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  • By Steve Hodges, M.D.

Constipation, Not “Slacker Parenting,” Causes Potty Accidents


I have a Google alert set for “potty training” and “bedwetting,” so nearly every day I read an article offering misinformation on these topics, which are the focus of my research and medical practice. Just about everyone — health reporters, medical doctors, parenting experts — gets the facts wrong.

Still, most of these folks are compassionate and well intentioned. It’s not every day that a writer blends ignorance about toileting issues with cruel and smug judgment.

Not every day — but today is one of those days!

Alarmed by reports that droves of British kindergarteners are having potty accidents at school, a LifeZette blogger wrote that students are “being potty trained on site because their parents are too lazy to train them at home.”

She continued: “Instead of teaching the 1,2,3s as they’d like to, teachers are concentrating on just number 1 and 2, fulfilling a duty that a family member should have properly performed before the children arrived.”

Clever — that bit about “number 1 and 2.”

This blogger also quotes, and commiserates with, a British mom who posted a comment: “What is the point of having children if you can't be bothered to bring them up properly but just leave it to a complete stranger? I despair."

I despair.

It is true that high rates of school-age children are having accidents at school — not just in the UK but also in the U.S. and elsewhere in the developed world. (This month alone I’ve Skyped with parents in Australia, Argentina, Germany, Morocco, and New Zealand about their children’s ongoing accidents.) For reasons I explain in It’s No Accident and the Huffington Post, childhood toileting troubles have reached epidemic proportions.

However, potty problems are not caused by parental laziness! It is constipation — a chronically and severely clogged rectum — that triggers pee accidents (enuresis), poop accidents (encopresis), and bedwetting (noctural enuresis). Yes, clogged pipes, not slacker parents.

Potty Accidents Have Nothing to Do With Bathroom Etiquette

The LifeZette blogger makes a common error, assuming that children who wet their pants have not been potty trained — that parents blew off their responsibility to teach “basic bathroom etiquette.

She writes: “Even with pull-ups and singing toilets to entertain children while they do their business, some parents apparently still can’t get the job done.”

In reality, these kids have been potty trained, usually by very conscientious and increasingly desperate parents.

Believe me, these folks have tried every trick in the book, and their lives are consumed by this struggle. To glimpse their despair (“Having a 5-year-old in diapers is the most embarrassing, infuriating, frustrating thing”), check out Extended Potty Training, a support site for these parents. Or, read this Scary Mommy blog post, I’m The Mom Whose Kid May Never Be Potty Trained.

The last thing these parents need is judgment from the likes of the LifeZette blogger.

The fact is, no amount of training or “entertainment” or bribery can stop a constipated child from peeing or pooping in her pants. Overcoming accidents isn’t about learning “bathroom etiquette.” It’s about clearing a chronically clogged rectum.

How Constipation Causes Accidents

When poop piles up in a child’s rectum, it forms a large, hard mass that stretches the rectum, pressing against and aggravating the bladder. The bladder hiccups without warning, and the child can’t get to the toilet on time. The bladder also becomes squished, even flattened (I see this daily on X-rays), and does not have the capacity to hold pee overnight.

In many cases, the stretched rectum also loses sensation and tone, so the child cannot feel the urge to poop, and stool just drops out, sometimes on the floor of the school gym.

None of this is debatable. Numerous published studies, including my own, demonstrate that virtually all children who have accidents are severely constipated. In my research, we use X-rays to gauge constipation. Children with a rectal diameter greater than 3 cm are considered constipated; most patients who have accidents have a rectal diameter of at least 6 or 7 cm.

Other studies have used a less-fun procedure called anal manometry: A balloon is inserted into the child’s anus and inflated until the child feels it. In children who have accidents, the rectum has become so stretched that even when the balloon is fully inflated, to the size of a tangerine, these kids feel nothing.

How do we know the rectal clog is the culprit? Because these studies also show that when the rectum is cleared out with daily enemas, it shrinks back to size and accidents resolve.

Why Slacker Parenting Prevents Accidents

The LifeZette blogger attributes accidents to lazy parenting, but ironically, a laissez-faire approach to toilet training is actually helpful in preventing accidents. Early and insistent potty training has the opposite effect, increasing a child’s risk of developing wetting and pooping problems.

This blogger insists that children have “the brains and motor skills to do way more than many people think” and that “most children are ready to start learning potty training when they are between 22 and 30 months of age.” She cites WebMD as the source.

Well, she and WebMD are wrong. As my research indicates, children trained before age 2 have triple the risk of later developing wetting problems, compared to children trained later. Based on my research and experience, I do not recommend training children until they are around age 3.

Toddlers may have the “brains and motor skills” to sit on the toilet, but they simply do not have the judgment to respond to their body’s urges in a timely manner. They are more likely than preschoolers to develop the holding habit and become constipated.

How Schools Contribute to Potty Problems

If the LifeZette blogger is looking for someone to blame when school-age kids have accidents, she can more accurately finger preschools that require children to be toilet trained by age 3. She can also blame celebrities, like Kim Kardashian and supermodel Coco Rocha, who brag about potty training their toddlers.

Preschool potty deadlines make life easier for teachers, but they do families a big disservice (and often create problems for kindergarten teachers). Parents, seeking to lock in potty skills before September, start training their kids at age 2 or 2 ½, and all goes well — for a while.

The preschool directors who set the potty deadlines may never see the damage those rules inflicted. It can take years for chronic constipation to become severe enough trigger accidents. Kindergarteners who wet their pants in class are often the very children who were diligently trained to use the toilet as toddlers — the opposite picture painted by the LifeZette blogger.

In cases where 5-year-olds have never graduated from diapers, it’s because the kids were constipated when potty training began, so the training had no chance of working.

Here’s what else the LifeZette blogger misses: The restrictive bathroom policies many kindergarteners encounter at school only make their toileting problems worse.

Some 88% of elementary teachers admit to discouraging or prohibiting children from using the toilet during class time when they ask, according to University of California San Francisco research. Worse, 36% of teachers reward students who don’t use bathroom passes or punish those who do. In other words, teachers are promoting the holding behavior that makes accidents worse.

(Holding pee and holding poop aggravate the bladder in different ways, as I explain in It’s No Accident, but both are bad news.)

I share the LifeZette blogger’s compassion for teachers. They are up against a lot, and dealing with wet or dirty underwear is certainly not something they signed up for. But most teachers know nothing about why accidents happen — only 18% receive any training on children’s toileting health — and they attribute accidents to laziness, anxiety, or behavior problems. They assume children are faking it when they ask to use the bathroom during class time.

I regularly write letters to schools on behalf of students who are denied free bathroom access and who have been threatened with suspension from school for potty accidents.

Parents who push for unrestricted bathroom access are often greeted with the kind of hostility spewed by the LifeZette blogger.

A Chicago parent, Andrea Craig, wrote to her daughter’s kindergarten teacher after witnessing children being denied bathroom access and learning of at least six different pee and poop accidents that happened in her child’s class.

The teacher did not appreciate the input. In an email to the principal that Andrea accidentally received and forwarded to me, the teacher wrote: “Maybe we need to tell her she may not volunteer because she is in everyone's business and stirring up drama where there doesn't need to be any.”

Let me assure you: A lot more drama needs to be stirred up over school bathroom policies.

Andrea was rebuffed by her school’s administrators and has brought the issue to the Chicago Public School Board in an attempt to gain unrestricted bathroom access for all K-2 students.

I applaud her efforts and certainly hope she succeeds. But given the ignorance and hostility that surround this issue — exhibit A: one LifeZette blogger — I suspect she won’t.

Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and coauthor, with Suzanne Schlosberg, of It's No Accident, The M.O.P. Book, and Bedwetting and Accidents Aren't Your Fault.

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• Bedwetting and Accidents Aren't Your Fault

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Feel free to contact Dr. Hodges or Suzanne directly:
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