By Steve Hodges, M.D.
Western Australia has done such a stellar job containing covid-19 that the pandemic no longer dominates local news. So, the Perth-area media must look elsewhere for stories, and here’s what the region’s newspaper, The West Australian, recently drummed up for the front page: “Teachers report ‘heartbreaking’ rise in number of West Australian children attending school in nappies.”
The gist of the story: Teachers are overburdened because lazy, overindulgent parents aren’t bothering to toilet train their children.
“For many families it may be that nappies are perhaps easier for them to deal with than dealing with accidents,” a physiotherapist told the newspaper.
That’s one interpretation — an uninformed one.
As a pediatric urologist, I offer another: Chronic constipation, not slacker parenting, is the cause of enuresis (wetting accidents) and encopresis (poop accidents).
Unfortunately, constipation in children is misunderstood, overlooked, and undertreated — or not treated at all. So, accidents persist, and children attend school in diapers.
The physiotherapist, a board member of the Continence Foundation of Australia, further told The West Australian: “If a child is five and is still using nappies or wetting or soiling, that’s actually incontinence by definition, so parents need to understand that.”
That must be the least helpful advice I’ve heard! What she needs to understand is how constipation causes incontinence and how enuresis and encopresis can be resolved.
On the first point: When children delay pooping, as they often do, stool piles up in the rectum, which stretches to accommodate this expanding mass. The enlarged rectum begins to press against and aggravate the bladder nerves, triggering “hiccups” — aka pee accidents. These hiccups come on quickly and without warning, so the child has no chance of making it to the toilet.
In the case of encopresis, the stretched rectum loses tone and sensation, so stool just falls out the child’s bottom, without the child even feeling it. The child can no longer sense the urge to poop, a scenario that adds to the pile-up, setting off a vicious cycle.
Though the physiotherapist apparently didn’t know this, others in Western Australia, do. I was pleased to see the newspaper ran a letter to the editor from a mom who took issue with the article. She wrote:
My 8-year-old son has encopresis, which is caused by chronic constipation. His bowel and bladder are damaged to the point where he has little control of both. We have been to specialists, doctors, chiropractors, physiotherapists, and naturopaths trying to find relief. It’s a silent, embarrassing, and secret condition to deal with. We homeschool but I’ve heard heartbreaking stories of how these children have been dealt with at school. It would be helpful if this article researched common reasons why children might not yet be toilet trained. This would assist teachers and parents in understanding the heart-wrenching physical causes of late toilet training in some children.
I hear this story often and wish that the specialists this mom visited understood how to address encopresis, a condition, along with enuresis, that is highly treatable.
In almost all kids, accidents will resolve by fully evacuating the rectum daily with enemas, then tapering enemas to every other day and then twice a week before weaning altogether. Meanwhile, oral laxatives help keep stool soft, so children don’t feel pain when pooping. It’s usually pain that triggers the withholding cycle in the first place.
Eventually, the stretched rectum shrinks back to size, rectal sensation and tone are restored, and the rectum stops pressing against the bladder. However, the bladder nerves may remain aggravated for quite some time, which is one reason enuresis typically takes a lot longer to resolve than encopresis. I explain this in detail in The M.O.P. Anthology.
In general, the longer the rectum has been stretched, the longer it takes for it to fully rebound. The enema-based regimen I recommend, known as the Modified O’Regan Protocol (M.O.P.), is as appropriate for 4-year-olds as it is for 14-year-olds, but teens typically need to stay on the protocol longer. In rare cases, the floppy rectum needs to be surgically repaired.
In Australia, as in most countries, enemas are frowned upon by physicians, and endless amounts of laxatives are prescribed instead. This approach does not serve kids well and is not based in science. As I discuss in the Anthology, studies very clearly show that enemas are safe for children and resolve bedwetting and daytime accidents far more effectively than oral laxatives.
Some parents, having read this research, implement M.O.P. even without their doctors’ blessing. In fact, the West Australian article was brought to my attention by a Perth mom whose son is following M.O.P. and who is a member of a private Facebook support group I run for parents of children with encopresis and/or enuresis.
As she astutely pointed out in a Facebook post, the trend identified by the newspaper’s “exclusive” cover story actually points to a constipation epidemic “rather than lazy parents not training their kids.”
Another mom posted: “This makes me furious. No one who hasn’t had to deal with this can ever truly understand.”
All true!
I have written extensively about the epidemic of childhood constipation. A good place to start is “Why Is Your Child Constipated? Because We Live in the 21st Century.” Childhood constipation has multiple causes, but ironically, the one cause identified by the West Australian — parental overindulgence — is not among them.
The root problem, according to the physiotherapist quoted, is that parents are letting children decide when they’re ready to use the toilet rather than setting the agenda themselves, like firm, responsible parents would.
“It’s a general trend in letting children themselves determine when they stop wearing nappies and start using the potty or the toilet,” she said. “So, it’s not parent-directed, it’s child-directed toilet training.”
She disparages the idea of “readiness,” suggesting parents must have the fortitude to take charge of the toilet-training timeline. This would be hilarious if it were not so harmful, as I explain in “The Problem with Preschool Potty Training Deadlines.” In reality, these deadlines nudge vulnerable kids toward chronic constipation.
The West Australian article is just one of many that connect enuresis and encopresis with lazy parenting. In fact, a while back, England’s Daily Mirror tabloid ran an almost identical article, reporting that at one school, as many as six pupils in each kindergarten class had toileting difficulties and that teachers were wasting a “large amount” of time on toileting instruction.
Horrified, an American blogger at LifeZette railed against "lazy" parents: “Are today’s parents so clueless that they are posting selfies while their kindergartner runs circles around them sporting a Hello Kitty backpack and a full pull-up diaper?”
And this: “Some parents, sadly, may be giving up on follow-through when it comes to this most crucial of skills, assuming teachers will pick up their slack. Or perhaps some moms and dads no longer have the grit to even make their kids use the toilet regularly and reliably.”
The truth is, the parents I work with, in my clinic and online support groups, have tremendous grit — you can't help a child with encopresis or enuresis otherwise. These parents are conscientious and well informed and work hard every day to help their kids overcome conditions that, in many cases, their physicians undertreated or dismissed outright, with the usual "Don't worry - she'll outgrow it" assurance.
These parents know it’s a stretched rectum, not slacker parenting, that causes accidents.
And they wish, as I do, that uninformed, judgmental people would stop suggesting otherwise.