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. 

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? 

Wrong! 

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.

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.

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.