Bladder Control - Getting up to Pee from the Dinner Table

When a child gets up to pee from the dinner table, some parents might presume this is a tactic to delay sitting down or to avoid eating what is offered. This is not the case. Getting up to pee happens because of the Gastro-Colic Reflex.

Whenever a person eats, the brain automatically initiates the Gastro-Colic Reflex. Gastro means stomach and Colic refers to the colon, the last part of the intestine. When food enters the stomach the brain automatically instructs the muscles in the intestine to contract and to move the variously digested contents further down through the intestine to make room for the newly ingested food.

Stool is stored in the rectum, the final part of the colon, until the person poops. The Gastro-Colic Reflex causes the poop in the rectum to be pushed lower down.

The bladder is located at the bottom of the pelvis and the rectum comes down the left side of the pelvis beside and below the bladder.

When the poop in the rectum is pushed along by the Gastro-Colic Reflex, the poop presses on the bladder. The increase in bladder pressure triggers a "bladder-is-full-signal" and this encourages the child to leave the table to pee.

Some of the children pee and poop in response to the signal but most children only pee. They likely could poop if they took the time to sit and relax, but most rush back to the dinner table.

This behaviour is frustrating for some parents and an understanding of why this happens might help some parents to be patient with this physiological behaviour.

I teach that a morning poop, great emptying, and soft stool is the goal for normal bowel health. Children who achieve this optimal pattern are much less likely to need to get up to pee at dinner. The rectum by then is emptier and the stool present is softer, and the resultant pressure on the bladder is less. 

Bladder Control in a Boy with Asperger's Syndrome

Recently I saw a 12 year-old grade 6 boy with Asperger's Syndrome (Autism Spectrum Disorder) for voiding frequently. The problem started in grade four.

During the summer before grade four the boy developed pinworms and he saw the worms moving in the poop. His memory of this image is strong and vivid. The event clearly made a strong impression.

Children with Autism Spectrum Disorder (ASD) are sometimes more intuitive about problem solving than other children of the same age. They see and solve problems in a unique manner based on their personal perspective. I listen carefully to these children.

With a careful and patient history the boy offered two important personal clues to the frequency problem. He reported that the frequency started right after the pinworm problem. He also reported that since the start of the frequency, the number of times that he needs to pee is related to how often he poops. If he does not poop very often he pees more frequently. If he poops more often, he pees less frequently.

Frequency implies a smaller bladder capacity. The most common causes are bladder infection, poop pressure on the bladder at the bottom of the pelvis, and personality considerations. There was no history or evidence of infection.

He had a longstanding history of constipation that started at four months of age. When frequency develops due to poop pressure it is a change in the pattern of pooping with less frequent movements and harder stool that triggers the change in the bladder size. His bowel health got worse after the pinworm infection. Perhaps he started to hold in his poop to avoid seeing the worms? He started to miss more and more days and finally the pressure of the poop was enough to change his bladder size and to result in the need to pee more often.

He also has personality considerations that modulated the response to the pressure signals of fullness in the smaller bladder and exacerbated the tendency to pee frequently. Mom scored him 10 out of 10 on the perfectionist scale. He has problems with anxiety. He sometimes has obsessive compulsive behaviours. Frequency is more common in children with anxiety, obsessive compulsive behaviours, and a perfectionist personality. Children with these features void more often because they are either very uncomfortable with the sensation of an overfull bladder or they are unwilling to suffer even a drop of pee in their underwear.

As a toddler the boy was "difficult" to toilet train. Whenever Mom tried him in underwear he "just wet" and carried on with his play activity. He did not try to hold his pee. He did not run to the bathroom. He just wet. Until Mom discovered him wet he was content to play in the wet clothes. He stayed in a daytime diaper until about age 4 years. This is a common story in a child with ASD. Interrupting an activity to go to the bathroom does not make sense to these children. They do not choose to hold the pee because they do not like the sensation of an overfull bladder. Rather than suffer this uncomfortable sensation or interrupt their play, they "just wet." The logic makes sense from their unique and valid perspective but is very frustrating for many parents. The boy still does not like the sensation of an overfull bladder. This is the reason he offered for why he pees so often. 

Bladder Control - School Fire Alarms and Daytime Wetting

Recently I assessed a 6.5 year old boy who I have followed intermittently for constipation and soiling since about four years of age.

His bowel health is no longer a problem. He poops every day, either after lunch at home or after school, and he has not had soiling for years. He still wets the bed and we are waiting for him to mature a bit more before we start a bedwetting alarm.

His daytime bladder control is usually very good but during December of his grade one school year he had problems with daytime wetting. Over that month he needed a change of clothes several times a week, but only at school. At home he was dry. He had enjoyed good daytime bladder control for a long time and the first few months of grade one were fine. Clearly something changed in December.

His Dad is a terrific bladder and bowel detective and he had the answer ready before I asked. “It was the fire alarm,” Dad reported. “My son was in the bathroom when the fire alarm went off, and he refused to use the school bathroom after that.

This was the second grade one child in six months who came to my office with the same story. School bathrooms are not built to muffle sounds. The walls, porcelain fixtures, tiles, and metal all reflect and accentuate the sound. I can imagine this would be a scary experience for many early elementary-aged children. Time and a lot of reassurance from Dad was necessary before the boy felt confident enough to use the school bathroom again. By January he was back into a normal routine.

While many elementary aged children might be frightened by the alarm only a few would stop attending the bathroom for this. This boy had a history of other toilet fears and also some anxieties that were not related to the bathroom. At 4 years of age he didn’t like the sound of “poop splashing.” He put his hand over his ears to block out the “flushing noise.” He was concerned about the “toilet plugging.” The automatic flushing toilets were a real concern for him in kindergarten. In the grade one bathroom, he is not comfortable with the urinals and he will only pee standing up in a cubicle and with the door closed. If there are too many boys in the bathroom he won’t go in.

Anything that restricts access to a bathroom is a potential trigger for daytime wetting. Toilet-related anxieties are one of the common triggers.

Bladder Control - Duck Waddle Gait as a Cause of Urine in the Vagina

Recently I assessed a 6 year-old girl for day and night wetting. The main concern was the daytime wetting.

At her second visit, the pelvic ultrasound showed urine in her vagina.

Urine in the vagina is almost always due to what is referred to as Vaginal Reflux of Urine. Vaginal reflux is presumed to be due to voiding while sitting on the toilet with poor posture. If the thighs are pressed together, the urine cannot come out between the labia and the urine wells up behind the labia and emerges at the bottom. Some of the urine that wells up enters the vagina and then leaks out after voiding and this is a cause of daytime dampness.

Urine can also enter the vagina will while walking to the bathroom. This happens when girls employ the duck waddle gait on the way to the bathroom. In this gait, the knees and thighs are pressed firmly together and the lower legs splay out with each step. The awkward gait is reminiscent of the way a duck walks. These girls have invariably held their pee during a very engaging activity and then rather than accept a soaker, the girls duck waddle to the bathroom, which helps limit the amount of wetting.

To minimise vaginal reflux during a duck waddle gait, the child needs to stop holding the pee. The reasons why a child holds the pee need to be addressed. The three common factors are solid poop pressing on the bladder that limits bladder size and control, bladder infection, and personality/behaviour considerations.

To minimise vaginal reflux while voiding, there are two interventions.

The first intervention is for the child to sit with the correct posture. The child should sit comfortably in the middle of the toilet with the knees apart. An over-the-toilet seat is necessary in little girls who sink in or perch forward. The pants and underwear should be taken off or pulled right down to the ankles so that the knees can relax apart. There should be no clothes pulling the thighs together. The feet should be flat on the floor. A footstool is necessary for little girls.

The second intervention is to mop up any remaining pee behind the labia with some tissue. After voiding, the child should be instructed to hold some toilet tissue between the labia for enough time to sop up the remaining pee (ten or so seconds should do).

Some physicians recommend that a child sit backwards on the toilet to insure the labia spread apart but this is wrong! Sitting backwards on a toilet does not allow pelvic floor muscle relaxation, which is essential for good emptying.

Bladder Control - Annoying Behavior in an Eight Year-old Boy Who Holds His Pee

I recently saw an 8 year-old boy for bedwetting. He wet every night and had uncommon dry nights. Mom reported that he has always tended to hold his pee to the last minute and then race to the bathroom. She described his holding postures as “bouncing” or “jigging around.” When she asks him to pee in this circumstance he sometimes denies that he needs to pee. When he finally does race to the bathroom he has minor prevoid dampness but he doesn’t wet enough to change his clothes. The last time he had a soaker by day was in preschool.

Mom also reported that over the years she noted that when her son has an overfull bladder he is “annoying” to his brothers. “His behaviour changes in an unpleasant way." The bad behaviour/holding the pee pattern was common and whenever the parents noticed him pestering his brothers, whether they saw the holding postures or not, they routinely asked him to go pee. The bad behaviour resolved after he emptied his bladder. 

I see negative behaviour due to an overfull bladder on a regular basis in the children in my office and I am sure these scenarios are commonly played out at home and at school. My sense is that the majority of mothers and teachers notice the poor behaviour but do not make the connection with the overfull bladder. Next time you see a child with poor behaviour, consider asking them to go pee. 

Clinic Data

Recently I reviewed some basic clinic data. I wanted to know how many children referred for bedwetting "graduate" each year. 

To "graduate," a child needs to achieve the four basic goals.
1. confidently dry and not wearing a pull-up
2. able to wake up to pee
3. improved bladder capacity and close to or exceeding the average for age.
4. well hydrated and able to drink as much as desired in the evening and still dry at night. 

I also determined the average number of visits and the average number of months from the first visit until graduation. 

The table below shows the data for the four years from 2011 to 2014. 

The clinic is open about 40 weeks a year, so we graduate about two children each week. The children take an average of 5 to 7 office visits to graduate and the journey to dryness takes an average of 8 to 14 months.  

Bladder Control - Children Who Continue to Play in Wet Clothes

Some children wet their clothes and they continue to play in the wet clothes. This behaviour is a source of concern and frustration for parents. 

In most of these children, the wetting has become so pervasive in their life, that they accept this as the usual and "normal" situation. 

The wetting is not their fault. Children who are always wet and who play in their wet clothes do not have control over their wetting. When wetting is not the fault of the child and when the wetting is routine, the child accepts that wetting and wet clothes are inevitable and they carry on with their play activities.  

This behaviour might be evident from the start of toilet training or might develop after daytime wetting is well established. 

When a parent discovers that their child is playing in wet clothes they usually either take the child to change or ask the child to change. When this becomes a regular event, the body language of the adult usually evolves from patient and and concerned to less and less patient and upset. Depending on the parent, the verbal language of the adult might become negative. Some parents eventually punish the child for this behaviour. I am careful to explain to these parents that the child has no control over the wetting and they should not be punished or blamed for this behaviour. 

To help the child and the parents with this problem, I explain that the child needs to learn to "value" dryness. When the parent notices wet clothes I ask them to insure that their body language is totally neutral. They should acknowledge the wetness and take the child to change into dry clothes. Next the parent should explain to the child the benefits of dry clothes in language the child can relate to. Dry clothes feel good. Dry clothes are clean. Then the parent should ask the child to advise them right away after wetting so that they can feel good and clean in the dry clothes. The parent should offer a reward for each and every time the child advises that they have wet their clothes. The reward needs to capture the attention of the child. If the language is neutral, the explanation consistent, and the reward attractive, the child will learn to value dryness and walking around in wet clothes will become less and less common. 

Bladder Control - Children Do Not Understand the Concept of a Half-full Bladder

Preschool and early elementary-aged children think about their bladder as either full or empty. Their brain development has not reached a stage when the idea of partially full makes any sense. 

This knowledge will help parents to understand the reasons for some common and frustrating voiding behaviours in their child. 

One common situation is when a parent suggests to their child that they should pee before they leave the house for a road trip. The child responds, "I don't have to pee." This might be true but the parent knows that a preemptive pee before the road trip is a good idea. So long as the child cooperates to pee this does not become a problem, but some children are reluctant to cooperate because the request does not make sense to them. "Why would Mom ask me to pee when there is no pee in my bladder?" If a child does not cooperate, this can lead to a confrontation and the parent might get upset. Confrontation and getting upset is never a good idea. 

Another common situation is when the parent asks their child to pee before they go to bed. 

The idea of "partially full" is an abstract concept for the child and abstract thinking comes later in childhood brain development. 

In children with daytime wetting who hold their pee, the child has lost touch with the early signals of fullness and has "blurred" the definition of full. For these children the bladder is therefore either empty or overfull. These children presume the bladder is empty even when they are doing the "pee pee dance."  

Bladder Control - Why Children Deny They Need to Pee.

Many parents tell me that their child denies that they need to pee even though the child is clearly posturing in a manner that indicates that they do need to pee. 

This can lead to a confrontation between the child and the parent. Many parents share that they are frustrated and that they get upset with these events. Confrontations and getting upset are never a good idea.

These children have a problem with daytime wetting and the parent would like to help the child to stay dry. The parent would like to be patient, does not want to precipitate a confrontation, and does not like getting upset. However, when the situation happens over and over again, many parents lose their composure over this issue. 

The usual story is that a child is engaged in a compelling play activity. The parent observes typical holding postures. There are many variations of the "pee pee dance." Mostly the children fidget, squirm, squeeze their thighs together, hold their groin area with a hand, tap their toes, or shuffle their feet. The parent knows that the child will either wet their clothes while playing or, that finally the child will disengage and run but wet on the way to the bathroom. 

As soon as a child starts to hold the pee on a regular basis they start to lose touch with the early signals of bladder fullness. Once a child is posturing and starts to deny they need to pee, they are not lying, they have actually lost touch with the early signals. 

Some parents have trouble accepting this concept. They believe that because the child is posturing and because this happens so often and usually ends up with wet clothes, and because the parent has pointed this out so many times, that the child must know what is going on. They tell me their child is "lazy" or that the child is "stubborn" or that this is a "control" issue. No, No, and No. These children have lost touch with the early signals and actually do not not know they need to pee. 

The early bladder-pressure-signals fade away in a fashion similar to how "background noise" disappears. The noise is there but we no longer "hear" the sound. We have five senses and the brain can "accommodate" our perception to any of these senses and make the sensation go away. 

Another way to conceptualise this situation is that the inability of the child to realise they need to pee might be an inability to "multitask." The child is usually engaged in a compelling play activity that has used up all the "attentiveness" available for the child. The bladder signals cannot compete with the compelling play activity signals. 

Some children have learning problems and testing reveals that they have difficulties "processing" information. This is a common observation in children with Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD). Having a processing problem is similar to an inability to multitask. 

Some parents worry that there might be a nerve problem in their child. The nerves in these children are normal. The presence of the behaviour confirms that the brain-bladder nerve communication is intact. The holding postures are a consequence of an intact full bladder to brain communication. The nerves are OK but the child is not in touch with the signals. 

I explain this carefully to parents to help them understand the problem and in the hope that the explanation might help the parents to be more patient and to avoid confrontations with their child. 

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. 

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.  

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. 

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. 

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.  

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."

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.