Saturday 26 December 2015

Bowel Health - Poop in the overnight diaper or pull-up

When a toddler has poop in the overnight diaper or pull-up, this implies that the child withheld the stool all day and that the poop came out while the child was asleep (unconscious).

Stool withholding is a fundamental learned behaviour in children with constipation.  

When I hear a story about overnight poops that have persisted for many months, this usually implies that the child is "really good" at stool withholding. In my experience, this is often a sign of more serious constipation. 

Saturday 19 December 2015

Bladder Control - Large bladder in a 10 year-old boy.

Recently a ten year-old boy was referred for a "large bladder." The large bladder was discovered when an abdominal ultrasound was performed to look for a cause of tummy pain. The ultrasound showed that the top of the bladder was up to the belly button and the estimate of the amount of pee was about 500 ml (16 oz). 

The tummy pain story sounded like intestinal colic (spasms) due to constipation. The Mom confirmed that the boy had intermittent constipation. The boy reported he pooped about three days a week. Dad reported that the boy plugged the toilet with 90% of poops.  

The ultrasound in my office confirmed that the top of the bladder was at the level of the belly button. The boy peed about 525 ml (17 oz). 

The average size for a bladder in a ten year-old is about 350 ml. 

I see large bladders fairly often in my office. Constipation from infancy (first two years of life) is the most common cause of large bladder. When there is significant constipation during infancy, the tiny pelvis is so filled up with poop that there is no room for the bladder to expand. The bladder is literally "pushed up and out" of the pelvis. Once the bladder is above the pelvic bones, the bladder can expand. I often see a bladder that extends to just below the belly button. Occasionally I see a bladder that reaches the belly button. Once I saw a bladder that went above the belly button. The bladder is meant to fill up and stay in the pelvis.

This boy was unique in my experience because he did not have any bladder symptoms. He was late to toilet train because of the constipation, but once he stopped wearing his daytime diaper, he peed regularly on his own initiative, Mom did not see pee holding postures and she did not need to remind him to pee. The boy did not have urgency and he did not wet by day, not even minor dampness. He was dry at night and did not need to wake up to pee. This is the first child I have ever seen with a large bladder due to constipation and without any bladder symptoms! This makes me wonder if this is more common than appreciated. 

The main reason why this boy did not have bladder symptoms is because he did not drink very much and he never really filled his large bladder. The Mom convinced the boy to drink for the previous ultrasound and again for the visit to my office, but he otherwise he never drank very much and never likely filled up his bladder. 

His hydration story was terrible. The most water he drank during an entire day was about 180 ml (6 oz)!!! He did not drink anything at breakfast. Mom reports that sometimes he would take "a sip" of milk before school. His first drink of the day was a chocolate milk box at lunch. After school he had about 3 oz of water. At supper he had 3 oz of milk. In the evening he might have another 3 oz of water. Milk is good nutrition but poor hydration. The optimal amount of water for a boy his age is at least 50 oz of water. Yikes!! Very poor hydration. Perhaps the only times he ever filled his large bladder were for the two ultrasounds?

Not drinking is a classic strategy to minimise bladder symptoms and this boy was an expert at not drinking. He has obsessive compulsive and anxiety traits that likely played a role in his hydration, bladder, and bowel behaviours.  

Saturday 12 December 2015

Bowel Health - Toilet trained toddlers who ask for a diaper to poop.

Toilet training for pee is often achieved before poop. Some toddlers make the transition for pee but are reluctant to sit on the potty to poop.

If a child is no longer wearing a diaper during the day and is reluctant to sit on the potty to poop, the child will start holding the poop in. Parents might note stool withholding postures (clenching the bum cheeks, squeezing the thighs together, walking on tip-toes).  

Some of these children will wait until a diaper is put on to sleep (night or nap), or as a precaution when the family is going out. Shortly after the parent puts on the diaper, the poop often comes out. 

Some parents learn from this behaviour and start to offer the child a diaper to poop. Some toddlers are articulate enough to ask for diaper. 

When a child is reluctant to poop on the potty and chooses the diaper route, this is usually a clue that the poop is difficult to pass. These children know that their poop is a problem to pass in the diaper. When the parent suggests that they should poop on the potty, the child considers this a bad idea. When they already have problems letting the poop out in a diaper, the potty does not look like a better alternative. 

If a parent notes this behaviour they should routinely offer the diaper as a transition phase. This is far better than allowing the stool withholding behaviour to persist. Stool withholding behaviour will make the bowel health much worse. The pattern will become more random, the child will start to miss days, and the poop will become harder and more and more difficult to pass. 

During the transition phase when the child is in underwear by day but still pooping in a diaper, the parent should soften the stool by encouraging the child to drink a lot more water and to eat foods with more fibre. Once the stool is soft enough, the transition from diaper to potty will be straightforward. If the child is not keen on fibre, a stool softener can make a big difference. 

Saturday 5 December 2015

Bladder Control - Getting up from the supper table to pee

Many parents presume that when a child leaves the supper table to pee that this has nothing to do with a full bladder. Parents often believe this behaviour is a tactic to avoid eating either because the child would rather play or because the child does not prefer to eat the food offered. The behaviour can infuriate some parents, especially when the child does this on a regular basis.

These children really need to pee. To the child, at that moment, the bladder does suddenly feel full.

Every time we eat, even a modest amount, the food lands in the stomach, and this initiates the Gastro-colic Reflex. This basic and automatic reflex makes perfect sense. When the food we eat enters the stomach, the brain instructs the bowel to contract and to move the previously ingested food lower down in the intestine to make room for the next meal.

Down at the bottom of the intestinal tract, the muscles in the descending colon and rectum contract and push the poop in this location deeper into the pelvis.

The bladder is located at the bottom of the funnel-shaped pelvis where there is the least available room. When the poop in the rectum pushes on the bladder, the increase in bladder pressure is recognised as a signal to pee. The signal is actually a signal to poop and pee, but most often the child leaves the table and only pees.

To minimise this behaviour the parent should instruct the child to pee before they sit down to the dinner table. A trip to the bathroom to wash the hands before dinner is an important personal hygiene behaviour. If the child pees first, washes their hands, and then sits down, getting up from the table to pee can be avoided.

The get-up-from-the-supper-table-to-pee behaviour is also a clue that the bowel health needs to improve. This behaviour is much less common in children who have a poop after breakfast because there is less poop hanging out at suppertime to press on the bladder. This behaviour is much less common in children who have soft poop because the impact of soft poop on the bladder is very different compared to the impact of hard or pasty poop. 

Saturday 28 November 2015

Bowel Health - Tip-toe walking in toddlers might be a clue to constipation.

Twice in the last month, as part of the past medical history, a parent reported that their child had a problem with tip-toe walking that required orthopaedic intervention.

Tip-toe walking is a common and usually transient behaviour in toddlers. When the problem is persistent, the conventional medical literature reports a variety of causes that include neurological problems such as cerebral palsy and muscular dystrophy. The behaviour is more common in children with autism. When tip-toe walking persists for years, the muscles of the legs might not develop in a normal fashion, and this can lead to orthopaedic problems. 

What is not commonly recognised is that tip-toe walking might be a clue to constipation in the child. 

Children with constipation routinely hold in their stool to avoid pooping. Stool withholding is fundamental to the evolution of constipation. 

Children adopt a variety of stool withholding postures to hold in the poop, and tip-toe walking is one of the common postures.  

Tip-toe walking results in an increase in the tension in the pelvic floor muscles and pelvic floor muscle tension is necessary to hold in the poop. 

Other stool withholding postures include squeezing the thighs together, crossing the legs, squeezing the bum cheeks together, arching backwards while standing. Some children adopt a posture and then brace their upper body against furniture to improve the mechanical advantage and increase the tension in the pelvic floor muscles.

To improve bowel health, I teach three fundamentals. One is a morning poop. Second is great emptying. Third is soft poop. 

Optimal posture is fundamental for emptying. The correct posture relaxes the pelvic floor muscles and is the opposite of stool withholding postures. For relaxation of the pelvic floor muscles the knees must be apart and the heels must be flat. 

Saturday 21 November 2015

Bladder Control - Girls who "squat" to hold in their pee.

Pre-school and elementary school-aged girls who have problems with daytime wetting sometimes learn to squat down on the ground to prevent a soaker. 

A sudden contraction of the bladder takes them by surprise and the girls learn to sit on their heel to control the wetting. 

Sitting on their heel, pressing their thighs together, and pausing motionless increases the tension in the pelvic floor muscles, and this enables the child to control the amount of pee that comes out into their clothes. 

Changing a soaker into dampness sounds good. Less wet is better than soaked. Right? 


The cost of squatting is a very high pressure in the bladder. Over time this high pressure can damage the bladder. The bladder wall gets progressively thicker and then irregular in appearance. The change in the bladder muscle affects how the bladder contracts and empties the urine. Emptying is compromised. 

From a bladder health perspective, squatting is bad. 

Squatting was first described in the UK in the middle of the last century. This behaviour was called Vincent's Curtsy Sign, because when a little girl in a dress crouches on the floor, this was reminiscent of a polite curtsy. This moniker makes the behaviour sound "cute," but squatting is neither cute nor healthy. 

Squatting is usually a marker for smouldering bladder infection. The inflammation due to the infection likely triggers the sudden spontaneous bladder contractions. In my experience infection is an ongoing concern in about 75% of girls who regularly squat. 

Girls who squat sit motionless for as long as it takes for the bladder contraction to pass. This can be more than a minute. The child sits motionless because they know that if they move at all, the control will be lost and a soaker will happen. Mothers report a variety of facial expressions, most of which clarify that the child is concentrating very hard on the behaviour. Sometimes the behaviour is painful and a child might be red-faced or have tears in their eyes.  

I consider squatting to be a "red flag" for the possibility of serious bladder problems. Always check for infection in a girl who squats.

Sunday 15 November 2015

Bowel Health - Children who stand on the toilet seat to poop.

Several times a year a mother will report that her child stands on the toilet seat and squats over the toilet bowl to poop. 

These children learned to do this on their own. The parents instructed them to sit on the toilet, but the children decided that standing and squatting on the toilet seat worked better for them. 

The squat is the natural posture that allows pee or poop to empty from the pelvis. The squat is also the natural posture for women to birth. Squatting is the natural posture that relaxes the pelvic floor muscles and lowers the resistance for anything in the pelvis (pee, poop, babies) to come out.  

After learning to walk, most infants learn to poop with a squatting posture. 

After toilet training, children are obliged to use a toilet to poop. The modern North American toilet is built for adults. Children do not fit on an adult toilet. To achieve a posture as close as possible to a squat, parents should encourage routine use of an over-the-toilet seat and a footstool. With these aids, the pelvic floor muscles can relax. Without these aids emptying is compromised and the stool builds up in the pelvis. 

The children who learn to stand on the toilet seat do so to make the poop process easier. How might they have learned to do this? My scenario is as follows. Perhaps they had a very difficult-to-pass poop and in the struggle to pass the poop they leaned back and brought their legs up and braced the heels of their feet on the front of the toilet seat to help push. Once they discovered that this manoeuvre allowed the poop to pass easier, they took the next step (literally) and brought their feet up further and stood on the toilet seat and then squatted over the bowl.

Sunday 8 November 2015

Bladder Control - Children who do not pee at school.

Most parents do not know how many times their child pees at school. Unless the child has a problem with daytime wetting, most parents do not inquire about this basic health-related behavior.

When I assess an elementary-aged child I always ask the child about their school day voiding behavior. Almost every child is able to offer a good description of how often and when they pee at school. The answers offer important clues about bladder control and hydration in the child.

If a child does not pee at all at school, this has several possible and important implications.
  1. At the very least, the hydration of the child at school is very poor. When a child goes 7 or 8 hours and does not pee, the most common drinking patterns include not drinking at all, limiting drinking to milk at lunch, or infrequent visits to the fountain. 
  2. There might be a bathroom phobia concern in the child. There are many reasons why children do not like school bathrooms. Bathroom cleanliness is the most common reason offered when I ask children about why they choose not to pee at school.  
  3. The teacher might restrict access to the bathroom to break times (recess, snack, lunch). Many children are very reluctant to use up this precious peer time for something as mundane as peeing. 
  4. Some children avoid peeing at school by "learning" to hold their pee for long periods of time. 
Most children who do not pee at school learn to hold their pee under pressure for variable periods of time and most are in a rush to pee when they get home from school. 

Regardless of the reason why the child does not pee at school, the school day hydration of the child is compromised. Poor hydration at school is an important health concern. In children who wet the bed, and whose parents limit evening fluids, this means the hydration of the child is poor during the school day, after supper when the parents limit fluids, and all night while they sleep. Some of these children are only well hydrated in the few hours from arriving home to whenever the parents starts to limit evening fluids! Ouch! 

Parents should ask their children how often they pee at school. Depending on their bladder capacity, a well-hydrated child will need to pee 2 to 4 times at school.  

If your child arrives home thirsty, your child did not drink enough at school. 

Make sure your child drinks at least one oz (30 ml) for every year of age at breakfast to get started on the morning hydration. 

Water is the best liquid for hydration. Milk should not be counted as a hydration fluid. Milk is good nutrition but poor hydration.  

Friday 30 October 2015

Bladder Control - Holding the pee affects the ability of a child to concentrate on homework!

Recently a mother reported that her 8 year-old son could not concentrate on his homework when he is holding his pee.

The boy routinely held his pee during a variety of activities. Mom could see the typical posturing that signals that a boy is holding his pee. He fidgeted, squirmed in his seat, or tapped his toes on the ground. Whenever Mom saw posturing she reminded her son to pee. She learned to insist that her son pee before he sat down to do his homework so that his concentration skills would be optimal. Smart Mom!

Many parents see these holding postures and most will remind their child to pee. What was different with this Mom is that she could tell that his ability to focus on his homework was impaired when he held his pee.

I hear similar stories every few weeks. I'm sure this is a common problem and that this situation plays out regularly in many homes. Unless a parent recognizes this potential problem and asks the child to pee before they sit down to their homework, the work might not be done as well as hoped.

This situation also plays out in classrooms. Teachers who restrict access to the bathroom clearly do not understand this possible consequence. Picture a busy boy or girl who would like to pay attention to the teacher but whose bladder is full. If the child must wait for a break, their attentiveness suffers, and the teaching lesson might be poorly understood.

To help parents relate to this, I ask them if they have ever attended an early morning meeting after enjoying several cups of coffee. I inquire if they remember ever trying to hold their pee while they wait for the meeting to wrap up so they can politely escape to the bathroom. If the parent replies "Yes," I go on to inquire whether the full bladder interfered with their ability to concentrate on the topics discussed. Most nod a confirming "Yes."

Saturday 24 October 2015

Bedwetting - Don't Limit Evening Drinking in Your Bedwetting Child!!!!!!!

Limiting what your child drinks after supper does not help and this common recommendation actually perpetuates the bedwetting!

About 75% of the parents who attend my clinic limit fluids in their bedwetting child. Most of the other 25% of parents experimented with this intervention and decided not to continue.

Some of the parents have limited evening drinking for years and their child still wets every night. “Has this helped,” I ask. “No,” they respond. “Ok,” I respond, "time for a new approach." 

I ask the parents to insure that their child drinks every evening. They need the hydration. Optimal hydration is one of the foundations of good health. 

The correct approach to hydration in a child with bedwetting is for the child to wake up in the morning and CATCH UP with their personal hydration by drinking LOTS in the morning. I recommend that a child drink about 40% of their recommended daily hydration before lunch. This works out to about 650 to 750 ml (22 to 25 oz) before lunch for an elementary school-aged child. After a child catches up, they should drink as per thirst or activity and they should
AWAYS DRINK IN THE EVENING. With this approach the amount of overnight urine production by the kidneys decreases even though the child is allowed to drink in the evening.

Many bedwetting children soak through their pull-up even though their parents limit drinking after supper. If these children are allowed and encouraged to drink in the evenings but if they also appropriately catch up with their hydration by drinking lots in the morning, the soaking through into the sheets goes away! Try it and see. 

The reason why limiting fluids perpetuates bedwetting is because this results in poor overnight hydration and this results in solid, pasty or hard poop that the bladder cannot push out of the way. Almost every child with bedwetting has a smaller bladder capacity than average. The bladder is smaller because the bladder cannot push the solid poop out of the way. Mothers understand this concept because during pregnancy their bladder was smaller because the bladder could not push the baby out of the way.