipated

12 Signs yPJG

By Steve Hodges, M.D.

Fact: Most parents — and many, MANY physicians — do not recognize constipation in children.

In our clinic at Wake Forest, X-rays confirm 90 percent of potty-trained children with toileting problems are severely constipated. Yet only 5 percent of parents even had an inkling their child was backed up.

Most of these kids were referred by pediatricians who didn’t notice the baseball-sized poop clogs in their patients’ rectums. Many of these doctors had ordered expensive and fruitless medical workups in an attempt to find the cause of their patients’ accidents, bedwetting, and recurrent UTIs.

Constipation is easily missed because parents and many physicians don’t know what to look for.

Sure, everyone knows a kid who poops once a week is constipated. But a child who poops twice a day might also be harboring a lump of poop the size of a Nerf basketball. Few adults realize that giant poops and hard logs are far more telling than poop frequency.

We hope our fun infographic, 12 SIGNS YOUR CHILD IS CONSTIPATED, will help parents, physicians, and schools detect constipation in kids.

Why “Patient History” is Meaningless

Many pediatricians don’t realize you can’t determine whether a child is constipated by pressing on her abdomen, nor can you rely on a “patient history” provided by parents.

The inadequacy of these measures was confirmed back in the 1985, in a published study by Dr. Sean O’Regan, a pioneering and brilliant pediatric nephrologist.

Dr. O’Regan’s study concerned 47 girls with recurrent UTIs. When Dr. O’Regan asked parents whether their daughters were constipated, nearly half said absolutely not. Yet air-filled balloon testing (aka anal manometry) showed every one of the girls’ rectums had become severely stretched from holding mega-loads of poop.

Yes, that test is just what it sounds like! Dr. O’Regan inserted balloons into these girls’ rectums and then began to gradually inflate the balloons. A child with normal rectal sensation will notice a balloon filled with just 5 to 10 milliliters of air; the girls in Dr. O’Regan’s study could withstand 80 to 110 milliliters of air without discomfort.

At 110 milliliters, the balloons were fully inflated, to the size of a medium tangerine!

This finding tells you why constipation is so easily missed. Often, the rectum simply expands to compensate, like a squirrel’s cheeks or a snake’s belly.

So much poop builds up in the rectum that even though the child may still poop regularly, she never fully empties. Many severely constipated kids poop daily, fooling their parents and doctors into thinking all is fine.

Somehow, Dr. O’Regan’s findings were ignored, and to this day, medical schools do not properly train students to diagnose constipation in children.

In fact, medical training has become progressively worse in this regard. Back in the 1980s, urology textbooks recommended anal manometry and rectal exams for diagnosing constipation in children. But today’s textbooks recommend less invasive and less accurate means: a general physical and patient history.

Some textbooks even recommend against the use of X-rays because they don’t correlate well with the frequency of stool—which is exactly my point! Frequency tells you almost nothing. (X-rays are both helpful and safe, as I explain in It’s No Accident.)

Today, few doctors diagnose constipation in children who come in with urinary problems or treat constipation aggressively enough when they do recognize it. They may recommend a small daily dose of laxative, fiber supplements, and frequent trips to the potty and call it a day.

This is a sad state of affairs, given that undiagnosed constipation in kids is the cause of virtually all pee and poop accidents, recurrent urinary tract infections, and bedwetting.

Our epidemic of toileting problems is needlessly causing pain and anxiety and costing families and the health-care system massive amounts of money.

Free Downloadable Poop Chart for Kids Who Have Potty Accidents!

MY POOP CHART is available as a free download at itsnoaccident.net.

MY POOP CHART is available as a free download at itsnoaccident.net.

By Steve Hodges, M.D.

Is your child pooping pellets, logs, or snakes?

The father of one of my patients told me his son poops out “big ol’ turkey sausages.” What comes out of his bottom, the dad said, “you could pick up and put on the grill.”

Not a good sign!

The size, shape, and consistency of children’s poop tells a lot about whether they’re constipated.

What most adults don’t realize is that human poop isn’t supposed to resemble a Polish kielbasa. It should be mushy, like pudding or a thick milkshake or a fresh cow patty.

When adults have firm poops, due to a low-fiber diet or inactivity, we can get away with it because we empty our bowels in a timely manner. But since kids tend to hold their poop, for reasons I detail in It’s No Accident, it’s essential that their stools stay soft.

Why? Well, imagine an assembly line with the slowest worker at the end. All the products pile up at that point and then start backing up.

Remember the candy-factory scene from I Love Lucy , when Lucy and Ethel tried to keep up with the runaway conveyor belt and ended up stuffing candies into their blouses, caps, and mouths?

That’s essentially what is happening inside a constipated child’s rectum.

She holds in the poop by squeezing her sphincter, converting her colon and rectum into storage units, a job these organs are not suited for. When a child’s rectum gets stretched often enough, the child loses her ability to sense when she’s ready to empty.

Her rectum may expand so much that it loses its normal tone, like the stretched-out waistband of elastic shorts. The intestine becomes floppy and can’t squeeze down effectively to expel the entire load of poop, so some of it stays put in the rectum.

And when intestinal walls lose elasticity, some poop may just fall out. One mom told me she’d find “hard little rabbit pellets” all over her house when she’d vacuum. When her son, a second grader, would go over to a friend’s house, he’d jump on the trampoline and hard pieces of poop would drop out.

Meanwhile, the poop that’s piling up is located right next to the bladder, squishing it aside. If you’ve been pregnant (and, admittedly, I haven’t, but my wife has given me the play-by-play), you know what it’s like to have your bladder encroached upon: You have to pee more often and/or more urgently.

Well, what if, instead of a baby, a solid, grapefruit-size mass of poop was pressing on your bladder? Same effect.

The stretching of the colon also can cause the nerves that control the bladder to go haywire, making the bladder hiccup like crazy. The result: wet underwear, during the day or overnight.

To help parents and kids keep tabs on poops, we commissioned artist Cristina Acosta to create a kid-friendly, illustrated poop chart. You can download it for free.

Print it out and hang it on your kids’ bathroom wall! Instruct your children to examine their poops, find the corresponding number on the chart, and report back to you. For younger kids, we recommend peering into the toilet bowl and inspecting the poop yourself. (Eh, you’ll get used to it.)

Our chart is adapted from the Bristol Stool Scale, developed by researchers at the University of Bristol. Yes, some folks in England actually stopped listening to good music and eating bad food long enough to produce a pictorial representation of the various forms of poop! We have changed the scale slightly to reflect a rating that I believe is more helpful for children.

$1,750 for Two-Day Potty Training? It’s Nuts — And Not Because of the Money

By Steve Hodges, M.D.

It doesn’t shock me that some parents in New York City are spending $1,750 for two-day, outsourced potty training.

Don’t people there pay, like, $140 for a hamburger?

I don’t care how people choose to spend their money — except when it hurts kids. And this business of accelerated potty training does harm children, in ways that may not surface for a year or two down the line.

Look, I get that potty training your children is a hurdle you want to sprint over. I’ve trained two kids myself, and I still have one to go. I look forward to the day when “Do you have the diaper bag?” is not a conversation I have with my wife.

But training your child quickly should never be your goal, even if you have a preschool or summer camp deadline. When it comes to toilet training, your concern should be minimizing the child’s risk of future urinary and GI problems.

Children who are toilet trained on an accelerated schedule are far more likely to have pee accidents, poop accidents, recurrent UTIs, or bedwetting problems a few years later.

I keep reading articles that speak of toilet training as a done deal — as something that “worked” and can’t go awry after the fact.

This notion is wrong!

As I explain in a Babble post, “The Dangers of Potty Training Too Early,” knowing how to poop on the potty is not the same as responding to your body’s urges in a judicious manner.

I wish I could offer a fast-forward glimpse of those little $1,750 boot-camp graduates. Even children who “train themselves” quickly and early without any pressure from Mom or Dad frequently end up with problems.

For a typical scenario, check out this recent post by Carrots Are Orange blogger Marnie Craycroft.

I see this kind of thing every day in my practice.

My issue isn’t with outsourcing potty training; that may well be a reality if you’re a working parent, and it’s fine.

But toilet training is a natural process — emphasis on process — and it shouldn’t happen on anybody’s schedule but the child’s.

How to Treat Encopresis, aka Poop Accidents

How to Cure Bedwetting in Three Months in Any Child

Don’t Be Afraid to Give Your Child an Enema

By Steve Hodges, M.D.

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.