Children Toilet Trained Before Age 2 Have Triple the Risk of Wetting Problems

By Steve Hodges, M.D.

For years in my pediatric urology practice I noticed a pattern: My patients with the most severe wetting problems were toilet trained as toddlers.

Some of these kids were pushed to use the toilet by overeager parents, but others seemed to lead the way. I’d hear from parents: “I don’t get it — she basically trained herself at 18 months and never had an accident. Now she’s 3 and wetting her pants every day in preschool.”

Virtually of these children were severely constipated, as X-rays in my clinic confirmed; based on their parents’ reports, most of these kids also were in the habit of holding pee.

I was seeing so many early-trained patients that I developed a theory: Toddlers — capable as they may be of using the toilet — simply do not have the judgment to respond to their bodies’ urges in a timely manner.

Compared to children who trained later, my theory went, toddlers are far more likely to delay peeing and pooping. As a result, they’re more prone to dysfunctional toileting.

Well, I am pleased to report that I now have solid research that supports my theory. The journal Research and Reports in Urology has published a study conducted in my clinic at Wake Forest Baptist Health titled “The association of age of toilet training and dysfunctional voiding.” Our key finding: children toilet trained before age 2 have triple the risk of developing daytime wetting problems down the road.

What’s more: In our study, the children trained as toddlers had triple the risk of constipation. In fact, virtually all of study subjects who had wetting problems also were constipated.

This is no coincidence. It is well documented that constipation is the main cause of enuresis (wetting). When stool piles up in the rectum, it forms a hard lump that presses against the bladder, shrinking its capacity and irritating the nerves that feed it. Holding pee exacerbates the problem by thickening and further irritating the bladder.

Our study is the first to consider daytime wetting and constipation status along with age of toilet training, and it confirms what I’ve been telling parents for years: Toilet training a toddler is risky business. Of course, not every child trained as a toddler will later develop problems, but in my study, 60 percent of the subjects trained before age 2 did present with accidents.

Bottom line: Parents who train their children early — to meet preschool deadlines, to save money, to save landfills from diapers, or because they think toddlers are easier to train or because other cultures train early — should know there can be serious repercussions.

I hope our findings will encourage parents to delay toilet training their children, to temper their expectations of toddlers, and to have more patience when children have toileting accidents. “Failed toilet training” is one of the leading triggers of child abuse, according to the Child Abuse Prevention Center. Every week brings more news reports of toddlers killed by parents out of frustration over toilet training. Often the reason toilet training “failed” is that the children were trained at too young an age.

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. Unfortunately, preschools fail to realize early training can backfire, and they end up blaming parents and children for accidents.

The most prominent case of this blame was when 3-year-old Zoe Rosso of Arlington, Virginia — who later became my patient — was kicked out of preschool for having “too many” potty accidents. Her accidents were caused by severe constipation that had gone unrecognized.

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.

How We Conducted Our Study

Our study involved 112 children ages 3 to 10. About half of these kids came to our urology department for dysfunctional voiding. We compared these kids with a second group of children who had no history of dysfunctional voiding and who had visited a general pediatric clinic or pediatric emergency room for entirely different reasons, ranging from ear infections to broken bones.

Using a questionnaire, we asked parents in both groups what age their child had begun toilet training and whether the child had dysfunctional voiding issues.

Then we grouped patients into three categories based on age potty training was initiated: “early” (before age 2), “normal” (between 2 and 3) and “late” (after age 3). Our sample included 38 early trainers, 64 normal trainers, and 10 late trainers.

Sixty percent of the early trainers had daytime wetting. Crunching the numbers, this translated to a 3.37 times increased risk of daytime wetness as compared to group trained between ages 2 and 3.

The early trainers also were three times more likely to complain of constipation than the normal trainers.

Does Potty Training “Late” Increase Risk of Problems?

So you may be wondering: What did we learn about the kids who potty trained after age 3?

As early training comes back into fashion, I often hear from parents: “I want to train my child before he starts pushing back and it becomes a struggle.” There’s this notion floating around that if you wait too long to teach a child to use the toilet, you’ll end up with a “potty refuser.”

In our study, the sample of “late” trainers was small — we had 10 kids who trained after age 3 — but the results completely jibe with what I see daily in my practice. Of the 10 late trainers, seven had wetting problems, and all seven were constipated. The three late trainers who did not have wetting problems were not constipated.

In no way do these results suggest that late training causes problems. The reason late trainers so commonly have wetting problems is that they were already constipated when their parents started training them. When a 3 ½-year-old has no interest in pooping on the toilet or seems afraid of it, it’s almost always because pooping hurts.

Training a constipated child is terribly difficult — with some kids, impossible. Parents whose 3- or 4-year-olds have trouble training are often blamed for waiting too long, but our data suggest waiting isn’t the problem; it’s the constipation.

What’s The Right Age to Toilet Train?

I hope folks won’t read our study and jump to the conclusion that there’s a “magic window” for toilet training between ages 2 and 3. It’ just that children trained before age 2 are at the highest risk for developing problems. Based on my experience and my research, I believe that most children under 3 haven’t developed the capacity to respond to their bodies’ urges to pee and poop in a judicious manner.

I personally would not recommend toilet training a 2 1/2-year-old, and I believe that preschools that require toilet training by age 3 are doing families a great disservice. Based on my experience and my research, I have waited until after age 3 to initiate training with my own kids. (My It’s No Accident co-author, Suzanne Schlosberg, toilet trained her boys at 24 months; she talks about the repercussions in a video titled “How I Screwed Up (Royally) By Potty Training My Twins Too Soon.”)

I understand that, for multiple reasons, many parents will potty 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.

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. And once the child gets the hang of using the toilet, remain vigilant about monitoring for signs of constipation and make sure your child pees every two to three hours. If every parent did all that, I’m certain my clinic would be a lot less crowded.

Enough with Potty Bootcamps!

By Steve Hodges, M.D.

Our culture is enamored with lightening quick fixes for potty problems.

A New York City company was recently showered with publicity after launching a two-day, $1,750 toilet-training service — perceived as a godsend by moms “frustrated” by their potty-averse 3-year-olds.

Then USA Today touted a physician’s four-day fix-it program for encopresis (poop accidents). A 5-year-old following the program was instructed to spend three days in the bathroom with toys and a TV. After two days, the child was still having accidents, so her parents, under the doctor’s guidance, implemented “tough love” and removed the toys. The accidents, the mother told her daughter, were “not acceptable.”

Here’s what is not acceptable — and is harmful to children: treating accidents as behavior problems. Also harmful: attempting to toilet train or fix toileting troubles on a deadline.

As a pediatric urologist who specializes in treating toileting dysfunction, I am distressed by the message that quick-fix programs send to both parents and children.

The message is this: If you, the parent, make a “total commitment” to the process and if your child is managed in just the right way, all potty issues will resolve asap. And if your kid continues to have accidents? Well, it’s because one of you isn’t trying hard enough.

This message is based on a faulty understanding of how the body works and what actually causes accidents. It also fosters unrealistic expectations that can prompt parents to lash out at their kids, sometimes physically, in frustration.

No, Potty Problems Are Not Caused by Behavioral or Psychological Issues

FREE download poster-How Constipation Causes Accidents_1c-01

According to a pediatrician quoted in USA Today, encopresis treatment “has to tackle the behavioral issues that underlie a lot of the difficulties that lead to the refusal.”

Wrong! The top reason children “refuse” to use the toilet is simply that pooping hurts them, because their stool has become hard.

The reason children have poop accidents is that stool has piled up in the child’s rectum, stretching the rectum to the point where it has lost tone and sensation. So, poop just drops out, and often the child can’t even feel it.

Wetting, whether daytime or at night, also is a red flag for constipation: The large, hard lump of poop that has accumulated in the rectum is pressing against the child’s bladder, shrinking its capacity and irritating the nerves that feed it.

The treatment for all this is straightforward — and not helped in any way by sticker charts or sentencing a child to sit in the bathroom for three days.

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.

The stool clean-out can be achieved either with a 24-hour, high-dose laxative regimen or, more effectively, with enemas. Yes, enemas!

A pediatrician quoted in USA Today insists enemas may be “very traumatic to the child.” This is false. Not only are enemas highly effective and perfectly safe when used as directed, but they also are not painful for children and in my vast experience do not bother children, let alone traumatize them.

When you explain to a child that enemas are the ticket to clean, dry underwear, 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. In my practice, the kids who get better the quickest are those who follow an enema regimen.

Once the child’s rectum is cleaned out, a daily laxative and high-fiber, whole-foods diet will keep the colon clear, as long as the child poops and pees with frequency.

A clogged rectum can be cleaned out in a day or two, and for some kids, that’s enough to stop the accidents. But for others, it can take weeks or even months for the rectum to shrink back to size and for bowel and bladder function to normalize. You simply cannot rush the process, even if you pay a potty training guru $1,750 or a doctor $450 for long-distance phone consultations.

You also cannot assume the program “worked” simply because your child emerges from a boot-camp accident free. In reality, children who are newly toilet trained or whose problems have newly resolved require constant monitoring, to make sure the child is not holding pee or poop. The glory may be short-lived if you don’t do the follow-through. That part is never mentioned in the media but is confirmed daily in my practice.

Potty Training Toddlers is Risky Business

Our culture is frantic about getting children toilet trained before age 3, on the theory that waiting longer makes the process more difficult. What irony! In fact, it’s this mad rush to train toddlers that is, in large part, fueling an epidemic of toileting problems.

In a study conducted at my Wake Forest clinic, we found that children trained before age 2 have triple the risk of developing subsequent toileting difficulties compared to children trained between ages 2 and 3. (The study will be published in Research and Reports in Urology.)

This is because toddlers are much more prone to hold their poop and pee than older children. Indeed you can train an 18-month-old to use the toilet, but knowing how to poop on the potty is not the same as responding to your body’s urges in a judicious 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 poop or pee accidents. Many parents have tried these boot-camp fixes, emerging even more frustrated.

In my opinion, children under age 3 should not be in charge of their toileting any more than they should be in charge of their college funds. Late trainers are much more ready than toddlers and less likely to withhold stool (and might do just fine in a 3-day program). Yet 3-year-olds in diapers are stigmatized. Preschools with potty-training deadlines do children and parents a huge disservice by forcing the process.

In the USA Today article, one doctor calls untrained 3-year-olds “potty-refusers.” He goes on to say, “They know what to do, however they will fight you every step of the way.” Newsflash: If they are fighting you, it’s either because they aren’t ready to train or, more likely, they are severely constipated.

You can’t train a constipated child. It won’t work. In my study, 70 percent of the children who trained at age 3 or later had wetting problems. It’s not because their parents waited too long to train them but because all of the kids who developed wetting problems were constipated when the training started.

Studies that have investigated the ideal age for toilet training have consistently failed to consider the constipation status of children and whether they later developed toileting problems.

What’s the Rush?

As a dad, I understand the appeal of potty boot-camps. I have three young daughters, one still in diapers, and I look forward to the day when we ditch our diaper bag for good. But I’m not going to push her to train by 3 for my convenience.

We need to take a hard look at why we are forcing children to train on our schedule, not theirs. What is our motivation?

A doctor in the USA Today piece says the four-day program “is quick, but it’s not easy.” Actually, he’s got it backward. Treating encopresis is actually easy, but it’s often not quick. This emphasis on speed is harming children.

Let’s Stop Blaming Kids (and Parents) for Potty Accidents

A spread from my upcoming children’s book, ACCIDENTS AND BEDWETTING AREN’T YOUR FAULT. I hope to make kids smile, even laugh, about a topic that normally bums the heck out of them.

A spread from my upcoming children’s book, ACCIDENTS AND BEDWETTING AREN’T YOUR FAULT. I hope to make kids smile, even laugh, about a topic that normally bums the heck out of them.

By Steve Hodges, M.D.

Kids who have toileting accidents shoulder a lot of blame.

Parents — at a loss to explain how a 6-year-old can poop in her pants or a 12-year-old can wet the bed — often assume their children are rebelling or angling for attention or are simply too lazy to get out of bed at night and walk to the toilet.

These assumptions are malarkey, but I do understand where they come from. The actual cause of accidents isn’t well known, even among pediatricians, and behavior this troubling — a 4th-grader wetting the bed, for goodness sake! — would seem to demand an explanation. Kids, whose behavior often baffles us grown-ups, make for an easy scapegoat.

Sadly, some “experts” pile on, abetted by the media. In a column that ran in 250 media outlets, parenting “guru” John Rosemond insists “there is no better motivator” for staying dry overnight than “waking up on cold, wet sheets.” The implication: If only your lazy kid were more motivated, she would stay dry overnight.

And in a recent radio interview, an enuresis nurse told an Australian interviewer that “the child must desperately want to be dry. If you have the cooperation of the child, you will have success.” Again, the implication: Your unruly kid isn’t cooperating.

Sometimes kids are blamed in subtle ways, like when Mom or Dad flashes that “Again — are you kidding me?” look when the child comes in at 2 a.m. for help changing the sheets.

Other times, the blame is more direct, like when a parent says (or yells), “You’re 7! You’re old enough to know better!”

On occasion, parents or caregivers lash out at kids in such horrific and criminal ways that it’s simply mind-blowing. I have a large collection of news reports on these cases, including a 2-year-old beaten to the point of multiple fractures because she was “slow” to potty train, a 3-year-old boy beaten to death for the same reason, and a teenager punished for bedwetting by being forced to sit on an electric cooker until she sustained severe vaginal burns.

Yes, these cases are extreme, but even when children are on the receiving end of accusatory glances rather than beatings, they suffer. I see this daily in my practice. A young patient will sit on my exam table with shoulders slumped, staring at the ground, while Mom or Dad tells me, “He claims he doesn’t even feel it when he poops in his pants. That doesn’t seem possible.”

I totally get the skepticism. Unless you understand what causes encopresis, it truly is hard to believe that a child can’t feel poop falling out of his bottom. (It’s because the child’s rectum has been so overstretched that the child has lost sensation. Children who have accidents typically can’t feel it when a test balloon inflated to the size of a tangerine has been inserted into their bottoms.)

Sometimes the blame comes not from the parents but instead from teachers or school directors. My former patient Zoe Rosso, the Arlington, Virginia, girl suspended from preschool for exceeding the allowable number of accidents, clearly got the impression from school that she was somehow responsible for her wet underwear.

One day when Zoe’s mom, Betsy, picked up her daughter from school, Zoe told her, “I had four accidents. Don’t get upset at me.” The Rossos had repeatedly told Zoe, “We know this isn’t your fault.” But apparently that wasn’t the message she was receiving at preschool. (Betsy is one of the most patient, compassionate, and unflappable parents I’ve met; I can tell you she and her husband, Randy, were not the source of Zoe’s distress.)

Incidentally, it’s not just children who are blamed for toileting accidents. Sometimes, it’s the parents — blamed by other parents who feel smug that their own children stay dry and somehow take credit for that fact.

When Zoe’s case was reported in the Washington Post, the story incited a slew of hostile comments. Betsy was called a “lazy person who wants to dump the kid off so she can shop and drink Starbucks” and told to “quit blaming others for her failures.” One commenter ranted, “It’s narcissistic for parents to insist that their untrained child has to be indulged. A parent’s job is to raise a well-socialized, functional member of society.”

Wow. Why is it so difficult to muster compassion for families who deal with wet underwear?

Look, children feel crummy enough about accidents even when they are not blamed by adults. They miss out on slumber parties and school overnights and sleep-away camp, and they get teased by other kids. Gradually they lose self-esteem, and many teens who struggle with bedwetting kids slip into despair or depression.

Trust me: All kids hate having accidents. All kids are motivated to stay dry. Nobody wants to wake up with wet underwear.

And, as you yourself probably know, parents of these kids suffer enough exhaustion and embarrassment without being judged by parents lucky enough to avoid these problems.

Here’s what I hope: By educating parents, teachers, and physicians about the actual causes of toileting problems, I can help minimize the blame and stigma connected with these issues.

But I also want to reach kids directly. One of the first things I tell my patients is, “Accidents aren’t your fault.” When kids hear this, they brighten up immediately. When they hear that other kids have accidents as well, they feel even better. And when they realize my job mainly involves talking to kids about poop all day, they may even crack a smile.

But I can only reach so many patients in my clinic. So, I’ve teamed up with Suzanne Schlosberg, my co-author on It’s No Accident, to write a children’s book called Accidents and Bedwetting Aren’t Your Fault: Why Potty Accidents Happen and How to Make Them Stop.

Our 32-page book is illustrated by Cristina Acosta, a talented artist whose bright colors and wacky drawings absolutely nail the fun, silly, upbeat tone of the book.

Don’t get me wrong: The book tackles important issues and is highly informative. Kids will learn what’s going on inside their bodies in frank and accurate terms. But I’m a goofball at heart. I set out to write a book that would make kids smile, even laugh, about a topic that normally bums the heck out of them.

The book tells parallel stories — one that’s nonfiction, one fictional — and so should appeal both to young kids (3 to 6) as well as to elementary-school kids.

Accidents and Bedwetting Aren’t Your Fault will be published in October. If you’d like to receive an email alert when the book is available for order, please subscribe to our website.

Our message to kids is simple: Hey, none of this is your fault! And guess what? We can get it all fixed.

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 bed 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.