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 Dr. Hodges

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 Dr. Hodges

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 Dr. Hodges

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 Dr. Hodges

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.

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

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

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

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

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

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

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

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

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

By Dr. Hodges

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

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

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

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

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

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

By Dr. Hodges

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

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

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

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

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

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

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

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

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

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

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

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

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

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