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Constipation, Not “Slacker Parenting,” Causes Potty Accidents

By Steve Hodges, M.D.

I have a Google alert set for “potty training” and “bedwetting,” so I often read articles offering misinformation on these topics, which are the focus of my research and medical practice.

Even when the facts are wrong, the writers tend to be compassionate and well intentioned. But sometimes, a writer will blend ignorance about toileting dysfunction with smug judgment.

Exhibit A: A family blogger, alarmed by reports that droves of British kindergartners are having pee and/or poop accidents at school, 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.”

This blogger also commiserates with a commenter who wrote: “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."

Wait, I despair!

It is true that many school-age children, including tweens and teens, have accidents at school.

However, enuresis (wetting) and encopresis (poop accidents) are not caused by parental laziness. It is constipation — a chronically and severely clogged rectum — that triggers accidents, day or night. Yes, clogged pipes, not slacker parents.

The family blogger makes a common error, assuming that children who have accidents have not been potty trained — that their parents simply didn't bother to teach them 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 mightily, and their lives are consumed by this struggle. The last thing these parents need is judgment from an uninformed 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, which is a much more challenging task than most adults realize.

When stool piles up in a child’s rectum, it forms a large, hard mass that stretches the rectum, pressing against and aggravating the bladder nerves. The bladder hiccups and empties without warning, and the child can’t get to the toilet on time.

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.

As I detail in the M.O.P. Anthology, 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.

How do we know the rectal clog is the culprit? Because when the rectum is cleared out with daily enemas and given enough time to shrink back to size, accidents resolve.

The family 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.”

This is untrue. As 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. This isn't a hard-and-fast rule — a child's readiness to toilet train depends on their maturity.

But in my experience, most 2-year-olds don't possess the judgment to respond to their body’s urges in a timely manner, even if they have the “brains and motor skills” to sit on the toilet. Toilet-trained toddlers are more likely than preschoolers to develop the holding habit and become constipated.

Preschool potty deadlines make life easier for teachers, but they do families a disservice (and often create problems for kindergarten teachers). Parents, seeking to lock in potty skills before September, start training their kids well before they are ready.

Preschool directors who set the potty deadlines may never see the consequences of those mandates. It can take years for chronic constipation to become severe enough trigger accidents. Kindergartners 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 family 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.

Shaming parents is not an effective method for resolving enuresis and encopresis. But the shaming never seems to end. The family blogger wrote: "Perhaps some moms and dads no longer have the grit to even make their kids use the toilet regularly and reliably."

This sentiment is totally off base. A clogged rectum does not respond to nagging or force.

Enuresis and encopresis need to be handled like any other medical condition: with appropriate treatment. End of story.

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