You’ve probably heard the arguments in favor of early toilet training. They train early in Europe! Toddlers are more compliant than three-year-olds! Diapers are bad for the environment! Perhaps you’ve even read scientific studies concluding that children who train later are more likely to end up having accidents.
As a pediatric urologist who specializes in toileting problems, I’ll tell you this: Children under age 3 should not manage their own toileting habits any more than they should manage their college funds. Preschools that require 3-year-olds to be potty trained – like the one in Virginia that suspended 3-year-old Zoe Rosso for excessive potty accidents – are harming kids. And infant toilet training, promoted in Mayim Bialik’s new book Beyond the Sling, is just plain nuts – unless, like Bialik, you monitor your child 24/7, feed your child a high-fiber vegan diet, and home-school your child. Babies need to experience uninhibited voiding, or elimination, without the expectation of using the toilet at such an early age.
It’s not that young kids can’t be potty trained. Sure they can. But knowing how to poop on the potty is not the same as responding to your body’s urges in a judicious manner.
Let’s fast-forward two or three years. That’s when potty prodigies show up at my clinic – one of a handful specializing in dysfunctional voiding – with the sudden onset of pee and poop accidents, urinary tract infections (UTIs), urinary frequency, and/or bedwetting.
“I don’t get it,” a mom will tell me. “I didn’t push her – she basically trained herself.”
I believe these parents, but unfortunately it’s typically the kids who trained earliest and most easily who develop the most serious problems. I see about 100 kids a week at my clinic, and about half are dysfunctional voiders; most of them trained before 3.
To understand the risks of early training, it’s important to know that virtually all toileting problems – pee and poop accidents, bedwetting, urinary frequency, and urinary tract infections – are related to chronically holding pee or poop or both.
Children – and I mean all children – don’t like to interrupt their lives to use the bathroom. Once kids learn to put off peeing and pooping, essentially the definition of toilet training, they tend to do so often and for as long as they can. This is a dicey habit. Each time you squeeze your sphincter to prevent the release of pee, you create resistance in your bladder. What happens when muscles go up against resistance? Exactly what happens when you train your hamstrings at the gym: They get thicker and stronger. But unlike muscular hamstrings, a thicker bladder is a bad thing. It has a smaller capacity and its sensation mechanism goes awry. When a child habitually delays peeing, over months and years, his bladder wall becomes more muscular and eventually the bladder can get so strong and irritable that it empties without any input from the child.
Chronically holding poop, a problem exacerbated by our kids’ low-fiber diets, compounds the damage. A mass of poop forms in the rectum, right behind the bladder, and can stretch the rectum from about 2 centimeters in diameter to 10 centimeters or more. There’s only so much room in the pelvis, so the bladder gets squeezed out of the way and can’t hold as much urine. What’s more, the nerves controlling the bladder, which run between the bladder and the intestines, can get irritated when the intestines are enlarged, causing unexpected and unwanted bladder contractions – in other words, mad dashes to the toilet and accidents.
Chronically holding pee and poop also causes urinary tract infections. The less often a child pees, the more opportunity for infection-causing bacteria to creep up to her bladder. And if this kid is also hauling around a hefty load of poop, she’s harboring about a gazillion (to be precise) more times the bacteria than when her rectum has been emptied. Since the bladder is only a couple of inches from the rectum, the offending bacteria have a short trip to make, crawling through the perineal skin and into the vagina and the area around the urethra.
Though nobody posts on Facebook, “My kid wet the bed again,” toileting problems are rampant in our culture. Physician visits for constipation have doubled among children in the last decade or so, while hospital visits for constipation have quadrupled. Eight percent of girls have had a urinary tract infection by age 7, accounting for one million annual visits to pediatric clinics and 14 percent of all emergency room physician encounters between young girls and ER docs. Furthermore, about five million kids wet the bed, including about 20 percent of 5-year-olds, 12 percent of 6-year-olds, and 10-percent of 7-year-olds.
Though the data is robust, I believe these numbers are actually underestimates. Since parents tend to believe potty problems are normal, many don’t bother bringing their kids to the doctor.
Even when they do see a physician, the cause of their children’s toileting troubles often go unnoticed. That’s because most parents, and even many pediatricians, equate constipation with infrequent pooping. In reality, many constipated kids poop regularly, even multiple times a day. Large poop masses in children typically go unnoticed because looser poop oozes by and finds a way out more easily than the hard stuff, giving the impression that the child has fully eliminated. This is what happened with Zoe Rosso, the girl who was suspended from preschool and who is now my patient. As it turned out, Zoe had a poop mass the size of a miniature Nerf basketball stuck in her rectum, which both her pediatrician and pediatric urology clinic missed because they failed to X-ray her.
Plenty of published research, including our clinic’s 2012 study published in Urology, demonstrates that when you clear up clogged kids and prevent them from holding, the accidents, UTIs, and bedwetting episodes cease. Our study simply confirmed results from a remarkable series of Canadian studies published in the 1980s. These showed convincingly that children with wetting problems were severely constipated, despite showing few or no outward signs, and that treating constipation resolved the wetting and UTIs dramatically. (Remember that by constipation we mean a rectum clogged with stool – not failing to poop regularly.)
The reason kids who train at age 2 have more of these problems than children who train later, in my opinion, is that they have spent more months or years deciding for themselves when they should pee or poop – before they’re mature enough to understand the importance of eliminating as soon as they feel the urge. What’s more, the bladder needs about three or four years to grow and develop, and uninhibited voiding (read: diapers) facilitates maximum growth.
Parents often tell me their child has accidents because she has a “small bladder,” as if an undersized bladder is something the child was born with. The child’s bladder may be small, but that’s because its capacity has been compromised by holding.
Do you know how often I see children who are still in diapers and have recurrent UTIs? Never. Do you know how often I treat newly potty-trained children for recurrent UTIs? Every day. These kids fill a quarter of my clinic. This is not a coincidence and demonstrates quite clearly that toilet training in very young children is harmful. There is no way that healthy, developmentally normal, un-constipated children who learn to use the potty at 3 ½ have a higher rate of chronic pee or poop accidents than children who train at 2 ½. Kids in diapers don’t hold; many toilet-trained children do. Every year of constipation-free, uninhibited voiding – in other words, wearing diapers – leads to bladder growth; every year of holding shrinks the bladder and makes it more overactive.
And consider this: Typical therapy for accidents involves giving kids laxatives and putting them on a pee schedule, taking the decision of when to eliminate out of their hands.
Perhaps you’re still not sold on waiting until age 3 to potty train. Maybe you’re wondering: What about the research suggesting that it’s actually late training, not early training, that causes constipation and accidents?
Well, there’s a major flaw in this research: The authors didn’t check, via X-ray, to see if these kids were constipated at the time they started training. The records we keep at my clinic suggest that among late trainers, it’s not the age of training, but rather unrecognized constipation that correlates with problems. We have found that children who trained after age 3 and have toileting troubles either trained late because they were constipated (their parents had tried earlier but failed) or trained late and are constipated.
So, if you are training your 2-year-old because the preschool you’ve chosen requires children to be potty trained by 3, I suggest you find another school. Sending an early-trained child to preschool only increases the risk of potty problems, particularly if these schools don’t allow the safety net of a Pull-Up. Think about it: You’re placing a 3-year-old in an unfamiliar environment where, for possibly the first time in her life, she has no family members around for half the day, and you’re expecting her to interrupt her teacher during the story circle and announce that she needs to use the toilet or to climb out of the fort she’s just built with her friends and make her way over to the potty. Whoever thought that was a good idea has surely never set foot in a pediatric urology clinic.
Making matters worse, these kids are ill-equipped to deal with the sub-par restrooms and restrictive bathroom policies that may await them in elementary school and beyond. I have countless patients who have developed the capacity to hold their pee and poop from 7:30 a.m. to 4:30 p.m. – and have developed serious bladder problems and recurring urinary tract infections because of it.
Children who are newly potty trained need a lot of follow-up, no matter how well they are able to stay dry, and the earlier you train a child, the longer it’s your responsibility to monitor the child’s peeing and pooping habits closely. Children need reminders to use the toilet about every two hours. (And caretakers should never ask a child if he needs to go potty, because most kids will say no. It’s your job to instruct the child when to go.)
It’s also important to glance at your child’s poops whenever you have a chance (luckily, kids often forget to flush!). Look for poop that’s thin and/or mushy, like mashed potatoes or hummus (it’s the watery, diarrhea-like poops that signal a problem). Extra-large poops and thick, formed poops are signs of constipation.
You can also teach your child to check on his own poop and report its appearance to you. (Yeah, all this sounds gross, but these conversations are important for families to have, and lots of kids think talking about poop is fun stuff.) Finally, try to keep track of the last time your child pooped.
I know most parents dream of the day when they can be completely removed from their children’s goings-on in the bathroom. Heck, I look forward to that day myself. But don’t get too fixated on your own potty liberation. You need to pay attention to your kids’ pooping habits until you’re absolutely positive they have it down.
This article is adapted from It’s No Accident: Breakthrough Solutions to Your Child’s Wetting, Constipation, UTIs, and Other Potty Problems.