Ep 125: Bladder and bowel issues? Consider constipation! The perspective of a pediatric urologist, Dr Steve Hodges

Ask Dr Jessica is joined by Dr. Steve Hodges, a pediatric urologist, discusses the connection between constipation and urinary issues in children. He explains that constipation is often the root cause of bladder and bowel problems, including urinary tract infections and bedwetting.   This conversation explores the topic of constipation in children and its relationship to accidents, particularly bedwetting.  Dr Hodges also provides  information on where to find more resources and treatment options. 

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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Transcript

Unknown: 0:00

Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. So today I have a great guest for you Dr. Steve Hodges, and he's a professor and author and a paediatric neurologist and we're going to talk about bedwetting and constipation. So Dr. Hodges strongly believes that Bedwetting, poop accidents and frequent urinary tract infections often have one thing in common, long lasting or chronic constipation. So in this episode, he talks about why there is that link between bedwetting and constipation, and he offers many solutions for parents to consider. And as a paediatrician, I can attest that chronic constipation is a very common issue. So I'm happy to introduce Dr. Hodges as a resource for families who are looking to find the right treatment for their child's toileting issues. And before you start listening to today's episode, I would be so appreciative if you would take a moment and leave a five star review. The reviews really help others to find this podcast, which in turn helps this podcast grow. Thank you so much for listening. Dr. Steve Hodges, thank you so much for taking the time to come on the podcast. I so appreciate talking to you. Thanks so much for having me. I really appreciate it. So tell everybody, what do you do for work? What kind of doctor are you? Yeah, my paediatric neurologist actually just just made professor and professor of paediatric neurology, at Wake Forest University School of Medicine. And so most delete surgeon for either congenital or kind of acquired issues with the gentle you're attracting kids. I've been doing for quite a while now. Now you're a surgeon by training, you have an interest. And you've written books about accidents and toileting, correct about half of my practice, the other half being surgical issues. And because of that I've seen firsthand, you know, I get to see these kids, lay hands on them, and see how the traditional therapies work. And that's early on my career found that traditional therapies didn't work that well. And that's what led me to all this research that led me here talking to you. So it's worked out pretty well. So you're saying that half the patients that come to see you even though you're a surgeon, half are coming to talk to you about their bladder issues and their bowel issues? Is that correct? You know, interestingly, most of the kids that come see me don't know they have bowel issues, right? They're the most are issues or urinary tract based, but when you actually look at the causes, then we uncover the bowel issues. And that's kind of how it guide the parents through the treatment. Like a simplistic example is like if you want you know, our residents take a test every year like an inservices exam to see the progress and if they say, you know, young girl with a you know, non February, February, UTI urinary tract infections comes in, you know, what's the first thing you do, you know, treat the bowel is almost like, a through B, A through D is his constipation therapy. And so even though these kids come in with urinary tract infections, the cause ends up being the poop. And one thing I struggle with just because I am a surgeon, so probably, I don't know, if it's how I was, how I'm wired, or through my training, you know, you probably know a lot of people like me, I'm not good at like, guiding people through the process, you know, slowly, I'm like, here's the problem. Here's the solution. Let's go. And so sometimes I'll scare people, I people have left my office saying I went there for pee problem, not a poop problem, this guy's you know, out of his mind. And so it's on me, the onus is on me to kind of explain it better. And hopefully, opportunities like this will help. So first, taking it back to the beginning, I get a lot of questions from parents about potty training. And when kids should be potty trained, and there's a lot of I think pressure from maybe their, their friends, their peer groups, even preschools will tell parents that they have to be potty trained by a certain age, in your opinion, when should parents start potty training? Yeah, so early on, I was pretty dogmatic about this. And then, you know, it's realised that debates on potty training are not fruitful. It's like a, it's a religion or politics discussion, very similar. So I tried to stay out of it. And I have realised that a lot of the issues that happen due to improper training only happen in people that are genetically predisposed to have those issues. So they may happen anyway. But all that being said, I don't think it kids physiologically ready to be potty trained. Meaning, do the things you need to do to get to the toilet on time and empty on time. Plus, have the awareness that it's important to do so much before three. So I would never want to get into a nother debate with like elimination communication folks, and all that and people can do what they want to each their own. But I've never seen a kid before younger than three, able to kind of handle the responsibility. And then once they're four, they should be trained. So I've always kind of ballpark did about three and a half. That's kind of been my rule of thumb. And I think that early portraying is a sign that they've quickly acquired the skill of not emptying by squeezing their sphincter, whether it be pee or poop. And emptying on time and completely is the key. It is kind of health in this field. And then think of it this way, like one of my examples I think is useful is what other responsibilities? Would you give a kid that age? And the answer would be zero. So then why would you rush to give them the responsibility of deciding when they have to go to the bathroom? And so not that you can wait till they're really old enough to know better, but at least, you know, three and a half, four, you can have a somewhat conversation and then as they get older, we can adjust it based on that. I think I remember as a parent when I was potty training my kids, the poop just got so smelly and big, and I was getting ready for them. That was my I think that's reasonable. Okay, so So now I also want to distinguish between pee potty training and poop potty training in your mind, is there is there a time difference when those two skills should be achievable? And also nighttime potty training? When should that be achieved? Correct? Yeah, so typically, kids are able to pee on the potty before they're able to poop on the potty pooping. I think it's funny, pooping ain't easy. It's a good slogan, we can make T shirts or something. But um, it causes a lot of trouble, right? I have a job probably because kids don't poop. It's not easy to poop. And so some kids do well, but typically they'll pee in the potty fine, but then pooping on the potty becomes an issue. And then honestly, the one the one downside of of delaying potty training a little bit because they get older is it they're so comfortable kind of pooping in a pull up, it's hard to transition to the toilet. But we have techniques to do that. And so I think you kind of put it out there, three and a half, but the potty is out there getting the opportunity and they usually do pee first and poop. But if you are already constipated, so to speak, so they've been having trouble pooping, from whenever it sets up in kids, whether it can be you know, birth six months, or, or a year, so you know, typical milestones, then it's all going to be difficult. So the foundation of easy pie training is regular bowel movements that are not large and kid doesn't stress out about it. If you got a kid that's having, you know, huge bowel movements that they have to go through, or do to get out every so often, then that's going to be that's a harbinger of bad things to come with potty training. And then a lot of people ask me that, like, Well, how do I potty train for Bedwetting, and so that's a, I don't want to use the phrase toilet training for bedwetting much because it's more of a natural process. And so typically, if they are more they need to be they should be dry at night. But once you get potty trained for four years old, and so you should be dry at night Honestly, even though the statistics are a quarter 25% of the kids, five and under the age of five are incontinent mostly at night. And about 15% Get Better a year. But you know, as as the number gets smaller, it's just 15% of that number. So it's it's not like in five years, they're all better. We have 18 year olds who still wet the bed. So and you can't predict you can't take all the kids are wetting the bed at five and say, Okay, you're going to be drying a year. That's why I see so many kids that are like, Hey, I'm 15 Since I was five, my doctor would say you outgrow it every at my checkup. And now it's been 10 years please help. And I hate that for him because that's a lot of laundry for something that was treatable. And also for nighttime Bedwetting, there's a huge genetic component as well correct. If I have a child who's in later elementary school years or junior high and they're still bedwetting at night, often I'll ask a parent and it turns out one of them as well was also a bed wetter into those later childhood years. Yeah, that study that said, Well, if you have a parent that outgrew bedwetting at nine then you'll probably outgrow but wait nine was one of the studies that I don't like because it's it kind of promotes waiting to treat it and it doesn't always work out. So there's sort of some I feel misinformation out there about Bedwetting, that kind of sabotage is of cure and some kids and that's one of them so I tell people that it's not that like they they had a gene and that or make up that made them with the bed tonight it's it's that you both had propensity, constipation, you both had bladders that were prone to over activity when constipated. So there's no reason we can't treat it, you know? So in other words, what you're saying is we need to first think about constipation. Yeah, I My opinion is bedwetting is never normal. You know, other than fact, you know, if you have a kid that's in a crib, that's not going to get up, get up to pee if they need to give a four or five year old kid is wetting the bed, you can fix it, you just have to treat the cause. I don't think evolution or God designed us to pee in ourselves while sleeping. I think it's a human acquired trait because of the way we go to the bathroom. So then let's talk about constipation. Why do you think constipation is such a frequent common issue these days? Yeah, I think I hope this is a good analogy. I use it a lot. But I like it. Do you give kids I don't even know. I'm sorry. I do have I have three kids. You have three kids two, right. Yeah. Three girls. How are your kids old enough for braces? I do have one child and braces. Yes. Yeah. Everybody. Invisalign? Yes, everybody. Right? Why? So making sense like is that like, why would be? And so I was asking that one day and found out this just because the diet has changed so much that our jobs don't grow and I keep getting like primitive human populations. Their teeth are straight because they're like You're going straight from breast milk to like nuts or something. I don't know what they're eating, but they're not eating what we eat. And so I think it's similar is that the way we consume food and poop has changed so much that it leads to unnatural holding. And I think, you know, you can look at diet and so forth. But the interesting part of that is, I think, the diet, the modern diets, so far from kind of maybe a primitive diet, that even the best diets, these kids will get backed up, because this is just me thinking philosophically, but you have a parent that's with it enough to feed their kid a perfect diet, which we both know is impossible and very difficult and highly stressful than that parents. Pretty neurotic. Pretty uptight. And what are uptight, people are more tentative, and you have a name or 10 of kid and they're going to hold their fruit more so like I've seen some of the most backed up kids and you know, really good diet. So me saying that diet has caused it is true, but I don't think it's even possible to get a good enough diet like in modern first world countries, it's really hard. Also, the positioning of the way that we sit on the toilet is not as our bodies were designed to do, primitively when it comes to going to the bathroom is that oh, yeah, I totally think I mean, I I work Squatty Potty. I love them this great company. But hovering on a squat is the probably the best position, right? If you're if you're sitting even with your knees raised, that's something but if you actually squatted, that would be ideal. But that's not easy. I don't think how many people modern people can even squat. I think kids can, but it's hard for me. So okay, so the first diet advice, even if, if we were to give a perfect diet recommendation for parents listening, what would you recommend to help with constipation? You know, you may not like this because you're patrician. But my recommendation is, you know, give them a well balanced diet, but she can because I know how hard it is. I've been there, you've been there. Howard is to feed kids. And then you know, if they get backed up, make up the difference with something. There's so many things out there. But I think you should you should watch your diet. But also keep keep in mind, it's so hard that you don't want to ruin your life out, you know, you could use some mural acts or whatever you want to use, and we can keep them going. Because I literally think it's that hard to do perfectly, that it's almost impossible to do with just you know, unless you're gonna go out and forage raw vegetables and nuts and stuff like that. It's really hard to do. Yeah, I usually tell parents to try their best to incorporate water, you need enough water to poop well, so make sure you're drinking enough liquids and try to have a diet that's incorporating foods that are grown from the ground. So if you can think about getting fibre, beans, fruits, vegetables, but I agree with you, it's impossible to do it perfectly. And then you know, you see things on it. This is not scientific, but it's uh, you know, I have my my n of three at my house. And my youngest, you know, brilliant kid, great kid, amazing kid was on formula pooping fine. We added rice cereal, completely constipated, like, would not poop. And so you know, at that point, I'm like, you know, give me a break. What can you do? You know, it's just, it's, it's really hard. Sometimes some, if they have it in their brain to kind of hold it in. If it hurts, then they're gonna hold it in. And so she started me relaxing, she did fine. The two most common times when kids are constipated when parents talk to me about childhood constipation are one when we start adding food into their diet. So that would work with your situation with your child when you started having rice cereal. And the other time is when they're starting to potty train 100% 100% And then I'll throw in there, but you give them antibiotics for something, they'll get diarrhoea. And then the moment the diarrhoea goes away, that change in consistency, it's it's really hard on them. Yeah, or on vacation. That's another common time vacation. Yeah, why? One of my kids would always get back on vacation. I don't get that either. I can't come up with a good reason for that. But I guess different environment. So can you actually define what is constipation? Because there's a lot of parents that are unclear. They'll tell me my child's constipated when I asked them what do you mean by that? They'll say Oh, well, they they go every other day. And does that actually mean constipation? give parents a definition of what we mean when we say constipation. early on. Prior to potty training, I'm saying you know, make sure they're pooping, you know, every day or every other day when I said every day I had some people really being aggressive with it. I felt bad. So you know, regularly, but the main thing is it shouldn't be in their head. It should they shouldn't be stressed out about it. Right? If they're hiding in the corner, pooping with red face, that's a bad thing. So they should be playing. They pause for a second poop and they keep playing that's like how much thought they should put into it. So that's what I think like pre portraying post by training you know you can look for the signs of delayed pooping large poops is the most common sign are difficult pooping, you know, but it's rare. The kid that's gonna sit there and be like, Mommy, I can't poop refers to poop. It happens but it's rare. So what I define as constipation in my kids is like if you come to me with accents, whether it's bedwetting daytime wedding or poop accents, and I get an x ray, and there's you're storing a bunch of poop at the end of the colon which the rectum then I call that constipation. And I will use that terminology because it's easy to understand, but also I think it does cause some misunderstanding because people come in say Kids not constipated. They've never ever had a hard poop. They've never not pooped. But you know, to keep these problems away that we're talking about the accents, you have to go on time and you have to empty completely. So what I'm really saying is that they're not they're in completely emptying the rectum. That's what I'm defining it as constipation. So I sometimes lose people because they'll say, Well, you know, constipation causes bedwetting, they hear the word and they think, Well, my kid doesn't poop once a week. So they're obviously not constipated. And that's what a lot of doctors do. Even urologist will say, here's some ear wax, get your child pooping daily. And if they don't get better, then they're like, well, it wasn't the poop. And that's where people missed, they missed the boat there. So just to clarify, when you're describing this, if I heard a child pooping every day with me relax, then I would also think the problem is better. Exactly. Families? No, it's not. So I'm talking about two different things. Now. One is pre potty training, because you want them to be set up well pooping Well, and that's where the traditional example of constipation applies. But if you come to me with accidents, whatever degree whatever however they're pooping, the answers is not enough, because they're not getting all the way empty, because if they weren't getting empty, they wouldn't be having accidents. So really, definition of the only way I say a child is not constipated, if they come to me with actions is either they get dry, or we have an x ray that looks empty. And so that's a little tricky. And what we're saying is that kids, I think the assembly line analogy is pretty good one, like if you're in an assembly line delivering product every hour, you can't just wait 10 hours and then start taking off a package every hour, right, you have to go you have to get rid of the backlog. And if you're a kid and you slightly delayed pooping every day, you're going to overtime, over accumulate poop in the rectum, you're not going to get it all out because you're gonna stretch the muscle out. And then you start living with poop in the rectum, which no one ever designed humans to, to do that. And that's what in that population causes bladder over activity. And if you fill up the rectum so much, that poop starts falling out, and you didn't even know it. And that's what increases your poop accents. So, what Dr. Reagan, who's the guy that kind of started this research, and one of my mentors said is it's not it's not really constipation, it's incomplete emptying of the bowels. And so, or untimely or delayed emptying of the bowels. And so unfortunately for people, nothing really let you know that's happening unless they present with accents where you get an x ray. Yeah, and I liked the point that you made about large poops, because oftentimes I'll talk to parents who don't think their child is constipated. But when we talk about the size of the poops, I'll hear oh, my four year old daughter makes the makes the size of a poop that you'd expect from an adult man. Yeah, that's constipation. And they, a lot of the times, that's the best sign, because it's so consistent people know, and they see it. And you don't know how you explain to him. But I'm like your jam and the colon for full boob, and you're delivering this huge eggplant. So you have to, that's why it's presenting like that. So I think it's a visual that people can can understand a little better. So what are other signs that parents can look for to notice constipation in their kids? So you talked about an x ray, which I think is tricky, because obviously parents can't always get an x ray on their kids. So beyond that large poops, not not pooping very frequently, so every other day might be assigned to think about. Are there any other signs that parents should notice? The typical ones like if you look at, like, what we have, like in the medical literature for definitions of constipation, like the room criteria, and so forth are like, okay, they're pooping rarely, They're pooping, hard poops. They're they're a sensation of incomplete emptying their weight. Anybody would think about if it was if they if they heard the word constipation. For for kids, there's not you don't have a good reporter of symptoms. Because a child, you know, sometimes things will be tricky is like unresolved diarrhoea, right. Like if you have diarrhoea all the time, you may be impacted and poop going around it. So these are some of the paradoxical ones that you don't expect or pooping multiple times a day, like every day, that pooping several times a day, but little small smears or small poops, that another sign they're not getting all the way empty. belly pain, you know, kids belly constipation is one of the primary causes of abdominal pain, a tummy upset and so forth. And so I tell people to look for the signs, but again, if they if they're coming in with accents that I'm like, you know, they're backed up until proven otherwise. And I think the X ray while it's a little scary to radiate a kid, it's very useful for these kind of problems. Because it gives you objective clear exactly that they're constipated. Yeah, and to make it a little more complicated, is you know, you have to know how to read it like what you're looking for, because I'm sure you've had an x ray before the radiologist said, you know, normal stone gas pattern, whatever, and then you look at it and there's poop everywhere. And so, radiologists don't really talk much about constipation and, and most of the definitions for constipation in the radiology literature don't apply to what we're talking about, which is mainly record. Now can you describe to people listening, what is the link between constipation and having urine and having urinary accidents? Explain how that connection exists? Sure. So I will Start with hydrating. So every everybody knows that when your baby you're peeing indiscriminately, you have no idea you're even paying, it's via reflex, basically it's a, it's a sacral reflex. So the bladder fills, these nerves are activated, they go, they send a signal to the spinal cord, the sacral spinal cord to the bottom. And then at some point, the body decides to empty and sends a signal back to the bladder to empty. But the baby doesn't even know they're paying because it never really gets to the brain. And so the definition pi training is when you basically recruit the brain into this process. And so you, you fill the bladder, you know, you feel it, and then eventually you feel like oh, cash should go and then you go actually initiate avoid that infant kind of spontaneous reflex void goes away, and then the adult pattern shows up. But it's not like an on off switch, you're more prone to this kind of reflex when you're young. And as you get older, that reflex goes away. Much like I, I compare it to other kind of infant reflexes that you guys see that go away, you know, over time, but if you the nerves that go from the bladder to the spinal cord, have to go around the rectum. And so if you have the rectum full all the time, then you're stretching those nerves in the brain or the spinal cord doesn't know what stretching them, it just knows those nerves come from the bladder, if they're stretched, it must be time to empty. And so it'll empty the bladder. And so I literally see the progression of that from like, a little bit of stretching with a little bit of activity might shoot it off at night, because you're not awake, you can't stop it, because you know, the brains involved a little bit but this, that it'll, it'll flip off that reflex and then as you get more full, you'll have maybe some frequency or urgency there in the daytime, where it comes on. And you feel a little bit but you can't stop it up to the extreme cases where I've had kids in my clinic that peed right in front of me. And I said, you just peed on yourself? Are they good? No, I didn't. And they had no idea. Tell me if I described this incorrectly to parents. But I'll say that when the when the bowels are so large, it's placed in atomically. So close to the bladder, that the large bowels will press on the bladder and it makes a sensation that's uncomfortable and it will feel like they have to frequently void. I think that's the best analogy that's most understand, almost understandable for parents. You know, I think pregnant women, I've never been pregnant. But I think you know, you get some of that with pregnancy as well. But I think the physiology of it is mostly is mostly the reef the stretching of the nerves. I think that the kind of real estate issues a little bit of it, but it's a lot less than the actual stretching out of the nerves, which is, which sets off the reflex. But yeah, definitely can affect bladder bladder capacity. This is interesting to clarify that it's more of a nerve issue than then as you said a real estate issue. Yeah, for sure. Okay, so So now, if constipation is the root of most of these issues, and we talked about how, yes, changing diet in an ideal world, or primitive diet, a healthier diet would be beneficial. Let's say we've implemented all the changes that are practical for our family. What's the next step to help a child with constipation? Can we maybe talk about the laxative options and what you recommend for kids? Yeah, I'll start by saying that if you have a child with accidents, then probably diet changes aren't enough. I would save the diet changes in terms of you're gonna make large ones for maintaining regular bowel movements once you're emptied out. But to get empty, you're gonna need pretty aggressive therapies. There's three things we usually use. One is osmotic laxatives, which are laxatives, which basically just make the poop soft and most commonly use would be MiraLAX. But there's also a prescription version called lactulose. There's magnesium citrate, magnesium hydroxide and various versions, there stimulant laxatives, which actually make the colon squeeze. And we use a lot more of that than we used to such as x lakhs, which is sent to see this or Santa. And then, you know, can go over the whole story about how this started. But the kind of father of this field of study Dr. O'Regan treated bedwetting in his own son, and he just went straight to the source, right, because he proved with this manometry test that his son had a dilated rectum. He said, Well, he's got dilated rectum, then I need to fix it. So give us an animal's every night. And that was his protocol. And that's what we've adopted. Because animals go right to the root of the problem, which is the end of the colon and gets empty. I don't want to put kids through something unnecessarily but it is the fastest way to get empty or daily Animas. But we use a combination of all those options based on how how aggressive we need to be, how bad the accidents are, and kind of what the kids and the families are capable of. Interesting. So the reason why this is so I'm so curious about this because a lot of paediatricians were taught that the first approach for treating constipation with a laxative is MiraLAX because it's tasteless, it's odourless. We can mix it in, you know, JUICE or WATER easily, and kids are compliant with marillac. In your view, that would not be the first step. It sounds like you would you would use an enema right away. Just invasive. That's why I'm curious. I know. I know. I have a hard time you know, I've gotten a lot of kids draw With mural acts, right? If a pretty aggressive mural acts like daily mural acts, combined with clean outs pretty regularly, and that's all I did early on, because, you know, it's been a learning process because I wasn't trained in the use of laxatives and and animals had to kind of learn from other people. And so I was scared to use enemas and next Lex just like everybody else is, you know, but once I realised that the animals were better, I use a lot of animals. And then once I realised that, like, I think you mentioned that the urge to poop is kind of mild with mural action doesn't lead to a lot of strong urge then I use a lot of extra x as well. But if you've already if a child is wetting the bed for example, and never taken a laxative ever made Alexa reasonable first start and then relax as a whole. The use from your Lexus is a whole topic for another whole podcast probably but you know, we use it a lot and that's fine, but you don't have to use it you can use it other ones. But um, it's easy to use as a daily or as a clean out dose because it's kind of so easy to dose doesn't taste bad and easy to mix a lot of different liquids. I use my likes my own kids, they did fine, but I would never force someone to use it if they didn't want to. I just want them to know that scientifically, everything says you know that it's been safe. But obviously don't use it if you don't want to or or you've had a bad reaction just like you wouldn't have your kid eat peanuts if they had a bad reaction. Magnesium has become a lot more popular in recent years then, when I first started practising as a paediatrician because I find a lot of parents view it as a natural laxative. Do you have any success with magnesium, magnesium become more popular with the issue of magnesium is it sold as in you know this it's as a supplement and as a laxative, right and the supplement people and by the supplement, like I had a daughter that had to take 400 milligrammes for migraines, that's like a basically a supplement dose, it might help you sleep in my migraines, but it's not gonna make it pooping different and the amount of magnesium you need to help you poop is quite a lot and it's not easy to find mag citrate bottles anymore. So yeah, magnesium fine. Magnesium hydroxide is sold, you know, and Peter likes make some, you know, milk, magnesium so forth. But what people mess up a lot with MiraLAX I mean, for me, magnesium is they will use a low dose and they don't really get the effect. So I'm saying use magnesium if you want to, but you really can't do cleanouts as easily with it because the taste because if you use a large amount and then even the maintenance dose is a lot higher than you think. So make sure you're using the laxative dose not the supplement dose. That's That's great advice because it is confusing because magnesium can be used for a lot of different Yeah, for sure. Yeah, for a lot of different things. So another example that is for Santa is kind of related as some people will you know, get x wax and they'll or they'll get like a natural centre from like Whole Foods or something. And that Salif extract and some leaf extract is non purified centre. So the dose is you don't know how much sin is in it. It's just an extract so there's kids, where they maybe they need 30 milligrammes of pure Senate to poop, they might need 1000 milligrammes of Senna leaf extract poop, so it doesn't correlate. So there's a couple of pitfalls I've had people fall into, and just out of curiosity that enemas tell parents what to expect with enemas, because I want to paint a realistic picture. How long do you expect a typical constipated kid to need enemas or other laxatives for because I think people are surprised at the length of time that it usually takes to recover or improved from constipation. Yes, I'll use a doctor Reagan's data for his son and the patients He treated he would do a three month protocol, which sounds like a lot, but I've got bad news for your protocols longer. But so if you just have Bedwetting, then he would give them an enema every night for a month. And then he expected them to be cured by the end of the month. And then he would taper them off in two months, so the second month would be every other night for a month and then the third month will be twice a week for a month we developed our mop protocol, which stands for modified or Reagan protocol. Because we're dealing with a lot worse cases than just Bedwetting, we're dealing with Bedwetting, daytime wedding poop accents, which as I hinted to earlier, means they're more dilated more full of poop. And we've seen a lot more kids now than Reagan ever did, because he kind of stopped seeing kids after he started this research. And we found that some kids are just really hard to get empty. So we have, I think, five different protocols now that we use all trying to find the best way to get these kids empty as fast as possible. And I don't know what if you had the world's perfect enema, you know, that will get a kid empty every time you use it. What's the theoretically fastest way you can get a kid dry but I think a Reagan's three month is probably as fast as you can ever be in terms of getting kids dry and keeping them dry. So it's definitely a process is a marathon not a sprint? What are the success rates being on these protocols? So I would say the answer that two ways one is if a kid is prone to constipation, they're gonna be prone to constipation until they're mature enough to know better honestly. And that could be you know, you probably know people adults are still constipated cuz they don't like pooping in public or something. So if you're prone to it, you're gonna be prone to wait until you just get the maturity to say you know what, I'm pooping wherever and whenever I need to, if I have the feeling now in terms of getting them empty enough so they won't have accidents. It depends on how many accidents they have at the beginning. If you start RT with what we call like all three phases. If you have nighttime view accents, daytime P accents and poop accents, it's gonna take about a month for the poop actions to go away. It's gonna take about a month for the daytime wedding to go away. And then at least three months for the bedwetting to go away. So you're talking about, you know, half a year of kind of working on these things. But hopefully people hear this. And they say have a baby that's constipated, they jump right on it. And you never get to that right. Because if you have a kid that's having pee and poop accents, they've been holding the poop for probably years at that point. Yeah, what I've learned is you want to catch it early and treated aggressively and fix it as soon as possible so that it does not become a lasting issue into the later childhood years. 100%. I can't agree more. Now, is there ever a time when this isn't constipation? And like, let's say we've, let's say a parents where their child's not constipated? You've done X rays are not constipated. What are other reasons why kids may be having accidents? Yes, so the short answer is always constipation. But there are rare conditions that cause it. I would hope this conditions would been picked up previously. But obviously you don't want to miss them. So number one would be spinal cord related issues. So some kids can't be continent, right. They're born with a condition where their bladder just doesn't work. We were born some kids are born with bladders that are open like bladder exstrophy. Or cloak works for these conditions where they don't even have a sphincter, right. So they're leaking urine all the time. So they can't they can't be continent they need surgery to and usually catheters to help them stay dry. And then there's some kids that are born with spina bifida, obviously, and spinal bifida, they usually that usually affects the nerves controlling the bowel and bladder. So they they have a very hard time being continent. So there's some subtle things that show up like, you might have a child that had a small dimple on their back. And as they grow, the incontinence gets worse, which would be a sign of maybe a tethered spinal cord, whereas they grow. I've had a couple people have a missed telephone cord. So as the child grew accidents got worse, actually looked at their back saw that got an MRI their back and found out that you know, this kid was never going to be continent unless they had surgery on their back. And so I always do two things, one to examine these kids, I, I feel a tummy and I look at their back, because I think if you do those two things, at least you're picking up that for boys and girls are a couple conditions that cause leaking that are very rare, but and I almost hate mentioning them because then every parent thinks their kid has it. It is rare, keep that in mind. But one is a posterior urethral valves which you know about which is a blockage in the urethra and boys. Most of them are picked up prenatally and they present at birth, but some I've had one it was really awkward because I it shows up late and I don't know why they show up late, but it can they can be fine. And so you always want to make sure there's no kind of anatomic issues within boys. And then girls can have a condition where they leak urine constantly. Like drip drip drip like a faucet like they're just a leaky faucet and that can be either from just peeing in their vagina with their legs together, which is called vaginal voiding or they can have an ectopic ureter and girls, if they have a kidney with two tubes coming out the kidney, one of the tubes can actually insert outside the bladder, and it will drip urine out continuously. So a girl that's always tripping urine, you need to evaluate those conditions. But I've probably seen, you know, five kids with missed valves or ectopic years in my life, whereas you know, I've seen 1000s of kids with constipation. Okay, so just to summarise by what age when you see accidential we think about constipation and your vote in terms of how to treat constipation. You're saying can be individualised from family to family and parent preference. But you tend to lean towards thinking about enemas. If it's if it's been a chronic issue, is that right? Yeah, I think I think never. I think ignoring accents and kids is just stuck. It's a bad policy, because they're probably going to get worse. You know, by what age? Should we really be thinking about accents being an issue that we Yeah, let's say like, you know, anytime they're potty trained, obviously, if they just potty trained, they're having some issues, that's fine. But if you have a kid that's been been in underwear for few months, and they're having accidents during the day, you know, I wouldn't ignore that. That's a warning sign. It could be one of those dangerous conditions we talked about. Right? So you don't want to miss it anyway. There's likely just the poop. I think for Bedwetting, five year olds great number during the daytime, I think will parents. I've used a good example. Parents who say well, they just wait till the last minute to go to the bathroom. Right? They wait to the last minute. Yeah, yeah, they do. But I tell parents this like, you go home and hold your pee until you have an accent. Okay? And you can't because that's the equivalent of me saying go home and don't sleep until I tell you or go home and don't eat. I'll tell you your brain will make you eat and sleep eventually, unless you have incredible willpower. And your brain will make up because it's a very, it's an overwhelming urge. That's what it's designed to do. So what kids have is they have this kind of hockey stick approach to the reflex where they hold a little bit but all sudden the urge comes because that reflex we're talking about and then it goes on autopilot and empties for you. So that's happening. They probably have constipation. So don't explain away You know, kids incontinence with well, they wait till last minute, because sure they wait till last minute to poop. But that's what's causing the pee issues, which they probably would pee normally if they had a normal sensations is what I'm saying. I do have to say I see a lot of kids that are so busy playing, they're having so much fun, they're on the playground, and they're doing their thing that you can see them do the potty dance where they are trying to hold it. And you can see that they, you can see that their body is asking them to go use the restroom. So I do think there's some situations where kids do hold it willingly, because they're, they're just too young to know better. Yeah, but that that reflex will kick off right where it won't in adults. And again, some of that has to do with how quickly that reflux goes away. But I mean, I've been there, right? Like, where you have to pee. It's like, oh, my god, I gotta go to the bathroom. And you know, it doesn't just happen. Where's for a kid? I mean, I'll let something out for you right now. And just as crazy. You know, the memory that came back to me. While I'm doing this, it was a very core memory when I in line to leave school in kindergarten. And I, I'm like next to the bathroom, I remember like, is really, and I peed on myself. But now that I remember back, I remember it happening. The teacher asked me, Why didn't you go to the bathroom? That was an excellent question, because the bathroom was right there. And I do see accents most commonly on the way home because you know, they're waiting, like you said, but the other day, I did not pee purposely. And that happened like a reflex and there was no stopping it. So it's we're both right. But I think if I had normal bowels at that time, normal, like an empty rectum, it would have I would have had a strong urge to pee, and that would have driven me to the bathroom. Does that make sense? It does, okay, so so it's it's more than just I always thought of it as just a maturity issue that children are young, they don't, they don't think like we think and they wait to the last minute. But you're saying that there's more to this story than that. I'm saying they definitely do that with poop. And since the poops dilated, they get messed up sensations for the bladder. So what might be like, we get this gradual urge, they go from zero to 100. And then at that point, you can't really get to the bathroom. So it's not so much the behaviour as you think otherwise, except for when it comes to withholding the poop, which leads to all this stuff, any other insights that you'd like to share anything that we didn't talk about with regards to constipation and accidents. I think just trust trust. We did this a long time. I've thought a lot about it. I promise. I've thought about this a lot about this more than anybody else in the world probably. And you just have to trust the process. I know it sound is very frustrating because these actions just happen. But what I say to you know, treat these things in a kind of a three step process, you know, you first you diagnose the bowels, and you treat them aggressively. And you either do that until they're better, or you give up right because some people you just can't get empty, I've been there. And then you can go on to medicines, there's medicines out there that can help with these problems. And then some kids is just, you don't have the time to get them empty, or you don't have the ability to get them empty. And you need them to be dry right away where they're going to college or school issues. And there are surgeries we can do for that including secret nerve stimulation and Botox. But if you think it's not full of poop, and they're having accidents, just get an x ray, send it to me, and I'll show you what's going on. And we'll go from there. I'm happy to hear that there's other things parents can do. If they're frustrated with diet, laxatives and whatnot, they can come talk exactly, I hate for them to lose hope you can always if your kids having accidents, there's a dose of Botox, it'll get them dry. Now, whether or not you want to go through all that without doing the first stuff, you know, is kind of up to you. And I'm just curious, also your thoughts? How much do How much do you find parents attitudes towards their kids bowel habits make a difference? Do we influence them at all? To be good? To be good? poopers in PE Yeah, I think that's a good point. I think there's three things that come to mind. One is the genetics Right? Like so if you if you think back to your childhood and you were with older than your kid probably going to be with older so you should I tell the other kids that I'm done treating, like, Come back when you have kids because we're not going to let them get backed up. You know. Number two is Everybody focuses you know, diligent parents who focus on on on what goes in their mouths. Typically you focus on eating, focus on exercise, you want to be active and not kind of sit on the device all day. But elimination kind of gets overlooked, right? No one you know, most kids come on office and I say when's the last time you the child poop and they look at the kid, you know, no one's looking at how often they poop. No one's looking at what it looks like. So I think being more involved in the, we'll call it the third II of that kind of eating exercise elimination. triad will be very beneficial. You should know what they're when they're pooping, how often they're pooping, what it looks like. And then the third concern I have with this field is that it is a common cause of abuse. It's frustrating trust me you have a kid with like, bed which sick of the wet sheets. I get. It's it's annoying. There are a lot of people that were punished for Bedwetting, and it's an appropriate because it's not there. I really want to make sure people understand that it's not something a child can control. I've never seen a kid that purposely pees or poops. I mean, I'm sure there's one out there. But I've never seen a kid that purposely pees or poops in their pants. It's almost always something but can't control. So you're saying, Okay, this is good for parents to hear, because I do hear a lot of parents say that they're doing it on purpose that they're too lazy to get out of bed, or they're doing it intentionally. But what you're saying is kids are not doing this on purpose for the most part, correct? Yeah, I'm not. I'm not saying I think you should focus your efforts on the behaviour that's wrong is that they're not pooping when they need to. That's what we need to treat. So make sure that pooping and we need to and that can be treated various ways. But in terms of once the poop is backed up, and they're having uncontrollable bladder spasms or poop Fallout, they can't feel you can't, you can't control that they're too far gone. So the behaviour to deal with is the poop withholding, and treat that early and aggressively. But yeah, there's no data that making them sleep and underwears they feel the wetness that doesn't help making them, you know, change the sheets doesn't help. I mean, there's subconscious components to every disease, but it's not reliable. Thank you so much. This has been so helpful. Where can parents find you if they want to learn more from you and learn about your protocols and what you do? Yeah, definitely, I think the best way to do is to go to our website, www dot Bedwetting, and access.com has links to all our books or Facebook page, all our research. And I you know, I am real confident in what we're doing. It helps people and it works. And it's a model that explains paediatric continence more fully than other models. So I really encourage people to give us a look and give it a try. If you think your kids pooping, okay, or you've done a week of MiraLAX in the in, they think they're empty, but they're not dry yet. It's not that simple. So make sure you read throw stuff in context if you need help. And you find that your patients graduate from seeing you how long does it How long can parents expect that they're going to have to see for do they graduate within a short period of time? Or what's the expected length of treatment? It varies. You know, I had a kid that, All I said was, it should take you 12 seconds to poop. You know, that's the cow average, the average time for a mammal to poop. And he got so obsessed with it. Then he started pooping right when he felt the urge to start pooping so quickly that he was dry, like in a month, you know, pretty much on his own with little bit of parallax, but then have other people that are just such a dilated colon, they're on enemas for, you know, a year or more. And so what I would say is that, you know, we treat it for four weeks. If we're not better we check an x ray, right? That's what I always do. I don't I don't just do enemas willy nilly. I treat it and then I check for progress treat it check progress, because you could do enemas and not get empty. I know it's amazing, but you want to be doing something that's effective. Not just going to go into the motions. I learned something new 12 seconds. The average mammal takes the average mammal Yeah. What's your dog next time? Yeah, I would say my dog this morning was a six second or so. Yeah, I mean, I'm not counting the I'm not counting the finding the spot right that's that's infuriating. She's better than the average. Man amazing how they never have trouble pooping. It is amazing. To me in the morning. They just don't write outside they don't think about and I'll see about that today. Literally let my dog out. It's a it's a break. And it's like, it's not like she had to poop then. The urge came earlier. She doesn't control when she can let it out. But she doesn't withhold that like if she goes out she just goes she's not overthinking it. We need to we need to think about a little bit less when it comes to poop for sure. So you think humans can be more like dogs? Yes, poop like dogs and be friendly. Like Be friendly like dogs and be friendly like that. Alright, 10 seconds or less. That's uh, yeah, I appreciate I appreciate all of your knowledge. I'm gonna think about 12 seconds or less I and everything else even parted. I'll all of the other wisdom you've imparted. And I appreciate your time today. Thank you so much. Thank you. I really appreciate it. Thank you for listening. And I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts. I would greatly appreciate it. It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr. Jessica See you next Monday.