Bladder Control - Teaching a Child to "See" Himself Holding the Pee

I assessed a six year-old boy with day and night wetting. He holds his pee to the last minute when playing and Mom reminds him to pee when she sees the typical postures. He often denies he needs to pee when Mom reminds him. Sometimes an argument develops. 

Mom advised that he recently started to cooperate when she asked him to pee. The way Mom reported this made me think she had intervened to gain the cooperation and I asked her to explain how this came about. She went on to relate, “I explained what he looked like when he was holding his pee.” With words and some acting skills the Mom demonstrated the typical holding postures culminating in the inevitable race to the bathroom. 

Once a pre-school child starts to hold their pee during compelling play activities, they also start to lose touch with the early signals of bladder fullness. The signals fade away in a  manner similar to how "background noise" disappears. 

One psychological reason for this common phenomenon is that these children are in the Early Childhood phase of development, a time of egocentricity when the children only see the world through their own eyes and limited knowledge. They are not yet able to "see themselves" through the eyes of their peers or parents.

Once a child matures into Middle Childhood, the next psychological phase of development, they learn that they are part of a group (family, church, class, team) and that what other people think (parents, teachers, peers) has a value. 

This Mom helped her boy to "see himself" and this worked because he was far enough along towards Middle Childhood that he could learn this important concept. In my experience this is possible in about 20% of grade one children and about 50% of grade two children. By the end of grade three about 90% of children will have matured into Middle Childhood and are able to "see themselves" through the eyes of others. 

Bowel Health - Didn't Poop for "99 days."

There is not much room at the bottom of the pelvis in a pre-school or an early elementary school-aged child. The bladder and the bowel are situated side-by-side at the bottom in the most narrow part of the pelvis. The bones don't move. The bladder is affected by the pressure of the stool. The bladder cannot push solid poop out of the way. Solid stool pressing into the bladder compromises bladder control (holding postures, urgency, daytime dampness) and reduces the bladder size (peeing frequently, waking up to pee at night, bedwetting).

Once a child is at least six years of age they are able to answer questions about their pee and their poop. I routinely ask the child questions about how often they poop. One of the questions I ask is, "Do you poop every day or are there some days you do not poop." Most of the children I see respond that they do not poop every day. If they miss days, a follow up question is whether they miss one day at a time or more than one day. If more than one day, I ask if they might ever go more than two days, and so on until the child settles on their best estimate of how many days they might miss in a row.

A six year-old recently told me he could go "99 days" without a poop. Most children at his age do not really understand big numbers. This child was telling me in his own words that he missed many many days in a row. 

Most children only miss one or two days at a time. An every other day pattern is very common. Missing two days at a time means only two poops a week and this is also common. About once a month I talk with a family with a child who can miss a week of poops. About once or twice a year I hear a credible story that fits with going two weeks without a a poop. Going more than two weeks without a poop is rare. I have only heard this from a few families over my professional lifetime. 

Bedwetting - Dryness Due to Dehydration is Not Healthy

A nine year-old boy was referred for bedwetting. He wet every night.

The only time the boy had ever had a dry night was during a trip with some cousins. His cousins were mean-spirited and they teased him about the bedwetting. The boy felt terrible about the teasing. He decided on his own to stop drinking at 4 PM and this allowed dryness for the last four nights of the trip.

Dryness due to dehydration was an acceptable temporary solution for this boy. I don't blame him for doing what he could to stop the teasing and to bolster his self esteem.

However, dryness due to dehydration is not the right solution.

Hydration is an important fundamental of good health. One of the major goals in my clinic is dryness with the ability to drink as much as desired in the evening.

My goal is always HEALTHY DRYNESS.

My hydration recommendations for children who wet the bed are to drink at least one ounce per year of age in the evening hours before bed. Children should hydrate well early in the day. I recommend that children wake up and catch up with their daily hydration by drinking 40% of their daily needs before lunch (about 20 ounces in an early elementary school-aged child).