Problems with Potty Training, Constipation, Bedwetting, and Preschool Policies (with Dr. Steven Hodges)

Pediatric urologist Dr. Steven Hodges joins Janet to address the most common questions parents have about children’s urinary and bowel problems. They discuss the physical and psychological reasons that challenges occur, what parents should look out for, and the practical steps we can take to both treat issues and prevent them from happening in the future.

Transcript of “Problems with Potty Training, Constipation, Bedwetting, and Preschool Policies (with Dr. Steven Hodges)”

Hi, this is Janet Lansbury. Welcome to Unruffled. Today, I’m welcoming pediatric urologist Steve Hodges to the show. He’s an MD. He’s an associate professor of pediatric urology at Wake Forest University School of Medicine. And many of the common issues that parents ask about, I’m going to be asking him today: potty training, constipation issues, bedwetting accidents, refusal to use the potty, preschool requirements and more. His website is It’s an invaluable resource for parents, medical professionals, therapists, and teachers. Their original materials respect children’s feelings and intelligence, and are grounded in rigorous scientific research. I’m really looking forward to hearing from Dr. Hodges on all these important issues.

Janet Lansbury:  Hello, Dr. Hodges. Thank you so much for being here.

Steve Hodges:  Thanks for having me. Thanks a million.

Janet Lansbury:  Well, I know you have a very busy day, so I really appreciate your time. And I have, of course, a zillion questions I would love to ask you because the topics that you have expertise in are of very great concern to so many of the parents I work with. There are so many common questions that I would like us to try to cover, but I thought I’d like to start with you telling us a little bit about your very unique perspective on bowel and bladder and “all things potty” issues and how you came to it.

Steve Hodges:  Yeah. So this is an interesting story. I could talk about it for a long time, but I’ll try to put it into a short synopsis. Early on, when I trained, I learned the traditional teachings regarding what we call dysfunctional elimination or bowel and bladder dysfunction, which is that kids get constipated, they have a dysfunction in their pelvic floor and it causes accidents.

The treatment that they typically recommend, the cookbook therapy is some Miralax to make them poop daily. Maybe peeing on a schedule every two hours. Perhaps some medications to relax the bladder. The mainstay was pelvic floor physical therapy, which teaches them to relax their sphincter so they can empty their bladder and bowels more effectively.

There’s a kind of a competing theory about the brain being involved. So people try some brain meds, but the dominant theory was the one I first described. In my clinic, I ended up seeing a lot of these patients on my own. Whereas in most urology clinics, they’re seen by physician extenders and maybe they do the cookbook and don’t have as much follow-up. But since I was seeing them regularly, I was saying that even despite the cookbook therapy, I was seeing very poor results and improvement.

Then a couple of things happened all at once that were quite fortuitous. One is that I had a child that ended up needing surgery for kidney reflux, which is related to bowel dysfunction and accidents in a roundabout kind of way. When I did the surgery for reflux, I noted that she was really, really, really full of poop, like so much so that the surgery was difficult because the bladder was moved out of its normal location because of the poop. So I was like: Wow, that’s bad. And the parents were legitimately concerned.

With the parents, I trusted them. So afterwards I said, “She was really full of poop. Has she been pooping?” And they’re like, “Oh, she’s been pooping great, she’s on Miralax.” I was like: Wow, there’s a disconnect here.

So that next week by chance, I went to Cincinnati Children’s Hospital to attend a bowel management program for their anorectal malformation course. And at that course, they tend to take care of a lot of bowel issues that are inborn. Kids are born with abnormal anuses and it affects the bladder and so forth. They do a lot of x-rays for these kids to make sure that they’re empty.

What are the odds? This is great. I’m going to go home and I’m going to do x-rays in everybody because I know by asking them, I get the wrong answer because I saw that kid last week.

Went home the next week, started x-ray’ing everyone, and the rest is history. We found all this poop and these kids on x-rays. You’d ask the parents, “Are they pooping normally?” They go, “They poop fine. All they have are bladder issues.” We would treat the poop on the x-ray and they would get better way faster. And that’s what kind of started this whole program.

Janet Lansbury:  And by bladder issues, do you mean accidents or bedwetting?

Steve Hodges:  Name it. Daytime wetting, bedwetting, UTIs, sometimes urgency frequency, dysuria, any kind of bladder dysfunction in a kid, almost any kind can be attributed to bowel dysfunction. The interesting part is when I first got this data together, I was like: I’m going to write this up. I’m going to win a Nobel Prize with it.

My resident pulled all the data. This had been already described in the ’80s by Dr. Sean O’Regan. He cured his own son of bedwetting. Then he said, “This is why this happens…” What Dr. O’Regan did, his son was wetting the bed and he was a nephrologist. He didn’t wait for somebody to fix his son. His son was only four years of age, which most doctors would not treat for bedwetting these days.

He took himself to the library at the University of Montreal and McGill University, did all research on his own, found a lot of papers describing bowel and bladder dysfunction were correlated. He did an anorectal manometry test in his son, which is a very advanced test. He put a tube in his son’s bottom, which sounds weird, but he inflated a balloon to find out when exactly his son would feel the balloon. And he found that his son felt the balloon at 150 CCs or almost over three times the normal volume.

So he found out very fortuitously that his son had a dilator rectum. He then treated that and the son stopped wetting the bed in a month. Then he’s published his results, had a lot of data. And again, somehow that’s been kind of lost to history and I’m not really sure why.

Janet Lansbury:  Wow. So besides informing you as to the prevalence of constipation and blockages and how that affects all of these common issues that parents have, how has all this information caused you to advise parents in regard to toilet training? And what are the pitfalls that parents could fall into that create these issues?

Steve Hodges:  Yeah. So early on I was really dogmatic. I was like: Well, kids are holding their pooping in. Right? So the younger kids that trained really early tended to withhold more because they were less mature, less aware. And for them… you could teach a very young child to be continent, to not go to the bathroom, to get out of diapers. But then you couldn’t convey to them the importance of going to the bathroom when they needed to. So invariably, if I saw very young children that were trained, whether it be, 12 months old, 18 months old, by definition, if they could train that early, they were really good at using their sphincter to hold their pee and pooping.

So then they would tend to overdo it, hold their pee and poop in too much, and then they present a few years later with accidents. So I became pretty dogmatic saying, “Listen, the later you can train them, the better. Make sure they’re pooping well. Make sure they’re not developing these withholding behaviors,” because that’s the root of all evil. So basically, I wasn’t seeing any kids with accidents obviously before they’re potty trained, but the later they trained the less accidents that we’re having.

I wouldn’t see kids with UTIs until they were potty trained, a lot of the times. So I knew that the potty training was inherently bad, in so much that kids don’t have the maturity to know when to go to the bathroom and parents don’t tend to watch them. Once they’re trained they kind of take their eye off the ball.

I’ve softened that a little bit because I found out that most of the stuff is genetic.

I think that every kid to some degree is a stool withholder. I’ve seen pretty bad x-rays all across the board. But if you don’t have the genetics for that to lead to bladder responses, and there is a variable response to rectal dilation to bladder function, which has been described in the literature, then you don’t have trouble. So I do like kids to train late — later, like after three. I do like them to be pooping very regularly before training, but I’m not so hard on people if they have no history of bedwetting or day wetting or UTI in the family.

Janet Lansbury:  Right. And do you subscribe to the idea that children should lead their potty training, that children should be the ones to let parents know that they are ready, a sort of following-the-child method rather than the parent doing a three-day potty training or one of these potty training methods?

Steve Hodges:  Yeah, for sure. I’m definitely a fan of child led instead of parent led, but with one caveat. So I’ve found that three and younger tends to be a little bit too young in terms of maturity for most kids, generally. Four seems to be a little too old because they’re in preschool and they should know by then. Honestly, if you can’t potty train a kid at four, then maybe they have an issue that makes it impossible and you can get it evaluated. But somewhere between three-and-a-half and four, most kids have the physical ability and the mental ability to kind of get it and to go. So I think introducing it gently at that point is fine. I don’t think that you have to force the issue.

Most of them… This is the one case of kind of positive peer pressure when other kids are doing it and they want to do it as well.

The one caveat for training late, and I’ve noticed it a lot, is that peeing in the potty is very easy for those kids. They control it well. But pooping in the potty, the more you get used to doing it in pull-up, the harder it is to do on a toilet. So it takes a little bit of help to guide them through that ,because some kids, as common as constipation is, as common as toileting issues are in kids, delayed pooping on the potty where they just ask for a pull-up to go poop instead of doing it in the toilet is very common as well.

It’s just old habits are hard to break sometimes and you got to work a little bit at it. The kids don’t usually willfully poop on the toilet as easily as they do in the peeing.

Janet Lansbury:  And do you think that’s just a force of habit or do you have the sense that it’s also a child feeling maybe rushed or push emotionally and isn’t quite ready to take that step and they feel that the parent is trying to urge them ahead? Do you ever consider those aspects?

Steve Hodges:  Yeah, I think pooping is just a hard thing for people to do. It’s very interesting. Every kid I’ve been around has had an episode where it kind of didn’t feel good to poop and they don’t really don’t know what to make of it. It’s an uncomfortable… They learn easily that you can hold it in and that kind of urge goes away. It’s so common. And then since their mind is involved so much where it’s such a stressful situation, I think kind of hiding behavior, having a pull-up to do it in just seems safer than sitting on a toilet, a little bit easier.

Janet Lansbury:  And who are they hiding from? They’re hiding from the parent, right? Or the judgment of somebody?

Steve Hodges:  Yeah. It is… The hiding to poop is so interesting. I tell parents if you have a kid that’s hiding poop, even if they’re pooping, they’re thinking about it too much. You know what I mean? Like something’s too much going on.

Janet Lansbury: Pressure.

Steve Hodges:  Yeah. You see like a horse or a dog, they just go poop. They’re not scared. So if you can keep them relaxed and they can just play, pause, poop, and then keep playing, you know you’re in a good zone. If they’re hiding in the corner, like red faced and so forth, then you got some issues.

Janet Lansbury:  Right. But from your perspective, it could also be that there are constipation issues at that point that aren’t being diagnosed or noticed.

Steve Hodges:  For sure. And hiding the poop is definitely correlated with constipation and numerous studies. It’s definitely a one-to-one relationship.

Janet Lansbury: Hmm. And what about when maybe the child has been toilet trained or they’re in the process, the parent’s trying to put the process forward and the child is saying they refuse?

Steve Hodges:  So, yeah. I can’t even tell you any child I’ve seen that just kind of refuse to go to the toilet, right? Most examples I’ve had… Okay. I’ve had poop refusal, and there’s a treatment for that, I can talk you through that. I’ve not had any kind of pee refusal because most of them want to feel grown up or whatever and feel like they’re doing it. The kids that are advanced age and can’t poop in the toilet usually have uncontrolled bladder accidents, which are due to constipation. So you would fix that.

So I think if the bowels are on point and you’ve got the constipation fixed, then they will be able to pee in the potty. At some point they’ll just start doing it, and that’s been pretty easy in my experience to get the buy-in. But if they refuse to poop on a toilet, you kind of have to ease them into that. There’s a good protocol that I’ve used a lot from The Ins and Outs of Poop book, where you have kids that refuse to poop on the potty, but will poop in a pull-up, and you just slowly migrate them from the pooping in the pull-up anywhere to pooping in the pull up in the bathroom, to pooping in the pull-up on the toilet.

There’s a great anecdote from that book where this one girl, they literally had her pooping in their bathroom with a pull-up, and pooping on the toilet with a pull-up, and they cut a hole in the pull-up. And she would go poop in the toilet, but she had to have the pull-up on. The pull-up was never getting dirty because she was pooping through the huge hole.

So months later it was just a belt basically, a shredded diaper that they were using because they didn’t want to have to use another one. And that’s what she needed as her security blanket to poop. So the psychology of it is very interesting.

Janet Lansbury:  Very interesting, yeah. Fascinating, actually.

So you also have some advice around preschool and what parents should do. A common question that I get, because I do advocate for a child-led approach, and they say, “Well, that’s fine for you to say, but my child is going to go to a school…” And now preschools, some of them are starting at two and a half years old or two years old and they have to be potty trained. The parent feels very pressured, and I feel for them, to get this happening for their child, which of course can then cause issues that delay it further. But what can we tell those parents? How can we help parents who feel in that bind?

Steve Hodges:  Yeah. I think there’s a generalized lack of understanding about the importance of good toileting habits in kids and how potty training is involved, and holding, and why accidents happen. That’s a discussion that spreads from preschool to regular elementary school, maybe even middle school and high school. But for the preschool question, I would say that if your child is not ready and you’re not ready, then I wouldn’t do it. I mean, I’m happy to write a note for anybody saying they can’t potty train, because it has been correlated with negative health outcomes, if they’re not ready. They can get more UTIs. They can get accidents. Talk to any of the people that we’ve talked to that have had accidents for years and they would definitely have rather delayed training if it could have led to more healthy habits.

I just don’t think the people running preschool, for example, or schools where maybe bathroom access is limited, or even parents of a child who’s having poop accidents or bedwetting, understand that there’s an actual medical reason for it. And because of that, kids are often punished or shamed, and it is a really big problem and I see it all the time.

I’ve tried to put a little bit of light on the… Not to jump topics, but on the child abuse issue with incontinence, because it’s one that gets me most riled up in terms of children that are bedwetters and the parents punish them as if they’re being too lazy or something. And so it all ties in, right?

Here’s a good way to think of it. Dr. Regan told me this: You don’t force a kid to walk, right? You don’t force a kid to crawl. You don’t force a kid to sleep. You put them in the right environment and when they’re ready, they do it. And toilet training is the same thing. If you do force those things, you can have negative outcomes. When you have accidents, you shouldn’t be blaming the child. You should be like, why are they having accidents? Is there a cause? And fix the cause. As a society, if we could get more awareness about that, I think we’d be doing children a big service.

Janet Lansbury: Yes. So educating these directors of preschools and having them know that this isn’t an okay sacrifice that we’re supposed to make to have our kid be in your program. As you said, it could be years of their health, besides the psychological issues that children feel when they’re not succeeding at something that seems really, really important to their parents. And they feel like they’re letting everyone down and they’re just not able to do something yet.

So when you write the letters, what happens with most of the schools? Because the schools that I’ve engaged with, they actually tend to have a more open attitude than they will say in their literature. They’ll say “this is our approach and these are our policies.” But most of them, I mean the good ones, they have a more flexible approach. Because the other thing that could happen is we get our child trained. They go, and now they’re holding the entire time that they’re in preschool, because that’s another thing for our child to be able to go in a different restroom or a public restroom or a school setting. That’s even tougher than going at home to the potty. So many issues could be created. Even if we “succeed” in training our child to go to preschool.

Steve Hodges:  You’re exactly right. It could be that the bathroom toilet looks funny or sounds funny or flushes too loud, or the room is too dark. Anything small like that can throw a kid off, and then they’re put in an environment where they don’t want to use the bathroom the entire day, and then it causes years of trouble later on and who knows how many thousands of dollars of workup and visits to the urologist.

Now, the one thing that people always bring up and you’ll see this, I’m sure, is like, “Well, now people are coming to school five years old, they’re not potty trained. Parents are too lazy, they won’t train their kids.” So I think it’s important to define some age range where it is normal, and I think there’s data. I have the data. And anyone that’s raised a kid knows that like at two and a half, they don’t know what they’re doing. But at three and a half you could probably communicate a little bit better with them. Again, after four, they definitely have the ability to be trained. And if they’re not trained, then there might be an issue.

So when we push for late training, the schools can be understanding, and most of them are. But when you get the argument back that, “well, then you’re going to have a bunch of kindergarten kids shelving pull- ups,” I would say if a kindergarten kid can’t control the bowel and bladder and they’re learning the alphabet and stuff, then they probably have a medical condition to be treated. It’s not like a parents are being lazy. I think that’s a real medical issue and that can be addressed.

So either way, I think we win, because we don’t force them to be trained too early, and that helps. And then if they end up showing up late and they can’t potty train, then they can see a specialist and they can get it fixed. So I don’t think one necessarily leads to the other, but I think they’re both important to talk about.

Janet Lansbury:  Good. Yeah. You have so many resources on your website. I really hope people check it out. You have a ton of downloads and books and booklets and everything.

One thing I noticed, that I had always thought, is that children bed-wet commonly because their brain isn’t able to function that way in the night — to give them the message that they have to go to the bathroom. But you think it’s actually more about constipation.

Steve Hodges:  So yeah. There’s a lot of misinformation out there about bedwetting. We have, I think the most valid theory, and I thought about it a lot. So number one, there is data in our literature, like in our major urology textbook, Campbell’s Urology, when they did bladder studies on kids, infants even, that they only urinate when aroused from sleep, which is interesting to me. So they were able to watch these kids and they’re not obviously waking up and saying they have to pee. They’re newborns. But they were in asleep, they aroused, they void and they go back to sleep. So the point is voiding while completely unconscious is very rare.

Janet Lansbury:  Oh, that’s interesting.

Steve Hodges:  Yes. And Dr. O’Regan showed in his son and he showed in a bunch of kids that if you have this dilated rectum, you get bladder spasms. Okay? And then you fix them and the bladder spasms go away. So that ties that in.

And then there was a study in the New England Journal 2014, I believe, where they measured sleep. And they said, “oh, well. these kids don’t sleep too deeply. They sleep not deeply enough.” And it was like a throwaway line at the end of the article. They go, “it seems like their brain can’t rest because their bladder is overactive.” I was like, “well, there’s your answer.” But it was almost like a throwaway.

So when in reality what happens is… they’re sleeping, right? They’re making probably normal amounts of urine, although that can vary. They’re probably sleeping as well as you can. But the bladder spasm doesn’t allow them to get restful sleep, almost like sleep apnea. It is creating a reflex that doesn’t get to the brain for this reason.

So when you’re a baby and you’re peeing… Imagine you have a six-month-old baby and you’re changing their diaper and they pee on you. They’re not thinking to themselves, “I’m going to pee.” That is a sacral reflex. So some nerve stimulus went from the bladder to the spinal cord, and then it went back from the spinal cord to the bladder to squeeze without going up to the brain.

And then when you potty train, what you do is you get the brain involved and so you can feel full, and then you say, “I’m going to hold it in or whatever. I’m not going to the bathroom.” Then when I do want to go pee, I will go to the bathroom and I will relax, and I will initiate a void.

Much like lots of infantile reflexes can persist, the voiding sacral reflex can persist, but it’s set off by this constipation. So you have these nerves being stretched by the rectum, and so you get these firing off — that typically, if you felt like you had to pee, you would wake up. But again, it happens so quickly in the sacral reflex loop that they’re not aroused.

So if you can keep the constipation from forming, which again is a very human problem, no other animal does this, then they will follow their normal physiology, which is to toilet train and then to arouse himself to go pee and not have these bedwetting issues that can persist for years in some kids. I saw an 18-year-old today still having issues.

Janet Lansbury:  Wow. So then from what you’re saying, when a child is trained during the daytime or they they’ve learned to go on the potty that they should then be able to do it at night, too, unless they have these other irregularities.

Steve Hodges: Yeah. The biggest misconception about night training is, number one, there is no such thing, right? You can’t train a child at night. Number two, there’s a huge drop-off with bedwetting at five in the numbers, so they attribute that as a good age where you can start treating it, but there are a lot of other factors involved, right? So if you really knew your child was toilet trained and was wetting while unconscious, while sleeping, then you should treat them.

But why I’m not so stuck on that is, what if they’re in pull-ups, they wake up and they’re too scared to go to the toilet and they don’t care? So that’s the kind of thing where if they’re like three or four, you really have a hard time teasing it out.

But if they’re potty trained during the day and they have no barriers to go into the bathroom and they wake up to pee and they’re not doing it while they’re asleep, then they should not be having bedwetting and you can fix it.

Janet Lansbury:  So what would be your top tips to help parents avoid this constipation which seems to create so many issues, or any of these other bowel and bladder issues that you’re treating? How can we avoid this? How could we prevent these from happening?

Steve Hodges:  Yeah. So I have three good examples, which were my girls that I was pretty tested with, and I learned a lot just from that part. And one is that almost kids have constipation, right? So some kind of withholding. So you have to be watchful for that.

Early on at birth, kids have a condition called dyschezia. I remember my oldest, she would strain, strain, and strain, like she was about to have the biggest, hardest poop ever. And when she would poop, it would be like a mustard, basically. It was like nothing.

So what that is, is a condition in newborns where they’re just not used to pooping, right? Because they haven’t been pooping, not been outside the womb. And so it feels weird. But if you get past that, they’ve kind of figured out that it doesn’t hurt. And while they’re on formula, if they’re on the right formula and the poop isn’t hard, if it’s mushy, they do fine.

What usually sets it off after that, once the dyschezia resolves, is changes in stool texture. That happens when you change diet, when you change formula, when you add rice cereal, when you add dairy, when you add table food. Or if they go poop diarrhea — so regular poop to diarrhea and then back to regular poop, that’s another inciting event. So if they go on antibiotics or they have a GI bug.

So anytime you have a change in poop texture, you should really be watching and see how they’re going. Are they straining? And honestly if they’re younger than six months, you can talk to your pediatrician about techniques. But six months and older, I think has been consensus that you can give laxatives safely. People may be pro or against Miralax, but that’s what I used, and it worked fine.

I aggressively treated them right when they had withholding. I kept it soft. And I can tell you, they never had any fear of toileting after that. They all pooped wherever they were. There were a lot of benefits I never foresaw. They really had very few hangups about pooping. I’m sure they’re glad I’m talking about this.

Janet Lansbury: They will now.

Steve Hodges:  And even my middle one who was a wetting the bed a little bit, I started Miralax and she stopped wetting the bed in a month. They ended up being a little neurotic about it. They talked about poop a lot. That would be the first thing they were telling me when I got home from work. “I pooped.” But it helped. You don’t maybe want to take it to my extreme, but to be involved in that is very important.

Janet Lansbury:  So you think that almost every child goes through constipation, but a lot of it just doesn’t pan into anything? They just sort of grow through it and they’re okay? Is that what you’re saying? There’s such a high percentage of-

Steve Hodges:  For sure. Oh, yeah. I think it’s by far the most common condition in kids. It’s a very human thing. I think we’re just too smart for our own good in terms of brain evolution and pooping in general with the diet we have nowadays, and being in clothes and having to go to… It’s just too tough for them. I’ve never seen a kid poop on time and to complete evacuation without help. I never seen it. They’re not having complaints and there’s no reason to treat it, right? There are kids that could probably x-ray and they’re full of poop, but they have zero problems. No belly pain, no accidents, nothing. And those kids, you can just leave them alone.

But if you have a child that’s having issues, then daily Miralax is very beneficial. And I don’t want to get on a hot button topic focusing on Miralax, but just something, whether it was castor oil or whatever, like the Little Rascals used to use. But something to help them poop regularly, so that it’s mushy and they don’t have any discomfort associated with going.

What I’ve found is if they’re a withholder early on, it’s a big mistake parents use… they have a six-month-old or a year-old or two-year-old kid, they’re constipated, and they had given something to help them poop. They poop fine. They stop it, and the kid has trouble to come back. They’re like, “Oh, no. My kid can’t poop on their own. They’re dependent.” And that’s not it. It’s that their personality or their genetics are that of a stool withholder, anal retentive, and they don’t know any better because they’re only two. So they’re probably going to need help until they’re old enough, which is usually five or six or seven, or maybe older until they can know that when you feel the urge to poop, you have to go right away. And by giving them help, it makes them more likely to not withhold, to go normally.

Janet Lansbury:  So how do you know when your infant is withholding? Because you see straining? Or are there other signs as well?

Steve Hodges:  Yeah. It’s tough to know, but you’ll see signs. They’ll be straining. They’ll be upset. I remember, you know… I sound like the world’s expert, right? My third kid fooled me because she was doing so well. We started rice cereal. I remember she was only six months old and none of my kids had gotten constipated that early, and I was like, “Well, she’s got to be fine.” She had pooped, but it was not as much poop as she usually does. I explained it away as people tend to do. And the next day she pooped this huge eggplant. I was like, oh my goodness. I can’t believe she fooled me. I felt so bad for her.

So you got to be really in tune to watching them, and it shouldn’t be that difficult to poop. And really, there’s no benefit in making them force it out, right? You could say, “Well, they poop every day, but it’s really hard and huge, and they strain to do it.” I mean, you could help them out with a little bit of laxative and it’s probably better for them than not. But I think if parents at least are aware of the problem, then they can pick it up pretty easily.

Janet Lansbury:  And then children that are… you said in the beginning that they are kind of constipated or they’re stuffed a little bit inside, but they end up okay, just on their own?

Steve Hodges:  So if you have backed-up poop…  like some kids put off pooping, most kids put off pooping, some adults do. And it doesn’t cause any dilation of your bowel that’s significant, so it doesn’t cause belly pain, and for whatever reason you have the genetics where it doesn’t affect your bladder, then no one would know, right?

I’ll do a kidney stone treatment on a kid and I have to x-ray them to see their kidney stone. And I can’t see it because of all the poop. I ask them, “Are you okay? Your belly hurt?” They’re like, “No, I’m fine. Other than the stone.”

Some people just don’t have symptoms. I guess if you’re a purist, you’d want to treat everyone, but then I’d have every kid in the world on something. So I try to just focus on the ones that have symptoms that I can make better.

Janet Lansbury:  And the others just grow up fine, and they’re okay.

Steve Hodges:  You know, that’s a good point because some of them do grow up and have irritable bowel syndrome. I’m a big believer that irritable bowel syndrome in an adult is a condition where the colon was abnormally dilated in childhood and no one addressed it. So they have intermittent diarrhea and constipation. So I can’t say it’s going to be perfect, but I have a hard time treating kids that are feeling fine.

Janet Lansbury:  Do you work with any adults that have that?

Steve Hodges:  No, but I am able to… This stuff is so genetic. Now, I got into a kind of hobby where I’ll see a kid in my clinic and I’ll look at the mom and I’m like, “He looks just like you. I bet you were constipated.” She’s like, “Yeah, I was.” And I’m like, “You ever have irritable bowel?” And she’s like, “Yeah, I do.” It’s kind of like anecdotes, it’s not scientific, but it makes sense.

Janet Lansbury:  Wow. What an amazing resource you are for parents. So thank you so much for sharing with us. I think some of your thoughts and your experiences are going to be very enlightening for people. So I really appreciate your time and thank you for being on my show.

Steve Hodges:  Thanks for bringing this topic to light. I think it’s important that we get it out there.

Janet Lansbury: I’ve been quoting from you for a long time and recommending your book, which is It’s No Accident: Breakthrough Solutions to Your Child’s Wetting, Constipation, UTIs, and Other Potty Problems. So I’m glad to finally get to speak with you. Thank you, again.

Steve Hodges: Thank you so much.


Please check out some of the other podcasts on my website, There are a lot of them and they’re all indexed by subject and category, so you should be able to find whatever topic you might be interested in. And both of my books are available in paperback at Amazon: No Bad Kids, Toddler Discipline Without Shame and Elevating Child Care, A Guide To Respectful Parenting. You can also get them in e-book at Amazon, Apple, Google Play, or Barnes & Noble and in audio at You can get a free audio copy of either book at Audible by following the link in the liner notes of this podcast.

Thanks so much for listening. We can do this.



Please share your comments and questions. I read them all and respond to as many as time will allow.

  1. Thank you so much for this great discussion! My 4.5 year old has been potty-trained for 2 years but still has daytime pee accidents and doesn’t stay dry at night. These accidents started after 9 months of secondary lactose intolerance caused by a virus, which involved a lot of diarrhea and stomach upset. Listening to this interview was a lightbulb moment for me because I realized there’s probably a connection between my child’s pee issues and his upsetting experiences with pooping. Constipation had never even occurred to me! I gave him some miralax as per the doctor’s recommendation and I’m hoping it’ll help. Thanks again for such thoughtful and actionable advice.

  2. Jessica Isles says:

    Such an important topic! I was curious to see that the doctor didn’t mention position for pooing – a baby can take any position to poo when in a diaper and that is always, in my experience, squatting or kneeling (never sitting in a chair position unless strapped in a car seat!). This is how we pooped throughout our evolution until…toilets. Funnily enough, 2 of my four children still squat to poo, on the toilet! They are teens…So I believe we need a conversation about how unnatural a position sitting on the toilet is for human beings and encourage any position that works for each person. The position we sit in on the toilet can prevent full and easy evacuation leading to hesitancy and constipation.
    Another point that was missing is that babies over the millennia have breastfed throughout the night right up until natural term weaning at the age of between 2 and 7 years old with an average age of 4 worldwide. That means fluid is being consumed and therefore baby is getting bowel stimulation around the clock – this means pooping around the clock and the fluids help keep everything mobile. The current misunderstandings about human infant sleep are causing parents to think that it’s normal for a baby to sleep through the night and then feel the need to sleep train. This can diminish mother’s milk supply and often means no feeding for those hours. This is another reason why we may see the unnatural state of constipation in the young – if we don’t treat a baby as nature intended we get unnatural consequences i.e. constipation.
    Also, taking a monkey see, monkey do approach is known to be useful – if baby or toddler sees you using the toilet they learn very quickly. But we often close the door and prevent them from seeing, hearing, smelling what we expect of them so it doesn’t become natural or normal to them – we are expecting them to do something they have never seen and never see…historically this was not the case.
    And, of course, we all know that constipation doesn’t exist in breastfed infants when only on breastmilk (unless medication is causing it) and in fact some breastfed infants only poop every 10 days and this is still considered normal! Crazy but true and have no problems at all. Also, a straining breastfed infant who produces a soft poop (which they all are when they are breastfed), is not constipated – their bowels are simply getting used to being used! Neither a delay in pooping nor apparent straining for a 100% breastfed infant is considered constipation.
    And, around the world there are different expectations for nighttime dryness. In the UK I was told that after 12 years old they start to see if there’s a problem. This worked for my family as my boys were in pull up for many years at night and had I not had that info I would have worried. As it was, I didn’t and they are perfectly normal! We don’t want to find problems where there aren’t any….
    Finally, we should ask ourselves how tribal/aboriginal cultures survive without Miralax?! Our culture is going quite wrong if we have to rely on a medication to do something that is as fundamental to our survival as pooping. Diet and plenty of fluid is key in keeping bowels regular and that includes breastmilk for many years as it has such a great amount of pro biotics etc (unpopular view but normal human behavior!). Many processed foods that we consider healthy or normal can cause constipation in some kids i.e. dairy, white flour and sugar.
    It is so important to recognize that our culture creates many of these problems not the child’s biology and finding ways to accommodate natural species behavior will go along way to alleviating these issues without stress.
    Daycare centers need to be educated on how to allow complete freedom around when to poop.
    I’m wondering as well whether there’s a connection between formula use, miralax use and IBS, crohn’s diseases etc. There are so many things we are and aren’t doing that have long term effects.

  3. Please, please, please do not recommend or use Miralax for children! Magnesium or buffered vitamin C is a much much safer alternative.

  4. I am curious of your thoughts regarding elimination communication (which is based on attuning to your child’s cues to go to the bathroom from birth/infancy, and is not the same as “training”). This form of “training” has been used across cultures for thousands of years, and has only been recently replaced by plastic diapers and potty training in the early 21st century. I myself utilized this method with my now 2.5 year old daughter, who is fully potty “trained” during the day (she does use diapers at night, but only for pee – I haven’t changed a poopy bum since she was 6 months old!). I recognize that this is approach is strongly connected to attachment parenting, so is not accessible to parents who return to work early, but I would love to hear more discussion of it in mainstream parenting discourse. Thoughts?

    1. Farheena Rahman says:

      I second that question. I’d be really keen to hear the view on elimination communication too.

    2. Julia Veisz says:

      In my opinion the problem is that it leaves very little room for independence and involves a lot of placing the baby into position he/she cannot assume alone yet.

      Dr Falk wrote this on EC in an article:

      “This is different from the parents who are ‘doing’ elimination communication. In many cases when parents say they are doing elimination communication with their child, they aren’t. They tune-in from the head – conscious and cognitive. Indigenous Mothers, however, tune in with their intuitive senses; they themselves can feel when the baby wants a pee, and hold them out, with 100% accuracy. No holding out in vain. Many people practising elimination communication are actually ‘potty training by another name’. The result of their practice is conditioning, and not voluntary control.”

      Hope that helps!

  5. I love Janet’s podcast but this one left me a bit puzzled… especially when doctor recommends leaving children in diapers so late in age (what about people in countries with no access to water or diapers?) Please do not think this is a judgment, because I know when you know better, you do better…

    The doctor in this podcast has very useful information and helpful tips. And I truly hope it’ll help parents with dealing with bedwetting issues.

    As I said I love all Janet’s podcasts, and hoping maybe Janet can reach to Andrea Olson to get another point of view on this topic, (she is mother of 5 babies, all ECed from birth, all out of diapers by walking – and owner of Go Diaper Free) and do a podcast with her…. she is all about Elimination Communication. She has some valuable information on Potty Training, taking an example from tribal cultures on different levels (not only Potty Training, but also deepening connection to your baby, start trusting your parental instincts etc)
    Here is some of her thoughts from her website:

    “Elimination Communication is a gentle, non-coercive way to respond to a baby’s natural hygiene needs, from as early as birth. Like all mammals, human babies instinctually resist soiling themselves, their sleep space, and their caregivers, and they clearly communicate about it from birth.

    I’m bringing a touch of the sacred to the profane: how we deal with our children’s waste, as a culture. Do we bury it (eternally mummified in plastic and gel goo), teach them to ignore their instincts, train our kids to poo and pee on themselves and pretend it isn’t there, give them the huge responsibility to train themselves out of something we’ve trained them into? Do we dishonor the Earth by stuffing Her with poo-filled Pampers?

    Or…do we honor this natural process, honor our babies’ communication and desire for cleanliness, tune in and assist our babies in property disposing of their waste?”

    Also I understand that it is also not for everyone, and like not everyone have access to diapers, not everyone have access to whole foods diet which is also a huge factor to dealing with constipation. (Plenty of water (not juice or milk) can help with that, too.)

    So I am hoping that Janet will find someone with background in kids nutrition (since the topic of Potty Training goes far beyond just actually potty training) and do a podcast on that as well…

    Either way thank you Janet and team for helping parents and bringing awareness and knowledge, I know it is a lot of work. It personally helped me tremendously in parenting, I truly appreciate your hard work.

    Thank You,

    1. Thank you for your kind words about my work, Elmira!

      Regarding: “…this one left me a bit puzzled… especially when doctor recommends leaving children in diapers so late in age (what about people in countries with no access to water or diapers?)”

      Did you understand why the doctor advised against earlier potty training? It’s because, in his professional experience, problems with constipation, bedwetting, accidents and delayed toilet learning are most often caused by children holding in their urine and feces, which is a common tendency beginning in infancy. To prevent this, Dr. Hodges strongly recommends that children (and everyone) relieve themselves immediately, which children feel free to do when wearing a diaper. If they need an adult to carry them to a potty, they may instinctively begin the habit of holding.

      In the communities you refer to, babies are able to relieve themselves anytime, anywhere, but that is not the case in most western societies. If you have that situation for your child and EC appeals, more power to you!

      Dr. Hodges shares his views on EC and other early potty training here:

      Would love to see any and all research you have for these statements: ” Like all mammals, human babies instinctually resist soiling themselves, their sleep space, and their caregivers, and they clearly communicate about it from birth.”

      Humans differ from other mammals in many ways. I have spent thousands of hours sensitively observing babies, and never has there been an indication when wetting their diapers that they’re thinking, “ugh, this is dirty, get this away from me.” That idea is the adult’s distaste speaking loud and clear and I wish EC proponents would recognize and own it. Instead they seem blind to their personal projections which, for me, raises red flags about everything they assert. And they do assert. They assert their views into every conversation about toileting, even in my post about toilet training being unnecessary, they are there preaching to parents in the comments that they should do this work.

      Also, it’s puzzling to me that rural communities without access to diapers are considered, but parents in our own communities who work one or more jobs to make ends meet and either cannot afford the luxury or just don’t wish to stay glued to their child 24/7 are not. Even if they thought it was a good idea (and I don’t), the EC method is impossible for the majority of parents. For that reason alone, I would not recommend it.

      Again, thank you, and I hope you won’t be angry with me for not valuing EC as you do! There are also other reasons that I don’t recommend it, but I won’t get into them here.

      1. Janet, thank you so much for this podcast. This is something we are truly struggling with my 4 year old and you are giving us mothers access to information that is so uncommonly known. I feel more empowered than ever that I can help my son through something that is causing him so much distress. Thank you, thank you, thank you!

        1. My pleasure, Lauren. Thank you for your kind support!

  6. Big Pooper says:

    Meat and dairy have zero fibre and fibre needs to be part of this conversation. This is why other cultures and other generations and vegans don’t have these same issues.

  7. Elizabeth says:

    I am curious how you would respond to a preschool that is forcing a child home for “accidents” when she has a diagnosed medical condition. Unfortunately, this isn’t a “problem” that can be fixed in a week. It’s going to take her body time to heal.

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