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

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

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

By Steve Hodges, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why It Helps to Have a Doctor in Your Court

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

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

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

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

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

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

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

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

The Patient Who Changed My Career

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

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

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

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

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

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

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

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

“My Child is Terrified of Pooping on the Potty”

By Steve Hodges, M.D.

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

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

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

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

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

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

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

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

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

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

By Steve Hodges, M.D.

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

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

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

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

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

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

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

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

By Steve Hodges, M.D.

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

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

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

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

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

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

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

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

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

No, Your Child Won’t Become Dependent On Enemas

By Steve Hodges, M.D.

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

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

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

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

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

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

Praise and Rewards Won’t Help Resolve Bedwetting

By Steve Hodges, M.D.

Praise and rewards won't help with bedwetting because a child has no control over a squished bladder!

Praise and rewards won’t help with bedwetting because a child has no control over a squished bladder!

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

Q: My 7-year-old wets the bed four or five nights a week. We track it on a chart. We try rewarding and praising her for being dry, but she just can’t do it every night. What should we do?

A: Praise and rewards aren’t appropriate for bedwetting. They send the message that staying dry is within the child’s control when, in fact, it’s not. Her overactive bladder has a “mind” of its own.

Be up front with your daughter: Explain that you’ve been mistaken and have recently learned she isn’t responsible for wetting her bed. (Our children’s book, “Bedwetting and Accidents Aren’t Your Fault,” will help on that front.) It’s just that her insides have gone awry, and luckily the problem can be fixed.

Her bedwetting is very likely caused by constipation. If you’re unsure, have your daughter X-rayed. (Yes, X-rays for constipation are safe and warranted!) Then focus on breaking up the mass of poop that’s clogging her rectum and squishing and irritating her bladder. You can accomplish this with a MiraLAX clean-out or, better yet, enemas. Then, start her on a maintenance regimen.

It’s impossible to know how long it will take for your daughter’s bedwetting to resolve. It could happen within a week, or it could take several months. The more aggressively you treat constipation, the faster bedwetting tends to resolve, but some stubborn cases do take longer.

The details of these regimens are spelled out in “It’s No Accident.”

“Bedwetting and Accidents Aren’t Your Fault”: Now Available on Amazon!

By Steve Hodges, M.D.

jpgCOVERBedwetting & Accidents

If you didn’t think bedwetting, poop accidents, clogged rectums, and enemas could make for entertaining bedtime reading for you and your child, well, just wait till you read our new children’s book!

Bedwetting and Accidents Aren’t Your Fault: Why Potty Accidents Happen and How to Make Them Stop is now available for order on amazon, in both paperback and hardcover editions. (Look for the ebook in 2015.)

I’m good with a scalpel but pretty dodgy around a sentence — and downright disastrous anywhere near a paintbrush. So I feel lucky to have collaborated the book with two awesome professionals, writer Suzanne Schlosberg and illustrator Cristina Acosta.

Our new book is so much fun. Seriously!

Just check out Cristina’s genius enema illustration:

Enema Poop Fighter

So many of my patients come to my clinic feeling embarrassed, bummed out, and stressed out — even hopeless or depressed. Suzanne and I conceived this book as a way to buck these kids up. Cristina took our ideas to places we never imagined, with her bright, upbeat, and darned funny illustrations.

I feel certain that children who read this book, either with a parent or solo, will come away feeling better about themselves and hopeful that their accidents will stop soon.

They’ll also learn a heck of a lot about what’s happening inside their body and why their doctor and parents are asking them to do certain therapies. (If enemas are on your agenda, this is the book you want your child reading!)

Here’s another peek:


I think parents will learn a lot, too — especially those who have not read It’s No Accident. And families will have a common vocabulary, including some colorful analogies, to use for discussions about toileting issues.

For example, here’s a look at the illustration explaining how the colon gets stretched when poop piles up. The shirt-stretching analogy came from Suzanne’s 7-year-old son, Ian, who had his share of accidents before his colon got cleaned out.

floppy colon

Ian and his twin brother, Toby — who in this video explain what healthy poop looks and feels like — were among several kids whose ideas influenced this book.

And the book’s wily rabbit — who first appeared in MY POOP CHART, our free download — has garnered laughs from preschoolers and elementary-age kids alike. (As a bonus, the poop chart appears on the last page of the book so you can cut it out.)

In short, our book is kid approved!

I’m also pleased to report we’ve had terrific reviews from adults, including Laura Markham, Ph.D., of AhaParenting.com, who said:

The illustrations are so much fun they remove any possible embarrassment, and the tone is friendly and supportive.”

Amy McCready, founder of Positive Parenting Solutions, said:

“Every family dealing with accidents or bedwetting should own this engaging and eye-opening book!”

And Angelique Champeau, NP, director of the Pediatric Continence Clinic at UCSF Benioff Children’s Hospital, Oakland and San Francisco, said:

“Finally – an entertaining, encouraging book about potty problems! I’ve dreamed about showing illustrations like these to my patients.”

We look forward to your feedback (and your amazon reviews)!

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.