By Steve Hodges M.D.
On a recent episode of the podcast Mr. Dad, hosted by Armin Brott, a guest misrepresented my opinions on potty training and toileting accidents, so I’d like to set the record straight.
The guest was Jamie Glowacki, author of Oh Crap! Potty Training, a book that recommends toilet training kids between ages 20 and 30 months. Referring to me by name, Glowacki told Brott, “He really encourages kids to be in diapers until they’re 4.”
In reference to me, Glowacki also said, “Everybody keeps thinking he’s a shill for Pampers,” and she called me “really inflammatory.”
For the record: I have never written or even suggested that parents should wait until age 4 to toilet train their children. What’s more, I’ve written multiple blog posts critical of Pampers for normalizing enuresis (bedwetting and daytime wetting). If Pampers has ever heard of me, which I doubt, I imagine they wouldn’t be pleased. Certainly, I am no “shill” for that company or any other.
My books and blog posts explain my approach to toilet training, so let’s review.
In my book The Pre-M.O.P. Plan: How to Resolve Constipation in Babies and Toddlers and Overcome Potty-Training Struggles, I advise parents to hold off toilet training until their child 1.) shows no signs of constipation and 2.) demonstrates readiness. I describe readiness as possessing “the maturity to listen to her body’s signals, even when she is engrossed in finger painting.”
I also recommend parents “ideally” wait until their child shows interest in the toilet, notices wet/dirty diapers, can dress/undress without help, and tells you when they need to pee or poop.
I write: “Most children meet these benchmarks around age 3. but that is not a hard-and-fast rule.”
Why do I think that age 3, give or take, is an ideal time for toilet training?
As I note in The Pre-M.O.P. Plan: “In my experience, the closer kids are to age 3, the less likely they are to struggle.”
My research, too, suggests early training is not a risk-free proposition, increasing the odds a child will develop toileting dysfunction.
A study conducted in my clinic found children trained before age 24 months have triple the risk of developing chronic constipation and daytime enuresis compared to children trained between ages 2 and 3.
Why? Because compared to toddlers, children a bit older are more equipped to heed their bodies’ signals in a timely manner. That’s key. Using the toilet when the urge strikes, rather than 10 hours or 2 days later, is critical to avoiding constipation and maintaining a healthy bladder.
Toddlers, by contrast, are more prone to override their body’s signals and develop the habit of holding pee and/or poop. This habit can become deeply ingrained and can lead to chronic constipation, bedwetting, daytime wetting, encopresis (chronic poop accidents), and chronic urinary tract infections, as I explain in The M.O.P. Anthology.
This does not mean every potty-trained 2-year-old will develop the holding habit! Of course not.
However, humans have the capacity to delay pooping for hours, even days, and toddlers, with a lesser grasp on the importance of pooping promptly, are often masters of delay.
In her book, Glowacki describes “ready” as a nebulous concept (true!) and says it’s better to ask yourself, “Is my child CAPABLE of doing this?” But here’s something to consider: Loads of toddlers are capable of pooping and peeing on the toilet — that’s not difficult. Many 1-year-olds can do it. Even some 6-month-olds can do it. What is difficult for babies and toddlers is reacting promptly to the signals. Those are two different skills.
I have countless patients who toilet trained easily and successfully as toddlers only to start having accidents in pre-K or kindergarten. Their withholding tendencies went unnoticed for years, and eventually their stool-clogged rectums expanded to the point of triggering pee or poop accidents.
At that point, reversing course is challenging (though totally doable). Left untreated or undertreated, enuresis and encopresis can persist for years, even into high school.
READ: Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable
In the majority of my teenage patients, their constipation can be traced directly back to the potty-training time period. That’s why I emphasize to parents of young children that “success” doesn’t mean getting your child out of diapers asap; it means setting your child up a for a lifetime of healthy toileting habits.
I take the long view.
READ: What Preschool Potty Accidents and Teenage Bedwetting Have in Common (Spoiler Alert: Everything)
Still, I don’t advise waiting until age 4 to start toilet training. In fact, I explain to parents that if a child reaches age 4 and has not been able to toilet train, this is a big red flag for chronic constipation.
For example, in The Pre-M.O.P. Plan, I reference 4-year-olds who “can’t seem to graduate from diapers”:
Parents whose preschoolers struggle to train are often blamed for waiting too long and missing that legendary window of opportunity. But as our data shows, the problem is not slacker
parenting; it’s constipation. When a 4-year-old “refuses” to poop on the toilet, it’s because the child is constipated and pooping hurts, not because the child is hellbent on exercising her free
will and defying you.
A child with an enlarged rectum can’t properly sense the urge to poop or pee, so attempting to potty train is an exercise in frustration for both parent a child. Better to revisit underwear when the child’s rectum is fully cleared out and the rectum has regained full tone and sensation. In some children that means waiting until age 4 to try again, since they've got much bigger problems to tackle first. But in a child without a history of constipation struggles, I've certainly never advocated waiting until 4 to initiate training.
I don’t know why Glowacki considers my views “inflammatory,” but I do understand she has a different viewpoint on the ideal age for toilet training.
Glowacki is a proponent of the “window of opportunity” theory — the notion that there’s a magic window, between 20 and 30 months, and especially around 24 months, where potty training is “super easy.”
If you wait until age 3, she tells Brott on his podcast, “That’s when free will and choice come in. That’s where you get the ‘no,’ the very contrary, the power struggles, because your kid has finally realized they’re their own person. And so, if you add poop and pee to this mix, it’s explosive because they actually, literally hold the power, and they can drive you crazy.”
Again, I differ. In my experience, as a dad who potty-trained three girls at age 3 and as a pediatric urologist who sees 3,000 patients a year, kids around age 3 do great. They tend to have the confidence to get up from the preschool play circle to use the toilet and a firmer grasp on why doing so is important.
I find that power struggles erupt only when the child either isn’t mature enough to toilet train or is chronically constipated. In the second scenario, the parent mistakenly perceives the child as obstinate, not realizing the child's signals to pee and poop are compromised and the child simply cannot comply. All the nagging, cajoling, bribery, and rewards in the world won't help.
READ: Frustrated by Your Child's “Potty Refusal” or "Lying" About Accidents? It’s Physical, Not Behavioral
Still, I’m not unbending on potty-training timelines. I know many parents feel pressured by preschool potty deadlines or by peers to potty train earlier, and some 2-year-olds insist on using the toilet and can manage just fine.
In these cases, I say: OK, go ahead and try, but be super vigilant for the signs of withholding, and be prepared to jump on treatment before the tendency to delay becomes habitual.
In her book, Glowacki writes: “If you potty train your kid successfully, then the people who said you couldn’t do it look like lame-os. And you’ve just kicked their parenting advice to the mat. In other words, they have an emotional investment in your failure. So be wary of well-meaning friends who tell you that your child is too young.”
She adds: “Plus—I know this from Facebook—in short order, you are going to have awesome bragging rights.”
I don’t tell parents they “can’t” train between 20 and 30 months, and I don’t have an emotional investment in anybody’s failure. But every day in my clinic, I treat third-graders mortified by having accidents at school and teens with enuresis who are depressed, isolated, and terrified they will need pull-ups in college. These kids shoulder massive amounts of shame and blame.
I want folks to be aware of the potential pitfalls of toilet training toddlers and to know that seemingly successful training can unravel years down the line.
I would caution any parent of a toilet-trained 20-month-old to avoid bragging on social media and instead to remain humble. You just never know. The parents of my patients are as stunned as they are devastated when things go awry.
While I’m not dogmatic about toilet-training timelines or methods, I am indeed insistent on another matter discussed on Dr. Dad: the fact that constipation is the root cause of toileting accidents.
During the podcast interview, Brott tells Glowacki that a doctor once told him constipation causes toileting accidents. He says: “[This doctor] was maintaining that one of the biggest issues having to do with accidents is that fact that kids are constipated and we’re encouraging kids to hold it.”
That’s when Glowacki identifies me by name, and Brott says, “That’s the guy.” So, I think we can stipulate they are referring to me.
Glowacki then disparages my position on accidents — that constipation is the root cause — as my “big party line.” (At least that is what I think she perceives as my “party line.” It’s not 100% clear on the podcast.)
Glowacki goes on to say: “The theory doesn’t hold water to me because we’d have hundreds of thousands of people with huge issues.”
You know what? We do have hundreds of thousands of people with huge toileting issues!
Millions, actually.
Heck, in the United States alone, more than 800,000 middle-school and high-school students struggle with bedwetting, a condition almost always caused by chronic constipation. (In the M.O.P. Anthology 5th Edition, I discuss the very rare medical conditions that can cause wetting accidents in the absence of constipation.) Between 20% and one-third of teens and tweens with nocturnal enuresis also suffer from daytime accidents, research shows (as does my clinic experience).
Among teens and tweens, nocturnal enuresis is about as prevalent as autism — it’s just that nobody talks about enuresis because of the stigma. (About 2.7% of children have autism; 2.6% of 10-year-olds and 2% of kids 11 to 18 have enuresis.)
Among elementary-age children, rates of bedwetting, daytime enuresis, and encopresis are far higher.
A typical study will find encopresis in about 4% of children. If you limit that figure to ages 5 to 10, roughly 880,000 American children have chronic poop accidents. With bedwetting in the same age group, you’re talking about more than 1.7 million kids. (These statistics are based on the fact that there are about 3.6 million U.S. children born each year.)
I believe this data underestimates the actual number of children with enuresis and encopresis because many parents perceive accidents as “normal” (thanks to companies like Pampers!) and/or are embarrassed to report accidents to their pediatricians.
It’s possible Glowacki isn’t aware of the high rates of toileting dysfunction in the U.S. and abroad, as her work focuses on toddlers and preschoolers, whereas I primarily treat children who are years removed from potty training. I treat the future fall-out. In addition, one-third of the members in my private Facebook support group live abroad, so I have a good handle on the prevalence of enuresis and encopresis in Europe, Australasia, and elsewhere.
I’d like to address a few other points raised in the Mr. Dad interview.
Glowacki allows that in some children, poop can “get stuck in the nooks and crannies [of the colon] and press against the bladder,” leading to enuresis. That’s true. The force generated by the enlarged rectum aggravates the bladder nerves, triggering the bladder to spasm and empty without warning.
However, Glowacki largely attributes accidents to emotional stress. She tells Brott:
“Usually that’s when a second baby is born or a new baby. When there’s a big divorce, financial strain on the family. Anything that’s going to make mom and dad really wiggly and argue. That will send a child back.”
While this is a common perception, there’s actually no evidence emotional stress causes wetting accidents and plenty of evidence that the actual cause is constipation. X-ray a child with daytime and/or nighttime bedwetting, and you’ll find a stool-clogged rectum stretched to two or three times the normal diameter.
Sure, some children may respond to emotional stress by delaying pooping, but it’s the stool pile-up, not the stress, that is directly causing the bladder spasms. Certainly, enuresis and encopresis cause stress, but evidence does not point in the opposite direction. Once kids are properly treated for chronic constipation, the "emotional stress" that parents had pegged as the cause of accidents typically disappears.
During the interview, Glowacki gives Brott another scenario she says can cause bedwetting: “Especially over a holiday weekend, the kid will be at a barbecue sucking down juice boxes behind your back, off his sleep schedule, knocked out because he’s been running around at the party. You can expect an accident because everything’s off and he’s probably having more fluids.”
Actually, you should not expect an accident in such a scenario. A child with a healthy, stable can drink plenty of fluid before bed and stay dry all night, even if their sleep schedule is out of whack. Again, x-ray a child who wets the bed, and you’ll find an enlarged rectum. (This isn’t to say all constipated children will wet the bed. The unlucky ones are those whose bladders are sensitive to rectal stretching.)
In the podcast interview, Glowacki does seem to agree that constipation is a problem for some children. She says: “I do get some very tough cases where the child’s sphincter muscle is just made of steel, and they have a really hard time releasing it.”
However, she attributes the majority of constipation cases to the modern diet, “the crap people eat in today’s society.”
Certainly, a highly processed diet plays a role in our culture’s high rates of chronic constipation, making stool harder, slower, and more painful to pass. However, I see more complexity here.
From where I sit, constipation is caused by a mix of cultural and individual characteristics: a child’s genetics and temperament, life in the 21st century, pressure to toilet train early, and school restroom policies that encourage children to override their urges.
I’ve come to see that diet as but one piece of the puzzle and, for many kids, a piece that doesn’t even belong. I have numerous patients with stellar eating habits who nonetheless ended up supremely constipated. Some became constipated in infancy, well before they even took a bite of solid food, let alone set food in McDonald's.
In many families, even families that studiously avoid eating “crap,” every child is has enuresis and/or encopresis. It’s clear to me that the tendency toward constipation has a hereditary component.
For some children, I believe, toilet training too early leads to constipation; for others, school restroom policies are the tipping point. Some schools reward students with trinkets or student-store "money" for not using the restroom during class (that is, overriding their bodies' signals) or simply deny or restrict restroom passes.
What’s more, children react in different ways to new environments and situations. One preschooler may feel perfectly comfortable marching over to the toilet in the middle of story circle, whereas another might find the idea unthinkable. Some kids are cool with pooping at school or in supermarket restrooms or become more comfortable doing so as they mature. Others feel self-conscious from the get-go and remain reluctant.
I believe children become chronically constipated for a whole host of reasons. Many parents of constipated children drive themselves and their children nuts trying to “clean up” a diet that is already super healthy when, in reality, what the child needs is a regimen of suppositories and/or laxatives.
In children constipated to the point of having enuresis and/or encopresis, dietary changes are typically unhelpful. No amount of kale and oats can dislodge the hard mass of stool clogging the child’s rectum.
Potty training and accidents are fraught topics. I hope I’ve given Dr. Dad and his listeners additional points to consider.
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