By Steve Hodges, M.D.
Carrie Tinsley is one brave mom.
In her Scary Mommy blog post, “I’m The Mom Whose Kid May Never Be Potty Trained,” she admits that her almost-5-year-old son, Tate, has daily accidents. She lists the ill-fated strategies she has tried: bribes, charts, timers, waiting patiently.
“I feel like such a failure,” she writes.
Every day in my pediatric urology clinic I meet similarly dejected parents and their bummed-out kids, and I want Carrie to know what I tell my patients: Virtually all accidents are caused by chronic constipation (as Carrie’s pediatrician told her) and, with appropriate treatment, are totally fixable. But treatment must be aggressive.
Carrie was instructed to give Tate “some daily laxative drink mix,” presumably Miralax or similar. She writes: “I just know it will take him time, and I need to be patient.”
Here’s the reality: a daily dose of laxative won’t suffice. And while patience is important, expecting a daily capful of Miralax to resolve accidents is like expecting a daily teaspoon of Drano to unclog your bathtub drain.
I’m not sure Carrie got the full picture from her pediatrician — about how constipation causes pee and poop accidents and what it takes to resolve these problems for good.
Carrie fears her son’s potty issues will follow him to kindergarten, and honestly, Tate is likely to continue having accidents if his treatment is limited to oral laxatives and patience.
For Carrie and other parents in her situation, here’s a rundown of critical information about constipation and accidents.
•The constipation that causes accidents is severe and chronic.
Parents don’t realize just how much poop can be stuffed into a small body. On patient X-rays I regularly see rectal poop masses as large as a grapefruit. These large, hard lumps press against, aggravate, and sometimes even flatten the child’s bladder. During the day, the aggravated bladder empties without warning; at night, these kids can’t hold enough pee to stay dry.
As for poop accidents, the rectum, stretched by the stool mass loses sensation; the child can’t feel the urge to poop, so even more poop piles up. Also, the stretched rectum loses tone, so poop just drops out, often without the child noticing.
•Constipation does not mean “pooping infrequently.”
Many constipated children poop daily, even two or three times a day, because a floppy rectum can’t fully evacuate. Pee accidents, poop accidents, and bedwetting are telltale signs of constipation in children.
Other top signs: XXL poops (adult-sized toilet cloggers!) and firm, formed poops, shaped like a sausage or rabbit pellets. Healthy poop is mushy like a milkshake or hummus.
•X-rays are the best way to confirm severe constipation.
Most pediatricians routinely miss constipation because they simply feel a child’s belly and ask parents about pooping frequency. These methods are worthless, as I explain in It's No Accident.
An X-ray provides evidence, plain as day. A rectum with a diameter wider than 3 cm indicates constipation; most of my wetting patients have rectums of at least 6 to 7 cm. Yes, X-raying for constipation is safe, as I discuss in “When to X-ray a Child for Constipation.”
X-raying isn’t necessary — you can almost always assume a child who has accidents is constipated. But for skeptical parents, the evidence can help a lot, guiding treatment and confirming the accidents are not the child’s fault.
•Children potty trained around age 2 face a high risk of developing potty problems.
Carrie suspects her son was “rushed to potty train at his daycare when he turned 2 and wasn’t quite ready.” Bingo!
Toilet training toddlers is risky business, as my published research confirms. Of course, not every child trained as a toddler will later develop problems, but in our study, 60 percent of subjects trained before age 2 presented with accidents at age 3 or later. Those trained before age 2 had triple the risk of the later developing wetting problems. This statistic applies even to children who appeared ready and eager as toddlers.
Personally, I wouldn’t train a child younger than 3. Most children under 3 simply haven’t developed the capacity to respond to their bodies’ urges in a judicious manner. They easily develop the habit of holding. Preschools that require toilet training by age 3 do families a great disservice.
•Daily enemas resolve accidents better than Miralax.
If there’s one word parents at my clinic don’t want to hear, it’s “enema.” Handing a child a glass of water mixed with a powder is a heckuva lot easier than inserting a tube up his bottom. No argument there!
But MiraLAX often does not fully clean out the child’s rectum; some softened poop may just ooze around the hard mass. So, the rectum may never shrink back to normal size, stop bothering the bladder, and regain tone and sensation.
A daily enema regimen maintained for at least a month before tapering (called the Modified O’Regan Protocol), will allow the rectum to fully heal. It is this healing process, more than the initial cleanout, that resolves toileting problems.
Enemas are plenty safe, they do not hurt most children, and they are by far the most effective way to resolve accidents. This has been my experience for a decade and was confirmed in a three-month study of 60 wetting patients, to be published next month. In our study, we found that 85% of the children treated with daily pediatric enemas reported resolution of their symptoms, compared to just 30% of those treated with oral laxatives, drugs, or other methods.
Sean O'Regan, M.D., the pediatric nephrologist whose research proved the connection between constipation and accidents, used enemas exclusively and with dramatic results.
What about dietary measures? While switching from a processed diet to a whole-foods diet is important, once a child is constipated to the point of having accidents, dietary changes won’t suffice. Prunes and broccoli won't dislodge a hardened rectal poop mass.
What about the 15% of children in my study whose accidents did not resolve with daily pediatric enemas? For the most stubbornly constipated children, I recommend a more aggressive regimen called M.O.P.+, which involves large-volume enemas.
•Rewards won’t fix potty accidents.
As Carrie discovered, overactive bladders do not respond to the promise of M&Ms, screen time, or praise!
On the other hand, rewards, like punishments, can be damaging to children, as they assume these kids have control over their wonky bladders. Rewards simply set up a child up to feel like a failure. Even if you don’t overtly “blame” your child for accidents, offering rewards suggests the child is at fault, and children internalize this message.
•Schools understand little about accidents.
Carrie worries her son will be teased at elementary school, but she should worry even more about how her son will be treated by his teachers.
Children who have accidents are often considered to have behavioral or psychological problems and are often referred to therapists for problems that are clearly physiological. Sometimes they’re just considered lazy.
I routinely write letters on behalf of children who have been threatened with suspension by their preschools or elementary schools. I also send teachers our free download titled “The K-12 Teacher’s Fact Sheet on Childhood Toileting Troubles.”
•Not all children “outgrow” accidents.
Carries feels confident that “Tate won’t go to college in a Huggies pull-up.” It’s very likely he won’t, and I don’t want to be alarmist, but I have many teenage patients who are freaked out about this very issue.
These kids were told year after year by their pediatricians that they would outgrow their accidents or bedwetting. Any parent inclined to wait it out should read, “My 15-year-old still wets the bed.”
Carrie Tinsley notes that her son “isn’t the first kid with this problem, and he won’t be the last.” True enough! But I don’t think most parents realize just how common — and how fixable — potty problems are.
Toileting problems, though epidemic in Western countries, are also preventable. If our culture recognized the risks of early toilet training and of restrictive school bathroom policies, parents like Carrie wouldn’t have to feel like failures.
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and co-author, with Suzanne Schlosberg, of It's No Accident and Bedwetting and Accidents Aren't Your Fault. Their website is BedwettingAndAccidents.com.