Overcoming Your Child's Potty Problems with Dr. Katherine Lamparyk and Kimberly Slocombe, CNP

Podcast Transcript

Nada Youssef: Hi. Thank you joining us. I'm your host Nada Youssef. Today we're bringing you two experts to cover our topic, potty problems. This has been a growing issue for many school-age children and their parents. These difficulties have caused embarrassment and affected the confidence of so many kids with their parents feeling helpless and not knowing what to do. Whether your child is experiencing constipation, incontinence, UTI or more, we'd like to hear from you. Make sure you put any questions you may have in the comment section below.

Nada Youssef: I'd like to welcome our experts. First, we have clinical director of the behavioral GI program, Dr. Katherine Lamparyk, and pediatric urology certified nurse practitioner, Kimberly Slocombe.

Nada Youssef: Before we get started, please remember this is for informational purposes only and it's not intended to replace your own physician's advice.

Nada Youssef: Thank you guys so much for being here. If you can just introduce yourself to our viewers?

Katherine: Sure. I'm Dr. Lamparyk. I'm a pediatric psychologist and the clinical director of the behavioral GI program. I see kids with a lot of toileting difficulties, specifically constipation but urinary incontinence kind of goes along with that. I really focus on any part of the GI tract, so I help kids with functional vomiting disorders and a lot of abdominal pain and coping with chronic GI issues and illnesses like inflammatory bowel disease.

Nada Youssef: Great. Thank you.

Kimberly: Hi, my name's Kim Slocombe. I'm one of the pediatric nurse practitioners in the pediatric incontinence center. I take care of children with urinary incontinence both daytime and nighttime, as well as, any sort of urinary tract issues that they may have, urgency, frequency, incontinence, infections, anything like that.

Nada Youssef: Great. Thank you guys so much.

Katherine: Of course.

Nada Youssef: Reasons for incontinence and all these potty problems. They range everything from simple to complex, so we have a lot to cover. First, I want to talk about when we talk about potty accidents or potty problems, as parents we think our children will outgrow it. At what age does this actually become a diagnosis?

Katherine: From a constipation standpoint for ... The technical term is encopresis, which is pooping incontinence and the diagnostic age is at 4. That we expect kids to be generally continent by the age of 4 with still occasional accidents, but not frequent accidents.

Kimberly:  Urinary goes about the same timeline. Normally around 4 or 5 we expect to see them continent with their urine. Then, as far as nighttime goes, it's a little bit later. We generally see around the age of 8 or 9, it's not even technically a diagnosis until the age of 6-

Nada Youssef: Oh, wow!

Kimberly: -that it's considered an issue.

Nada Youssef: For nighttime?

Kimberly: Correct, for nighttime.

Nada Youssef: Okay.

Katherine: Day time, the official diagnosis of encopresis is 5.

Nada Youssef: Oh, okay.

Katherine: So, a little bit later.

Nada Youssef: So, it varies too.

Katherine: Mm-hmm (affirmative).

Nada Youssef: So, is this like a hereditary thing, or could it be?

Kimberly: Can be.

Nada Youssef: It can be?

Kimberly: Mm-hmm (affirmative).

Nada Youssef: Wow. Okay. Great. Now, when does something like bedwetting signal a serious issue because I know a lot of people going through potty training it could take a little longer, especially for boys versus girls, when is it a problem?

Kimberly: Yeah, so boys are more likely to wet the bed than girls. Girls are more likely to be incontinent during the day. When it tends to be a problem is when a child has been dry for a significant period of time, typically around six months, and then they begin wetting again. I don't want to say it's necessarily a problem, but that's when we go looking to make sure that there's not something else going on that may be causing the wetting.

Nada Youssef: Sure. Sure. Okay. Now, you know, a lot of these problems are due to holding your poop, or holding their pee. What is behind the holding? Big question.

Katherine: Yes, I think about it as the perfect storm that happens in usually preschool, toddlerhood, where two things that happen with your poop actually is that your poop changes. So, you no longer have the mushy baby poops. You now have the more formed adult-like stool. For many kids that can feel at least different, if not a little bit uncomfortable. Then, also around toddlerhood you learn that you can control your bodies, and you learn the wonderful word of "no".

Nada Youssef: Yes.

Katherine: From a toddler mentality, 2, 3, 4-year-olds, this doesn't feel comfortable. I don't like the way this feels so I'm not going ... and I now can control it, so I'm not going to do it. So, what happens then is that then turns into sort of a vicious spiral where the next time that they poop then it becomes larger, and harder. Then, they really don't like the way that that feels and then, they're definitely never doing that again, so they hold it even more. Then, it gets bigger and harder, and on and on you go.

Nada Youssef: Wow. Sure. Sure. Same thing with urine?

Kimberly: Yeah, it's actually very interesting that you say that because we see the same thing with urine incontinence especially young girls, and boys, that get urinary tract infections because they learn that it hurts when they go to the bathroom. So, then they start holding, and they don't want to go to the bathroom and it leads to more and more issues.

Nada Youssef: Wow, okay. Well, if my child's never had any potty issues, but then recently just had an accident. Should I be worried, or is this just an accident? When is it an accident, and when is it time to go see a doctor?

Katherine: Kids around the age anywhere between 3 up until 6 even are likely to have occasional accidents for a variety of reasons. Usually, because they're kind of distracted and really focused on playing and other more enjoyable things. They haven't fully picked up on that connection when their bladder or their bowels are telling them, hey, I'm full. You need to pay attention to me.

Nada Youssef:  Right.

Katherine: They haven't 100% made that connection. So, they're bound to ignore it every once in a while.

Nada Youssef:  Sure. When it comes to incontinence, is it just behavioral?

Kimberly:  Not always but a significant portion of it I would say is.

Katherine:  Well, and I would actually argue a little bit that it's never just behavioral or hardly ever just behavioral.

Nada Youssef:  Sure.

Katherine: There's almost always a behavioral component to it, but so what we call functional constipation, or functional incontinence is about 80 to 90% of all kids who are continent, that there's some type of behavioral component to it. The vast majority of kids that I see are also either constipated, or have a long history of constipation.

Katherine: So, my whole goals as a psychologist is try to help kids and help families learn that pooping, or peeing does not have to be a painful, unpleasant experience. I have yet to ever be successful, if it's still a painful, unpleasant experience.

Nada Youssef: Yeah.

Katherine: If they're still constipated then we're not going to be very successful. That's why having joint treatment with both someone to focus on behavioral aspects, as well as, the mental aspects are really important.

Nada Youssef: Sure. What causes a child to wet the bed? Let's talk about maybe are there drinking restrictions that we should be making as well?

Kimberly: Again, there are many things that go into bedwetting. Oftentimes, it's the fact that the child just needs to grow a little bit, needs to mature a little bit. The body itself needs to mature, but we do ask all of our children to stop drinking about an hour to two hours before bed to try at least to eliminate that factor as something and then you spoke about constipation. Constipation goes into it as well with the bedwetting, so we always try to work on that with our kids too.

Nada Youssef:  Sure. Now, did you mention behavioral had 80 to 90% something to do with it or is that-

Katherine: Yeah, so there is, depending on the study, about 10 to 20% of kids there's no behavioral factors, it's an entirely medical condition, but for most kids they fall into that sort of cycle of, this is uncomfortable and unpleasant so therefore I'm going to take active steps to not do that and then it by in large they're making it worse for themselves without knowing.

Nada Youssef:  Now, like facing any major life changes for a child, new school, new home, divorce, and death?

Katherine:  All of the above.

Nada Youssef:  Yeah, all of that can-

Katherine:  And we're just about to head into summer so the-

Katherine:  Well, the routine ... A lot of kids are pooping on routine. So they poop right before school or they get home from the bus and they go and poop, well, if you're no longer going to school and now you're in summertime and there's no routine, then that can cause and then also you're outside a lot more, you're sweating more, anything that affects your diet can affect it and definitely anything that can cause stress or change your routine can cause issues.

Nada Youssef:  I'm glad you brought up diet, that was my next question. I have two little children, I go to a restaurant, kids menu with all the colors and all the toys and as soon as they look at it, it is burgers, buns, mac and cheese, tenders. How much is diet affecting our children and what do you guys recommend our children should be eating to add more fiber in a kid's diet.

Kimberly: That's a difficult question.

Katherine: Yeah, that's loaded. Yeah.

Kimberly:  They're very picky eaters to begin with.

Nada Youssef: Yeah, right.

Kimberly:  I struggle with my own child to get her to eat, all she wants is mac and cheese all the time, so it's always difficult, but for us we always try to get as many fruits and vegetables as possible to increase that fiber intake and hopefully get things moving a little bit more.

Nada Youssef:  Sure.

Katherine: Yeah, I would say definitely focusing on the natural fibers of fruit and vegetables and along with that making sure that they're drinking enough and especially drinking during the day. For my concern just drinking at all fluids, because what happens and what causes, one of the factors of causing constipation is that your body is reabsorbing all of the liquids that you're drinking so if you're not drinking enough then it's absorbing too much and then that's how you get hard stools.

Nada Youssef: Okay now with a lot of children that are constipated, because I know with constipation one of the biggest things that I see with my kids or my friend's kids is this a ... Well, I want to call it a habit if it's just behavioral, but is this something you need to tackle early on that can become a habit into adulthood or is this something that can change when you're older, is it easier now?

Katherine: Absolutely and it is a little bit of a biological habit, not something that they're doing consciously necessarily, but the challenge with chronic constipation is that over time your bowels can expand, you become less sensitive and it becomes enlarged and so that it takes more stool than to even get the sensation that you need to eliminate so it's a problem that can kind of exacerbate itself over time, so definitely the earlier that we can catch it and treat it the better.

Nada Youssef:  Sure. Now, okay, besides diet, I want to talk about some treatments and solutions. Is there lifestyle home remedies that maybe our viewers should know about to make it easier?

Katherine: So fruits, vegetables, and liquids are the big thing that we recommend from a constipation standpoint as regarding home remedies at least. I think the other big thing is to make the toileting environment comfortable and relaxed. In order to poop, we talk a lot about your muscles and which muscles are necessary. You need to be relaxed, so your bottom muscles as we refer to with the kids, is that your bottom muscles need to be relaxed in order to allow the poop to come out.

Katherine: A lot of times by the time kids have come to see us, the entire toileting environment has become really negative and that they are getting yelled at, parents are frustrated, they know that the bathroom is a place that they can't do what mom wants them to do and so the whole thing. When you're tense and tight and stressed essentially you're just squeezing your bottom muscles and you're not allowing the poop to come out and so really focusing on allowing the bathroom to be a pleasant, positive, relaxing place which is hard, because it's a porcelain, it's not the most relaxing place ... yeah.

Nada Youssef: Put toys for them or something, but I've heard about like the squatting position even so sometimes what I do when my daughter's really constipated, I have no idea what to do. I have no idea as a mom what to do if my daughter's telling me that she's in pain and she doesn't want to push it because she's terrified of the feeling and you can relate, so I put the stool under her feet and I've heard, is that helpful?

Katherine: Absolutely. And we think about how kids fit on the toilet anyways, you've got these tiny little butts, that what they're doing is they're kind of doing this balancing act that what they're doing is they're engaging all of those muscles that are supposed to be relaxed and just trying to balance and not fall in. Making sure that they fit on the toilet seat and then elevating their legs will also help to relax their bottom muscles a lot.

Kimberly: We do a lot of the same with our kids for urinating and we actually tell our kids, they have a basket that they keep in the bathroom with them where they can play on their tablet, they can blow bubbles, they can play with a pinwheel something like that to help relax them a little bit and allow all the urine to empty out of the bladder.

Nada Youssef: Okay, could that ever be a negative thing to sit too long on a toilet if your child, especially with pooping, pushing when you're not supposed to, is that bad if I have my child sitting on a toilet for a long time or is it ... okay?

Katherine: Yeah, that's a great question actually, so a lot of the gastroenterologists that I work with will say that they want to limit the time to some extent, because when you're sitting in that environment your muscles are also not supported and so sitting there for too long can also cause problems in that regard.

Nada Youssef:  Sure. We talked about frustrated parents, right? As a mom, how do you cope and how do you support your child? What are you supposed to do? What is the response to an accident whether ... I know bedwetting is probably more common maybe, but how am I supposed to respond?

Kimberly: It's very difficult because it's very easy to get frustrated especially when it's happening time and again and you want so badly for it to stop, but there's nothing you as a parent really can do. Unfortunately, a lot of it is on the child, but it's very important to try as best you can to stay calm. Remember that the child had an accident, they're not doing it on purpose. Try to reassure them we're working on this, it's going to get better. Make it something you're working on as a team. The family, mom and dad and the child are working together, not something that the kid has to take care of themselves.

Nada Youssef: Sure, very good.

Katherine: I want to say absolutely give yourself credit for being a parent and being frustrated. This is a messy, gross, socially undesirable problem that we as parents are dealing with on usually multiple times a day so it absolutely is a frustrating thing and yet we know that frustration makes it worse. Frustration causes tension, it makes it harder for you then to pee or poop and so trying to help your own ... sort of pay attention to your own level of frustration can be really helpful. One of the things that I found to be helpful is to think about as something that they're still learning about.

Katherine:  I have a 3 1/2 year-old, I also have a 1-year-old and obviously the expectations are different for the 1-year-old and that things that the 1-year-old, so when she's throwing food off of her tray, I'm like, okay, she's still figuring out how to pick up food and that's okay. Now, if the 3-year-old were to do that, that would not be okay and I would get much more frustrated and much more angry.

Katherine: To think about it as this is something that they're learning to do regardless of their chronological age, because I think that that's what we really get caught up on of they're 6-years-old, why can't they do this already? Instead, think about this is something that they have not mastered yet just like writing their name, or putting their socks on, or whatever other skill we can kind of hone in. I'm like, okay, they're still working on this, I'm calm with that, I can be calm with this.

Nada Youssef:  I think that's a very important thing that you just said even with two kids, they could be 2 or 3 years apart, but it's completely different the way you treat that one with more stern with the older child because they should know.

Nada Youssef: Now,

Katherine:  So not assuming that they should know better.

Nada Youssef: Right, right versus, yeah. What kind of treatments for incontinence? I know this is going to be different for you so I'll let you go first.

Kimberly:  Okay.

Nada Youssef:  What kind of treatments are there and then of course me as a mom, I always think side effects. Are there side effects are they worth it?

Kimberly: So, there's many things we can do. Medication is always one of them, but we try to avoid that. We try to work on more toileting behaviors, how often they go during the day, when they go, how they go, all those kind of things that we try to work on first and then we can work on medication if we get there. Oftentimes, we don't even get there and we don't have to worry about it, but it's something that we kind of have there on our back burner too in case we need to use it, but of course medications have side effects and unfortunately the medication that is most often used at least in our practice causes constipation which can then compound the issue.

Kimberly: It's one of those things is it better to kind of give it some more time, kind of work on everything or do that and potentially make it worse.

Nada Youssef:  I want to kind of have you elaborate a little bit about if we don't go to medication, what kind of things are we telling our patients and their kids to do. You said, don't drink two hours before you go to bed, maybe don't eat watermelon, tangerines. What kind of things are we telling them to do?

Kimberly: One of the big things is we see a lot of kid's hold their urine. We talked about it already that they hold for such a long period of time. We tell them to set an alarm, get a watch that sets an alarm for them and reminds them to go to the bathroom on regular intervals, because it's very frustrating as a parent to continually remind them and continually be told, no, I don't have to go, no, I'm not going to do it. That way it puts more of that responsibility a little bit on the child as well.

Kimberly:  Like you had said before, make sure they have a stepstool so their feet can be flat on the floor and they're comfortable in the bathroom. They're able to empty as best as they can. There are a couple of dietary things that we've found just by doing a little research with the child. Having the child keep a chart of, okay, these are the days I'm wet, this is what I'm eating and drinking, this is what I'm doing and then sometimes we can draw correlations that way that help us to try to change it.

Nada Youssef: Great. I lost my question to you, I'll go back to you.

Katherine: So the question being treatments, right for constipation and encopresis or fecal soiling. I think about it a little bit as the hierarchy of prerequisites. The first thing is to manage the constipation from a medication standpoint actually, usually medications are actually one of the first things that are used and oftentimes that can be helpful in that they never end up coming to see me. That once they realize that pooping doesn't have to be painful and unpleasant then they're okay.

Katherine:  Either dealing with that from a medication standpoint or dietary and lifestyle changes along with the medications backing off in terms of pressure. When you've got really young kids, usually the first thing is just quit pressuring them. Pooping is the most priority and then where they poop we'll worry about that later.

Katherine: Then once we've got that under control that they're having daily bowel movements that are really nice and soft in consistency. Oftentimes, even mushier than adults would probably prefer, because they're more sensitive to it. A lot of times the key is applesauce consistency. Yeah, most of us would probably prefer not to have applesauce consistency, but for kids that feels more comfortable for them.

Katherine: Once, that's happening then it's about helping them to associate the bathroom with a relaxing, comfortable place to go so the goal would be getting them to sit on the toilet and be nice and calm and comfortably relaxed sitting on the toilet.

Katherine: Then, once they're successfully doing that then it's about pairing that with when are they most likely to poop and so kids, and all of us actually, tend to poop after meals, that's when our body most likely wants to poop and so having scheduled sittings usually after breakfast, lunch, and/or dinner depending on what their bodies currently doing so we'll also have them monitor and see what is their body currently doing and then try to schedule the sittings based on what their body is kind of telling us.

Nada Youssef: Now for adults, we have like Miralax, we have all this stuff over-the-counter. Are there over-the-counter meds for children or does this need to be like we need to see a specialist and needs to be a prescription.

Katherine:  I would definitely recommend talking to your pediatrician, or gastroenterologist about it. You can buy medications over-the-counter so you don't technically need a prescription for it, but yeah, I would just talk ...

Nada Youssef: Okay, great, great. I remember my question to you. If someone's having issues with their child's bedwetting, is it okay, normal, good to wake them up to go?

Kimberly:  We recommend against it.

Nada Youssef: Against it.

Kimberly: Actually waking your child at night obviously will make them more tired, because they're not getting the sleep that they should and then they'll fall into a deeper sleep and they have a higher risk of then wetting the bed even more because they're going to be so exhausted.

Nada Youssef:  Sure. Now, if my child is having issues and it's time to see a doctor, can you explain to me what my initial appointment will be with my child? I'll start with you first.

Katherine:  Yeah, with me as a psychologist, I get the benefit of I'm not a touching master so we're going to talk a lot about poop. I'm going to ask lots of questions about the behavioral mechanisms of toileting. How often they're pooping, what does it look like? We're going to show them poop charts. The Bristol stool chart in case you guys want to look it up.

Nada Youssef:  What is that called, say that again?

Katherine: So the Bristol stool chart.

Nada Youssef:  The Bristol stool chart, very good.

Katherine: Yeah.

Kimberly: Yeah. I want that.

Katherine: Did you know there's a chart that describes all of people's poops?

Nada Youssef: Oh, that's great.

Katherine: But the really nice thing about it though is that it describes it in a way that there's different category's and different numbers so you can have a Type 1 or a Type 7 and so instead of kids having to describe it then, they can just say I have a Type 3.

Nada Youssef: Oh, so they just look at the picture?

Katherine: Yeah. Or they can just point, exactly.

Nada Youssef: Very good.

Katherine: So we'll talk about what type of poop they have and what kind of strategies that they tried in the past. I also ask a lot about other ... They are more than just their pooping problems and so I'll ask about family dynamics, what kids like to do for fun. A lot of it is seeing if there's any other factors that could be getting in the way or that we could actually use. Making sure to know who all is caretaking. If they're going to daycare that's going to change kind of some of the recommendations that we have. What kind of things they like to do for fun can be great ideas for rewards that we can use for behavior planning.

Nada Youssef:  So are there any questions as a mom that if I'm noticing soiled underwear after school, or anything like that for my let's say a 6-year-old, or 7-year-old are there questions that I should be asking to kind of figure out what's going on if it's never happened before? What are the right questions to ask your child?

Katherine: Yeah, a lot of times if they're soiled underwear it'd be more of what we call streaks, like just a small amount in the underwear, and typically that means that they're holding and the streaks are kind of leakage that are around a bigger mass. So one of the bigger things is to start to track when your child is actually having bigger, larger bowel movements in the toilet and what those look like.

Katherine: Again, you can look up the Bristol stool chart and see what consistency it is.

Nada Youssef:  I will have to check that out.

Katherine: So actually for kids that we see having Type 4 so if you guys [inaudible 00:23:03] there's going to be a whole bunch of people Googling Bristol stool chart-

Katherine: Yeah, exactly, so Type 4 is considered the most ideal for adults, but kids with constipation issues we're actually looking for even Type 5 or 6.

Nada Youssef:  5 or 6, I will look this up, thank you. And then Kim how about you, initial appointment?

Kimberly: So it really depends on what the diagnosis is. Our job first and foremost is to rule out that there's anything else medical going on. Depending on what the child is coming to be seen for, we may need to do an ultrasound or an x-ray, a urine test, something like that so they may have those studies done before they come to see us. Most of our appointment is the same as Dr. Lamparyk's it's a conversation. It's really not something that kids want to talk about, it's not something that they want anyone else to know about, so sometimes it's really hard to pull that information, but it's important to really try to sit down with the child and try to make them and the family as comfortable as possible, because that's when you're going to get the best results.

Kimberly: Unfortunately, there is an exam on my end we do make sure that anatomically there's not anything wrong with the child that could potentially be the cause.

Katherine: Well, and I will add that if just in talking with the parents and concern that there's constipation, they still have to see one of my colleagues and get an exam, it's not me that's doing it.

Nada Youssef:  You paired up with someone else that has to do the exam?

Katherine:  Exactly. So the exam is typically either a digital, rectal exam or I joke that they have the magic touch so they can feel their bellies and see if there's poop in there or not or there can also be an x-ray.

Nada Youssef: Now, you said digital, rectal exam. Please explain.

Nada Youssef:  Should I ask?

Katherine: Yeah.

Nada Youssef:  I don't want to scare anybody away, but what is a digital, rectal ...

Katherine:  At times, and this is up to the physician to determine when this is appropriate and when it's not, so it's not a guarantee it wouldn't happen at all visits, but it was when they take their digit, or their fingers and place it up the child's rectum.

Nada Youssef:  Okay, so digital, I thought of a computer. Okay.

Katherine: No. These digits.

Nada Youssef:  These digits, okay, good. Well, I actually I'm getting a lot of live questions so I'm going to put my glasses on and start asking these questions and whoever wants to answer can jump right in.

Nada Youssef: I have Jennifer. I have three children and all three have nighttime issues in Pull-Ups and my youngest who will be 5 next month, still barely goes on a toilet. Doesn't recognize the sensation to go. They all have various mental health issues including ADHD, PTSD and ODD. So, who's going to answer that one and if you can explain what ODD is.

Katherine: I can take that part on. ODD is oppositional defiant disorder. So kids who have oppositional defiant disorder have a hard time following any commands or any direction and it's usually if I tell you to do this you're going to do the opposite. That especially can make it really difficult for toilet training in general because this is hard for any kid to follow through on and for any kid to kind of, we're going to be giving them a lot of commands that they are not comfortable with and don't want to do, so it's going to be extra complicated if they're not following through on simple commands and commands that don't provide anxiety, it's going to make this more difficult.

Nada Youssef:  And not knowing the sensation when to go, so what do you do with that?

Kimberly: From our standpoint, it would be best to have the child be seen. Make sure that there's not something else going on. Make sure that we maybe do further testing to make sure that they are able to actually have sensation down there, they're able to feel what's going on and then that way we can then help guide them to be dry.

Nada Youssef:  Sure. And again some of these answers to our viewers will not just be black-and-white, there seems to be a lot of gray, so that's okay.

Nada Youssef:  Then I have Kate. What options are available for children with chronic constipation for medically needing to be on a high-calorie diet other than Miralax. I haven't heard a lot of good things about Miralax.

Katherine:  Miralax gets a really bad rap and without getting too much into it, it is one of the most commonly used medication's sort of both within our GI department here, but also nationally. Despite its bad rap I think most physicians will consider it really safe for kids.

Katherine:  There are alternatives and I think it's fair to start with lifestyle recommendations focusing on increasing fiber, increasing fluid in your diet first I think is a very reasonable first step.

Nada Youssef:  Now, do they have Miralax for kids or is that the same Miralax you get for adults, just different dosage?

Katherine: Mm-hmm (affirmative).

Nada Youssef:  I see, okay. Then Jody. My son turned 3 in March, he is pee trained during day, even tells us when he has to go. Don't even need to tell him to go, but pooping we have no luck. He poops his hands and then comes to me and says, I pooped, need changed. Not sure what else to try. He's refusing to sit on the potty to poop and don't know what else to try.

Nada Youssef:  Again, it's them knowing how to say no could be a challenge for parents.

Katherine:  I think the first thing is to figure out what do his poops look like? What do they feel like to him, because if it's something that feels uncomfortable it's going to be much more difficult for him to go and making sure that we can get his poops as soft and consistent as possible and then helping him.

Katherine:  Sometimes with boys it can be more difficult because they transition to standing while they're peeing and so they're not even used to sitting on the toilet. Helping him to just become comfortable sitting on the toilet sort of having daily sitting practices after meals especially and so the goal initially is that you sit for a couple minutes, we read a book, life is good and then you're done and it's like, oh, that was easy, that was nice and no big deal.

Katherine: Typically, what will happen is they'll be so relaxed that eventually if their poop is soft enough something will just kind of naturally happen and they'll have this look like, I'm really good, that was no big deal, like that was pretty easy and then eventually they start to make that connection of when I feel this then I do that.

Nada Youssef:  This is what I should be doing.

Katherine: Mm-hmm (affirmative).

Nada Youssef:  Great. I have Angie. My son is 3. He has chronic constipation which is treated with Miralax and mineral oil. We think the constipation is due to holding as he has been tested for milk allergies, Celiac Disease with nothing available. He's perfect at not pooping his pants, but pee he has a problem with. We've tried to make him go 30 minutes after he eats. He's very headstrong, sometimes he'll pee on the floor, sometimes I feel it's totally intentional, and I feel he doesn't even realize it.

Nada Youssef:  We've totally abandoned Pull-Ups besides sleeping at night he keeps his underwear on as he likes being naked all the time. We thought he was intentionally peeing to get his clothes off. Please help.

Kimberly: He's 3 at this point, I believe you said, right?

Nada Youssef: Yes.

Kimberly:  Honestly, I would wait, 3 is a little young at this point to really be doing a bunch of testing or doing anything like that to figure out what may be the issue. He is likely still learning. He's still learning how his bodies working, learning what that sensation is. I would give him some more time before really trying to do anything and unfortunately if he's truly constipated depending on how well the medications are working that may be part of the cause too, because that can irritate the bladder a little bit and cause incontinence.

Nada Youssef: It sounds like there may be a line between potty training and incontinence issues. The age for boys is usually a little bit older than girls, is that right? Is it harder for boys with potty training versus girls because I've always heard that and I don't know if it's a myth, I have two girls.

Kimberly: Technically they say it is a little bit harder for boys than it is for girls, but generally the age at which they should be potty trained is still around age 4 or 5-ish for both.

Katherine:  And I think the challenge thing, my heart goes out to all parents of 3-year-olds because and even 2-year-olds because a lot of the preschools around here and nationally don't allow kids to enter preschool until they're potty trained and so this is where you get that conundrum of it's not technically an issue from our standpoint, but it is starting to impact their ability to be with their peers.

Kimberly: Their parents feel pressured.

Katherine: Mm-hmm (affirmative). Exactly.

Nada Youssef: And you should not be pressured, this is natural.

Katherine: Exactly because pressuring makes it worse and so you're kind of in this catch-22 where parents are looking at the calendar and be like, okay, we've got two months to accomplish this, but I know that the more pressure I put on them the worse it's going to get.

Nada Youssef: Yeah, yeah, very good. Thank you. I have Joellyn. Do you have tips on potty training on special needs children? I don't know if that's your forte.

Kimberly: I think that's a difficult question because special needs can mean a variety of things so it really depends on that individual child. No matter what every child is different, but especially a special needs child takes a little bit more care.

Nada Youssef: Sure.

Katherine:  Yeah, I would absolutely agree. I think the big thing and the advice I have for all parents is to meet the kid where they're at. Forget about their chronological age and sometimes even forget about the developmental age to focus instead on this is where they're at from a toileting perspective. So if they're not noticing it at all, that's where we're going to start. If they can do it sometimes, but not other times that's where we're going to start.

Nada Youssef: Sure. Great thank you. And now I have Ashley. How do you know when your child is ready to potty train? My daughter's 18-months old and will let us know when she's pooping in her Pull-Ups, she'll sit up on the potty sometimes or she'll just take her Pull-Up off.

Kimberly: Go ahead.

Katherine:  I think that there's a wide range of it depends on how assertive you want to be as a parent. The big thing is when they can start to notice when they have a way of verbalizing it, so actually this kind of goes to the last question of the special needs is that they need to have some way of letting you know either verbally or sometimes at 18 months they may not be talking so there are kids that can sign and say, I have to go potty. It definitely helps if they're able to pull down their pants and that they can do that independently. Those are some readiness signs.

Katherine: Oftentimes, they'll say to wait until after 2 and definitely in the beginning for most kids the first several months, and I definitely experienced this with our daughter, we're like, why did we do this? It was a lot easier to have them in diapers at first and so it's about ... Because their bladders are also really small at that stage, so you're going to be running to the bathroom a lot.

Nada Youssef: Sure. Sure thing.

Kimberly: Can I interject real quick just from a bladder standpoint-

Katherine: Yeah definitely.

Kimberly:  We find that the children that are potty trained younger and that are kind of pushed into it by the parent rather than truly being ready end up having more issues later on in life. I don't know if you guys see the same, but we end up seeing those children back later for their having a lot of urgency frequency, they have the recurrent UTI's those kind of things, so I would agree, we always recommend waiting until they're later even like 2-1/2, 3 until the child is really voicing that, I'm ready, I want to go on the potty, those kind of things.

Nada Youssef: So potty training early is not necessarily a great thing?

Kimberly: Not necessarily. Not every child obviously that potty trains early is going to have issues, but quite a few of the ones that we see later on once school age are the ones that potty trained early.

Nada Youssef:  Very, very interesting.

Nada Youssef:  Margaret wants to know, my little one will pee in the potty during the day, no accidents but will not poop. I'm nervous to let her not wear a diaper overnight because she has poop every morning in the diaper. Do we have anything for that?

Katherine:  I'm curious about how old she is also, but the transition ... I'm going to speak about the transition to diapers versus underwear because a lot of parents and for some kids I think it might make a difference, you put them in underwear and then they're more likely to go. For a lot of the kids that we see it does not matter and so it becomes more of a laundry issue and do you prefer to throw out diapers and spend your money that way, or do you prefer to wash underwear and potentially throw out underwear that way?

Nada Youssef: Right.

Katherine: My general rule of thumb is that at least 50% of the time they should be having either a Pull-Up at night or dry underwear in order to make that transition.

Nada Youssef: Great, thank you. Mole wants to know, my 6-year-old son had a tumor in the lower part of his spine which affected his bowel and bladder leaving him incontinent, no sensation of when he needs to go. Are there any medications that can help improve, he's going to first grade and I'm nervous about him being teased?

Kimberly: That's a very good question. Really when there's a child who has a spinal abnormality of some sort, whether it's a tumor or they were born that way, spinal bifida, something like that it really is medical management. I would really recommend that they either speak with their pediatrician or urologist to talk about that. Unfortunately, if he doesn't have the sensation from the spinal tumor, it's unlikely that he's going to be able to be fully continent without the use of a catheter or something like that.

Nada Youssef: Sure. Great. I have Christine. My daughter's constantly withholding poop. She waits 3 to 4 days and ends up with poop trying to come out in the underwear and she refuses to go. Thank you for these tips to try. Do you have a recommendation on the amount of Miralax to give children or is there anything else you would recommend?

Katherine:  No, I'm actually going to answer that question because I think it's really based on the child, and I would definitely encourage you to talk to your pediatrician or one of our gastroenterologists, but I do want to speak out to the fact that thank you for sharing, because this is much more of a common issue than people realize and appreciate, and it can be extremely isolating because of the shame that goes along with it. I get so many parents that come to me and have like word for word that exact concern and struggle and then the next sentence will be, am I the only one that's going through this, because it's not something that's very easily talked about.

Nada Youssef: Sure. Sure. And of course depending on the age and everything like that for medication as well.

Nada Youssef:  I just have a comment from Rhea. She said my son withholds. We're starting toileting clinic in a few weeks and I cannot wait.

Katherine: Awesome! Look forward to meeting you.

Nada Youssef: Lindsay wants to know, can general anxiety make the child hold back on going to poop. He's not afraid of the toilet at all.

Katherine: There is absolutely a relationship between anxiety and constipation and we have some kids who have anxious temperaments in general and then that results in constipation and we have got other kids who are very carefree in other parts of their life, but then when it comes to this one ... you can almost think about it like a specific phobia when it comes to pooping.

Katherine:  General anxiety can affect stooling in that anxiety physiologically is stress and stress can slow down our digestion and can result in slowed motility which can then result in constipation.

Nada Youssef: Sure. I have to say, a lot of adults don't poop in public, so I think that's why I always try to explain to my kids when they don't want to poop in school or in a restaurant that it's absolutely okay, that everybody does it. Because sometimes just like you said it gives them anxiety.

Nada Youssef: Melissa wants to know, how often should my son be urinating during the day? He will go all day at school and not pee at all, should I be concerned?

Kimberly: I wouldn't say we need to be concerned, but I would encourage him to go more often. Generally speaking, children should be able to go to the bathroom about every 2 hours, 2 to 3 and they should be drinking enough fluids that they're able to go that often so if he's not going that often then you wonder if he's maybe getting a little on the dehydrated side, or if maybe he doesn't want to use the bathroom, there's an issue that they only get so many passes to the bathroom or he doesn't want to miss class, which happens but to find the time during the day that's good for him to go, so he can go more frequently.

Katherine:  More water I'd say too, more water. Kids don't drink enough water. Especially at school it's hard to allow them to drink water. Sometimes if it does become more of an issue then we can always write letters to the school and can request that they be allowed to have water with them instead of just-

Nada Youssef:  During lunch, during snacks.

Katherine: Mm-hmm (affirmative) so having a water bottle here. I always experience when the waters in front of me I'm going to drink so much more than when it's behind me or if I have to walk to a water fountain. Then the other thing is to potentially have a bathroom pass that he can go outside of class or go to a private bathroom if it's an issue of going in a stall with 20 other kids it can be intimidating. We can get him a private bathroom.

Nada Youssef: Sure. I have Dina. My daughter isn't diagnosed with constipation, but she does not go regularly. First of all, what is regular for a child? Second of all, what can I do to keep her stool soft?

Katherine: The goal is 1 to 2 times a day. Some kids will go up to 3 to 4 times a day. If you're going more than that it's likely that you're not fully eliminating when you're going and just allowing a little bit out which is a sign of withholding. If you're going less than that, I will have some kids that go every other day and I joke, I allow that. Any less than that is definitely probably a sign of constipation and that they're withholding.

Nada Youssef: So if your child is not pooping regularly and going maybe 2, 3 days or longer, you should be seeing someone then?

Katherine: Yes. Starting with either your pediatrician or the gastroenterologist.

Nada Youssef: Okay, very good to know. Carla wants to know, is there a difference in nighttime wetting versus daytime wetting? Is one more serious than the other?

Kimberly:  I wouldn't say that ones more serious than another. It all kind of just depends on the underlying issue, if there is an underlying issue. Generally speaking the daytime comes sooner, and then the nighttime follows. Unless there's an underlying medical ... diabetes or something along those lines that may be causing the wetting either day or night it's hard to say that ones necessarily worse than another.

Nada Youssef: Sure. When I think of bedtime is it so much behavioral like I just don't want to get up, or could it be your muscles just not ...

Kimberly: Could be, I've had children who were afraid of the dark so they didn't want to get out of bed to go to the bathroom because they're afraid of the dark. I've had children, actually my nephew, he wears a Pull-Up to bed at night and he'll be dry all night and he just doesn't want to get out of bed in the morning when he wakes up he'd rather lay a little bit longer and he just pees in the Pull-Up. It kind of depends, so everybody's a little bit different.

Nada Youssef: Okay. Sharon, my grandson is 3-1/2 he refuses to use the potty, he says he's afraid. He won't even pee outside which is why we thought we need help. He has also chronic constipation since he's an infant, what are our options for helping him?

Katherine: Yes, and we see this a lot where kids will have constipation since infancy and they really come by this honestly. Essentially, his entire life this has been an uncomfortable, unpleasant experience for him and I joke that I'm pretty sure that if all the kids, if we could pull out our magic wands and say you never had to poop again-

Nada Youssef: They'd be okay with it.

Katherine: Oh, yeah, they'd pay all their life savings at 3 to do that. This other question being things that could help? So one is making sure that the constipation is definitely addressed. That we're treating that effectively and then going slow and helping him just be okay with the bathroom. It may even start with, I've had kids and the most serious conditions where we just walk into the bathroom and we wash our hands in the bathroom and the bathroom itself becomes this really negative place, but then sitting on the toilet even with your clothes on, if you can't sit on the toilet naked to just kind of get comfortable in that space without any expectation.

Nada Youssef: Sure. Now, what do we tell moms and dads, parents, how do you make it okay to go pee and go poop and it's summertime, people want to play and they don't want to leave their friends and it's recess. Sometimes my child will come home and tell me that she hasn't peed all day because she's in school, she's so excited all the time. What should I tell her to help her understand that she absolutely has to go without being too stern.

Kimberly:  Right. It's difficult because oftentimes children don't really understand it, they don't comprehend it, but I always try to explain to children a little bit about how the body works, we're constantly eating and drinking throughout the day which means we're constantly making poop and pee so we should be able to go to the bathroom multiple times throughout the day and as best you can and try to encourage them to go. It's challenging because especially kids get busy. They don't want to stop what they're doing, they don't want to stop playing with their friends doing their math test, whatever they may be doing during the day. It's difficult.

Katherine: It's hard when you're not with them too, but even during those times in the summertime when you are with them more and to think about the times that they're sort of mentally unavailable from the bathroom. Traditionally, parents are pretty good about, we're about to get in the car and we're going to be in the car ride for a while so everybody go to the bathroom before we get in the car.

Katherine: Think about for them, being outside playing is the equivalent that the bathroom is just as unavailable as if they were in the car, we know it's not, but mentally it is and we're about to watch a movie. The bathrooms probably going to be mentally unavailable to them for the next hour and a half, so it's like before we go to the movie everybody go to the bathroom. Before we go play outside or before we get in the pool everybody go to the bathroom.

Nada Youssef:  Make it like a habit so they know before we sit down and eat go use the potty or after ...

Kimberly: It's helpful too, you had said everybody ... make sure that it's not focused on the child that you're having an issue with. If you have multiple children or mom and dad are going to the bathroom too, let's all go together rather than making it an issue for that child.

Nada Youssef: Yeah and that's what I try to do so I take them to the restaurant and before we sit down we're all going to go potty. There's a lot of whining and I don't have to, I don't need to, just sit on the toilet whatever comes out let it come out, but you have to.

Katherine: And it always does, right?

Nada Youssef: Yeah, that's the thing, they always do it's just not long enough or whatever. Now, we really didn't talk a lot about UTI's so I just wanted to ask you about that. What are the causes of UTI in children, is it common, is it not common, when to see a doctor?

Kimberly: It's much more common in girls than it is in boys. It can happen in both. Most often in boys they should be seen by a urologist pretty much right away because it's uncommon to happen in a boy. In girls, it does happen relatively frequently. Typically, causes can be constipation. They can be holding. It's hard to say how often it happens, because some children they have UTI's once a year, a couple times a year, some never have them, but they definitely should at least be seen by the pediatrician and then if it's something that's worse, sometimes a UTI can land you in the hospital depending on how bad it gets, then you need to come and see us.

Nada Youssef: Sure. Well, you guys, it's been great. We're running out of time, but I wanted to give you the floor if you have anything else you wanted to add, I know we covered a lot though. Is there anything else you want to tell of yours before I let you go?

Katherine: Just in general that you're not alone, that it may feel like you're alone because this is something that is not talked about a lot, but this is most of my caseload actually. Most of my day is spent talking to people like you.

Kimberly: There you go.

Katherine: And that as much as possible and as difficult as it is having a sense of patience.

Nada Youssef:  Sure.

Kimberly: I would have to agree. I always tell our patients the same thing, I spend my whole day talking about pee and poop, but if-

Katherine: And vomit.

Kimberly: You have a concern

Nada Youssef: I didn't get the vomit part.

Kimberly: But really and truly if you have a concern you don't feel like you know what to do or maybe the pediatrician has given you some ideas that haven't really worked, then you should absolutely get it checked out even if it's something as silly as there's nothing wrong, don't worry about it. At least you have that reassurance of okay, everything's all right. I can keep doing what I'm doing and hopefully we'll get there.

Nada Youssef:  And hopefully this brings awareness that you are not alone, this is normal. Everybody poops and pees, it's okay to have issues and to bring up embarrassing questions, it's not embarrassing.

Nada Youssef: Great, well thank you so much for your time today.

Nada Youssef:   For more health tips and information please follow us on Facebook, Twitter, Instagram, and Snapchat at Cleveland Clinic, one word. We'll see you again next time. Thank you.