By Steve Hodges, M.D.
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’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.
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.