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.