Potty Training, Bedwetting and Other Pee & Poop Problems – PediaCast 481

Show Notes


  • Dr Steve Hodges visits the studio as we explore potty training, bedwetting and other pee & poop problems. Learn the central role constipation plays and discover practical tips for helping kids. We hope you can join us!


  • New Year’s Resolution
  • SMART Goals
  • Potty Training
  • Bedwetting
  • Constipation
  • Pee Accidents (enuresis)
  • Poop Accidents (encopresis)




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We are in Columbus, Ohio.


It's Episode 481 for January 12th, 2021. We're calling this one, "Potty Training, Bedwetting, and Other Pee and Poop Problems". I want to welcome all of you to the program.


So we have another important topic for you this week. One that spans multiple age groups from toddlers to teenagers, as we consider potty training and bedwetting and other pee and poop problems.




It turns out there is an underlying condition that is often related to all of these issues and that problem is constipation, which we've talked about numerous times on this program. We have even devoted entire episodes to constipation, for instance, PediaCast Episode 292. And that one would be a terrific companion listen to today's episode. I'm going to put a link to it in the show notes for this episode, 481, over at pediacast.org, so you can find it easily.


Today, we're going to talk about constipation again, but this time, in particular, to how it relates to potty training and bedwetting and also daytime accidents with pee and poop. These are conditions known as enuresis. That's the medical term for accidents with urine. And encopresis, those are accidents with poop or stool.




And I mentioned these words, enuresis and encopresis here at the beginning of the program, because when two doctors get talking about accidents surrounding pee and poop in an already potty-trained child, those are the words that just sometimes slip out without us remembering that they are not the words that parents and families typically use.


So enuresis is pee accidents. Nocturnal enuresis, that one means bedwetting. And that makes sense, right? Nocturnal means nighttime. Enuresis is a pee accident so we have bedwetting. And again, encopresis, those are those poop accidents that some kids have in their pants.


You got to love pediatrics, right? We can just throw around words like pee and poop like they're nothing. It's plain language. But now you also know the medical terminology for these things.




And to help me talk about potty training, bedwetting, and other pee and poop problems, I do have a terrific guest joining us this week. Dr. Steve Hodges is a pediatric urologist at Wake Forest Baptist Health, also author of The Mop, or M.O.P. series of books, and the curator of a very informative website called bedwettingandaccidents.com. He will be with us shortly.


Before we get to Dr. Hodges, I wanted to mention, as we stand here at the beginning of the new year, it's the time of year that many of us make resolutions for the new year. And we just want to improve something in our lives, and so we make a new year's resolution.


And I decided to take a different approach to my new year's resolution this year. Many of us make sweeping plans. Like, I'd like to eat better or I want to get more exercise, I'd like to get more sleep or I want to spend more quality time with the family.




But we fail in plotting out the specifics of how we're going to meet the goal that we have in mind. So this year, I decided to take a hint from the business world and turn my new year's resolution into a SMART Goal.


So what is a SMART Goal? If you're in business, you've heard of this before. But many of us have not heard of SMART Goals. So what it is, it's basically making my goal Specific, Measurable, Achievable, Relevant and Time bound. And each of those words spells out SMART as we look at the first letter of each of these characteristics.


So my resolution this year, and I have to be honest, I actually made this resolution at the end of November, coming off of the Thanksgiving holiday. And so my sweeping goal that I decided to do a month early is just to exercise more. And I ate too much at Thanksgiving and I've let the pandemic turn me into a couch potato.




And so I wanted to make a routine exercise, kind of a daily exercise as I headed in to the new year. How can I turn that into a SMART goal? And so far, it has worked out pretty well.


So here's what I did and I share this as an example of creating a SMART goal at home, whether it's for yourself, for your kids, for your family as a unit. And my hope is, of course, not for you to follow exactly what I did, but just to help you see the process of how you can try to make your goal long lasting as you maybe seek a healthy change for yourself, your kids, or your family.


Again, your goal may be something completely different but the process of developing a SMART goal really is the same. So yes, I want to exercise more, but let's be more specific. I'd like to engage in some sort of intentional aerobic exercise every day. So that's the specific part of my goal.




Then, I'm going to make it measurable. And I decided that I was going to take 30 minutes a day of total aerobic exercise. Now again, I can change these goals as time goes on. But for right now, 30 minutes of total aerobic exercise each day, hopefully large chunks of time. But the ultimate measure is going to be closing the exercise ring on my Apple watch every day.


And so that's the measure. It's not necessarily that I set a timer for three minutes. But at the end of the day, is my exercise ring closed? Then I know that I met my goal.


And to make it more fun and competitive, my wife decided to take on this same goal. Now, we are fortunate enough to have an exercise room in our home. It's not one that we built, it came with the house when we bought it about ten years ago.


And it's a nice room. It's got a padded rubber floor. We have collected some exercise equipment over the years of our marriage, including a treadmill and an elliptical. We have some hand weights, a couple exercise balls. You know the drill.




But honestly, and you know this drill too, the room has not seen much use over the years. It's collected some junk and some other storage item. My wife set up her sewing machine in the room. For a while, it functioned as my studio in the early days of the pandemic.


So the first thing we did was we cleaned it up. We emptied the space of all non-exercise stuff, right? So we just made it back into an exercise room, that's what this room is for.


And we arranged the equipment, which was not easy to do because treadmills and ellipticals are heavy machines. I think the elliptical is like 300 pounds and it was just the two of us and we're 50+ years old. So it's not easy but we did not hurt ourselves too much.


And the end result was that our home gym felt like a new space. In fact, my wife even painted one of the walls like an accent color, just to make it more pleasing. And we wanted it to be a space, we wanted there to be a reason for us to want to be there.




And so, it didn't take much, tidying it up, rearranging the furniture, painting a wall. That was it. And honestly, that really has provided motivation, at least another source of motivation for us to use the room.


We also have a television and access to our Nintendo Ring Fit Adventure. So lots of exercise options without really spending any additional money other than paint.


So we have the space. And as we think about making our goal measurable, my wife and I printed out calendars. And each day that we complete our 30 minutes, so we close our exercise ring, we color in the corresponding day on the calendar, giving us some visual accountability.


Now, we also wanted our goal to be achievable. So that's the A of our SMART goal. Because sometimes, life gets in the way of our plans. And there are very busy days and days that we may not feel well. We may feel a little under the weather or we just may lack energy on a given day.




So we thought, in order to really make it realistic and achievable, that we would put five give-me days in each month. So these are days we can skip exercising if we want, but still meet our goal as long as we don't skip over five days in a given month. So five is the limit.


And as we go on and we really enjoy exercising, maybe we'll take that down to four or three. But we want to make our goals realistic and achievable right at the beginning. So we said, okay, five days a month, we don't have to do it. And then, at the end of the month, if we've only skipped five or fewer days, we've still met our goal.


We want our goal to be relevant. I think this one is easy for new year's resolutions. I mean, the reason that we come up with a new year's resolution is because something is important to us. But when you're dealing with SMART goals, you want it to be relevant. And this one is, because it supports our desire to live a healthier lifestyle.




And then, finally the goal is time bound. And what that means is we're going to actually say, let's do this for a few months. Let's maybe make it six months and then if it's going well and it's become a habit and we like exercising every day, maybe we'll make a new goal. Maybe it'll be for the entire year.


But the other thing that time bound helps is a reward system. Because pediatricians are kids at heart, and kids do well with rewards, and so of course, I have to put in a time-bound reward. And for us, that reward is if we achieve our goal over the course of the month, at the end of the month, we get a little extra cash in each of our personal spending account.


So we have a household budget and, in that budget, we have a little discretionary amount of money that each of us can spend on what we want. And you don't have to convince the other that this is a good buy. You're just allowed to use it, as long as it's something that's, it can't be a bad thing, but you know what I mean.




So you come up with internal rules. And that's how we manage the budget in our home. And so, as a component of our household budget, we just get a little extra in our spending account if we met the goal for the month.


So we're working to stay healthy, yes, but there are some fun and motivating extras like competing with my wife, coloring in a calendar space, and a little cash reward if I meet my time-bound monthly goal, which by the way, we did, both of us meet during the month of December. And we are well on our way to meeting our goal for the month of January. So go us!


And there you have it, a new year's resolution fashioned into a SMART goal and working out pretty well so far here, on January 12th. If you have a new year's resolution, I would encourage you to make a plan surrounding that goal, including some incentives to help you out along the way.


Of course, this is something you can also help your kids spell out as they make their own goals and plans for the year. You can also do it as a whole family. Again, the opportunities are limitless and you can really get creative on how you make your goal SMART.




And I'm going to hold myself accountable to you, the PediaCast audience and let you know how it's going as we journey down the road of 2021.


All right, let's wrap up the show intro. I do have a few quick housekeeping items for you. Don't forget, you can find PediaCast really wherever podcasts are found. We are in the Apple and Google Podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


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And we have that handy Contact link over at pediacast.org if you would like to suggest a topic for an upcoming program.


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Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.


So, let's take a quick break. We'll get Dr. Steve Hodges connected to the studio. And then, we will be back to talk about potty training, bedwetting, and other pee and poop problems. It's coming up right after this.






Dr. Mike Patrick: Dr. Steve Hodges is a pediatric urologist at Wake Forest Baptist Health in Winston-Salem, North Carolina and an associate professor of Urology at Wake Forest School of Medicine.


He helps families troubled by potty training, bedwetting and other pee and poop problems in his clinical practice, through his Mop, or M.O.P series of books, and on his website, bedwettingandaccidents.com.


These are the very problems he's here to talk about today. So let's give a warm PediaCast welcome to Dr. Steve Hodges. Thanks for stopping by.


Dr. Steve Hodges: Thank you very much for having me. I really appreciate it.


Dr. Mike Patrick: Yeah, great talking to you. I think one question right out of the gate that a lot of parents are going to be interested in hearing the answer to, is when is the right age to start potty training? When should that process begin? 




Dr. Steve Hodges: So as we get into, as we discussed it, one of my big concerns in these kids and one of the causes of accidents is withholding or not going on time. So although I don't like to be, I made a point in my career where I don't like to be too dogmatic about ages, because a lot of stuff I think is probably more genetics than timing. I do think that if you're trying too young, it's hard to know if the child has the maturity to eliminate on time.


And so, what we've kind of agreed upon amongst our studies is that if you’re not potty trained by four, there's probably a probably a problem. And if you're potty trained before three, you have a higher rate of issues.


So somewhere between three and four, typically three and a half, children have the physical ability and the mental ability to kind of navigate through potty training.


Dr. Mike Patrick: And as you talk about holding, what are the consequences of starting that process too soon, not only in terms of just failure and frustration because the child is not really ready to do it. But are there long-lasting problems that can sort of creep in down the road if you start too soon?




Dr. Steve Hodges: If you can't communicate with a child, it's hard to communicate with a three-year-old, but you can talk and kind of get a feel of how they're experiencing things. If you can't communicate with them, you won't know if they need to go or they're not, or they can't.


It's very easy to train a young child, one or two-year-old to withhold, to stay dry. But to teach them that yes, you can stay dry but then you should empty when you feel it in a timely fashion, that is very difficult. And I feel like a three-and-a-half year-old can tell you, "Oh, I tried to poop and I couldn't." And you can intervene. The two-year-old, you may never know. And it won't present itself too much later when they have problems with controlling peeing and pooping accidents.


Dr. Mike Patrick: So if they start holding at a younger age and you're not quite sure that that's what they're doing, then as they get older, it would just become a habit and becomes more difficult for them not to hold anymore. And then they get too full and it runs out?




Dr. Steve Hodges: Yeah, basically, what we'll talk a lot about when we talk about our books is that just not pooping on time leads to accumulation of poop at the end of the colon, rectum. It stretches out the rectum, then they're unable to empty well and that dilation of rectum has some effects on bladder function, colon function that leads to most of these problems.


And it kind of sneaks up on you. It may happen over months to years. And then, by the time the accident shows up, it takes another few months or years to resolve it all. So much better to prevent that instead of trying to cure it later.


Dr. Mike Patrick: Yeah, that makes sense. So then, how is potty training best accomplished? What's the process looks like that's going to yield the quickest results with the less headache?


Dr. Steve Hodges: Yeah, the way I did it and I think you know there's a million ways to potty train, obviously. A lot of people like kind of the bootcamp methods, where they're quickly done. But I believe in kind of like the laid back approach.


One of my biggest influences in my research was Dr. Sean O'Regan who's a retired physician in Arizona. And he said several brilliant things, but one they told me, I remember, he said, "Potty training, it's not an activity. It's a physiologic process like sleeping or walking."




You don't teach a child to walk. You don't teach them to sleep. You put them in the right environment and you give me them the right tools so they can do that on their own.


And the same applies to potty training. You make sure the child is developing normally. They have regular bowel movements. They don't have over-dilated rectum. And then when they're ready after about three, if you present that potty to them, they're likely just through mimicking, start peeing on the potty and sort of defecating or pooping on the potty as well.


Now, pooping is more difficult and we have a little bit more interventions needed for kids that kind of withhold and we can talk about that. But if you keep them free of constipation, meaning they're pooping freely and don't even think about pooping too much, they tend to go on the potty very easily after about three and a half years of age.




Dr. Mike Patrick: I think it's interesting that you mentioned they're thinking about the character of their poop even before you start potty training. Because I think for a lot of parents, the first thing you think about is just having them go on the toilet. You don't really even think about the character of their stools.


By why is having a mushy stool daily really important before you even begin potty training?


Dr. Steve Hodges: So the root of all evil in urology is constipation. And constipation in kids means it hurt to poop so I didn't want to let it out. And so if you learn that habit, just like any bad habit as a child, you start withholding, then your first instinct when you feel the urge to poop is to guard or just squeeze your sphincter and stop that instead of just going regularly. And like any bad habit, that's very tough to break.


So if you immediately intervene and help them with whatever intervention to keep the poop mushy, pooping doesn't become painful. It's just another activity they're doing during the day.




I like to compare a kid that maybe has constipation that's in diapers and needs to poop and goes, hides in the corner, and holds on to the wall that they're straining versus a child that has a soft poop that that's just playing, kind of pauses for a second, poops on their pull-ups and then keeps on playing. That's a much more healthy pattern and leads to much less issues down the road.


Dr. Mike Patrick: And then, what about the role of deadlines? Here in the pandemic, we don't have to worry about this quite so much, but pre-pandemic and certainly when the pandemic is over, there are some expectations for certain daycares or pre-school classes for kids to be potty trained before they can go.


And so, sometimes, there's deadlines and expectations and pressure. That can really cause a problem with potty training as well, right?


Dr. Steve Hodges: Yeah, I have published quite a bit or written a lot about the danger of deadlines just because I think some kids aren't ready. Especially since most of the deadlines are before three and we don't really like training before three. So I feel for preschools and so forth that don't like to have to deal with changing these children. But I do think that if you have a child that's not ready and you force the issue, you can be setting them up for trouble down the road.




If a student goes into the preschool environment, if you could give them some leeway till about three and a half, they will likely be able to train. And then, if you have these children, I get a lot of complaints, well, they may show up four or five and not be potty trained.


If they're showing up that late, then there may be a good reason why they can't control it, not usually evaluated by a physician. But I think the better deadline should be maybe four because most four-year-olds if they're healthy can control that process.


Dr. Mike Patrick: Yeah, absolutely. So you may want to pick a different daycare or preschool that doesn't have the strict requirements if this is an issue for your family, especially that three-year-old range.


Dr. Steve Hodges: For sure.


Dr. Mike Patrick: And another thing that I found helpful with my own kids is just to encourage them to go every few hours. Because kids get busy playing and they may not pay attention to urges, but just like, hey, go try. Even if you don't go, that's all right, you don't have to sit there forever. But just to give them a chance to interrupt what they're doing.




Dr. Steve Hodges: Yeah, I really like that. I like some people every time they bring up, "The child says no, and it's a power struggle," but I just like the concept there that it's top of mind. Because a lot of parents will, they potty train their child, then they're done. They're just like, "I guess they'll be fine."


And they troop to my office, I say, "How often they poop?" And they have no idea, or how often they pee. And they just know they pee on themselves or urgently, but they don't know how often they actually go.


So with my kids, it's probably a little bit too much neuroticism. When I'd come home from work, it's the first thing they would tell me is "Daddy, I pooped." And I was like, "Okay, great." But I think somewhere in between there is a good knowledge that you should talk about it, just like you should talk about what they eat and if they're active in school. You should talk about their elimination habits because they are very important.




Dr. Mike Patrick: Yeah, absolutely. As we think about constipation, are there foods that can help potty training go better to just try to keep those stools loose?


Dr. Steve Hodges: Yeah, in my first book, we talked a lot about diet. And, obviously, in the modern diet, we both have kids, it's so hard to get them to eat healthy food. And there's lower fiber content and there's less fruits and vegetables. There are less raw foods that tend to promote regular bowel movements.


We talk about the importance of that, but what I've seen is a lot of… And I don't want to undermine, the diet I can say is the baseline. You have to have a good well-balanced diet to get nutrition and to have a healthy child. But a lot of problems I see are in well-meaning parents that track me down, and they've already done a really good diet, and these kids are still getting backed up. And that's when I've come into my conclusion that a lot of this is just genetic and personality based.


And even with the best diet, some children can withhold, but that does not mean that you should get your child whatever they want. They need to get a regular diet. And if they were eating a perfect diet, maybe, you know, which might be impossible this day and age with raw fruits and vegetables and a large amount of fiber, maybe these issues wouldn't exist. But it's very difficult to get to that level in modern parenting.




Dr. Mike Patrick: Yeah, absolutely. And then, before we leave the basics of potty training, one other thing I wanted to mention that I did find interesting in your book is that you really need to squat to poop effectively, to get all of the stool out. And so kids on an adult toilet with their legs hanging down, that's not really squatting, is it?


Dr. Steve Hodges: No, it's not. And actually, I guess the perfect way, honestly, would be with their bottom hovering, like in a full squat, which is hard for us, but kids are more flexible. So if you can have their feet elevated when they squat without their bottom touching anything, that would be the most anatomically appropriate position. But since that's difficult to achieve, simply raising the feet on the stool or squatty potty, whatever, is the next best thing.




Dr. Mike Patrick: Absolutely. And then, what about motivation? Do you have to wait for kids to want to potty train? Or is there a way that you think from a developmental standpoint, they're ready?


I have a three or four-year-old, and I really think that they can do it. But they don't show any interest at all. And yet, maybe I am facing a little bit of a deadline, but yeah, they don't want to push it and rush them. Like how can you motivate your kids to want to be potty trained?


Dr. Steve Hodges: The only thing I've run to, I think if potty training is one of those areas where peer pressure is a good thing, just a couple of places like that, where all their classmates or friends are potty trained. And I don't support shaming anyone, but if you mentioned that all these other kids are doing it, they tend to really act on that.


The only issue I've had with three and four-year-olds is that peeing on the potty happens really easily. I found if their colons are proper functioning, they've not had constipations ever, but pooping they get so comfortable as they're older. The one downside of training a little later is they're going to get a habit of pooping in pull-ups whether standing or in unique position or just kind of unique location.




And shifting to pooping on the potty is very difficult. And we do have several strategies for that, but that's where they need some encouragement. "Okay, you can poop in your pull-up but you need to do in the bathroom." And that kind of ease them into the toilet. And once they go, they do fine. But that's the only issue I've had. In terms of motivation for peeing, I haven't had much difficulty at all.


Dr. Mike Patrick: I know there are some books out there about kids who are going to the process of potty training, and you know how kids like to read the same book over and over again. So sometimes, you can get a story and the kid likes and relates to the character and hey, they're doing it. And so, you can leverage that sort of thing.


And then, of course, sticker charts reward systems can be helpful. But you really do want to not get angry or upset or discipline a child because toilet training is not going well, right?


Dr. Steve Hodges: I cannot stress that enough. I don't know how we can get that, it's a good start, these kinds of programs. But I follow childhood stories related to pediatric incontinence, and every one of them is… It's too many, obviously. It breaks my heart, it's just really prevalent.




I wish we could do a better job educating parents that if a child can't potty train, there's probably a good reason. It's not their fault. They're not being defiant and they're not doing it on purpose. I've never seen a child peeing or pooping on themselves on purpose. So if we can get that message out there, I think we've done a great job today.


Dr. Mike Patrick: Yeah, absolutely. Let's pivot to problems after potty training. So what causes daytime accidents with urine after potty training is accomplished? So it's a condition we call enuresis. It's the medical term for it. But what causes that?


Dr. Steve Hodges: So I'm going to deviate a little bit from the standard teaching but this is where my research has shown me. And Dr. O'Regan would agree and I think it's where all this is heading, is that at the end of the day, if you have an accident while potty training, you're having what we call an uninhibited bladder contraction or a bladder spasm.




Your bladder basically squeezes when you don't want it to or you can't control it. And that happens from this rectal dilation. And there are a lot of other theories of how the pelvic floor works. But at the end of the day, you have to have this bladder contraction.


And what we find, and what we can't replicate is that as the rectum stretches, it will stimulate the nerves that go from the bladder to the spinal cord that sends bladder fullness. And they can actually cause almost like an infantile bladder spasm like in babies, they just void by reflex. They don't pee willingly. It just happens naturally.


And so, this stretching reflex from the rectum will go to the spinal cord and send the impulse right back to the bladder and have the bladder empty. And the child never even felt it in their brain. It happens without them knowing.


So although there are some rare conditions that we can get into that can cause leakage that aren't related to constipation, those are very rare. Ninety-nine percent of the time, this rectal dilation is the inciting event. And if you address it, they do much better.




Dr. Mike Patrick: So in younger kids, the bladder contracts and they just go and have these accidents. In some older kids and even in some younger kids, they can recognize, "Hey, my bladder is getting ready to contract," and so they will have to run off to the bathroom. And so you have a kid, you got to dinner with the family, and they need to go to the restroom four or five times during the course of the meal. And you start thinking, is this a behavioral problem? But really, it could still be constipation is the root of that sort of an issue, right?


Dr. Steve Hodges: Yeah, I've seen now, the nerves, it makes sense when you look at the physiology, and it's amazing. It's not gotten kind of more coverage. But all the nerve that control bladder pain, of sensation of fullness, bladder contractions, all run right around the rectum. And so stimuli in those nerves in different ways can give you all those symptoms.,




And I know it's frustrating for parents because a child may need to pee frequently, but there's definitely cause. And each time they feel it, it is real. And then, also, it appears to parents that the child waits the last minute to urinate because they're like rushing. But again, when you have this constipation, the reflex contraction happens so rapidly. They don't have the leeway or the time to let it gradually rise like we do. It goes 0 to 100 right away.


And so, I have seen so many kids where the parents blame their behavior on it. Say, they don't go to the bathroom on time, but we actually fixed the colon, fixed the bladder, and I mean, the reflexes and they void normally. They have normal patterns. And that's kind of the natural state, when you can restore things to where they're supposed to work, the kids do fine.


Dr. Mike Patrick: Absolutely. So this is kind of like your arm hurts when you have a heart attack. There's nothing wrong with your arm. It's just that these messages are coming by way of nerves to the brain and the brain has a little trouble telling where those impulses are coming from. So you might feel pain in the different locations. It's kind of that sort of thing, right?




Dr. Steve Hodges: Yeah, it's like a referred thing. It's so funny. And so one of them, let's take the frequency alone, right? So you're stimulating for whatever reason. Your colon, your rectum is stimulating the nerves that make you sense the urge to urinate. So you feel like that you have to pee on time.  So to you, it's real. And you go to the bathroom every ten minutes.


But then, all these kids they sleep through the night. And so, because they're unconscious, that doesn't happen. And so, if you actually look deeply in these problems, you'll see that it makes most sense if you follow our model.


Dr. Mike Patrick: Yeah, absolutely. Now, some parents will say, "Well, but they've had a soft bowel movement every day. How can my child be constipated if they're going to the bathroom and making poop?"


Dr. Steve Hodges: Yeah, and that's a great point. It's mostly my fault for using the term constipated. I just didn't know what a better term would be. But again, to bring up Dr. O'Regan, when I first spoke with him. I said, "These kids aren't really constipated, Dr. O'Regan." And he interrupted me, "Yes, you're actually right. They're incompletely emptying their rectum."




So that's the deal. So to bring another hard analogy, you know, from med school, left heart failure. So if the heart gets so dilated, it can't eject well. You have this poor ejection fraction. The same thing can happen to the rectum. You get so dilated. Now, it can't squeeze well. And not only does it not able to squeeze well, but you confound the factor.


So if you can't squeeze your rectum that way you're supposed to poop, you just relax your sphincter and the rectum squeeze and everything happens.  You don't actually do anything, just like when you urinate. If your rectum can't squeeze, you relax, nothing happens, so then you start bowel salving. You start squeezing your belly muscles and now you can't relax your sphincter because you got your muscles all tight. So it's all this kind of intertwined muscles that when one doesn't work, you try to augment with other muscles and that makes it even harder to go.


Dr. Mike Patrick: So even if kids are having a bowel movement that's soft every day. If they're not completely emptying their rectum and there is stool left in there that they could have gotten out, then this could still be the problem.


Dr. Steve Hodges: And most likely, most of these kids, they probably have the urge to poop three or four times earlier in the day and they put it off. And so you do that every day.




I'd like to tell parents, imagine a kid was emptying an assembly line with product delivered every minute, but they just took a 60-minute break and when they got back, they just went back to their previous schedule. There's still going to be 60 boxes out there. So you have to know that if they don't go on time, it takes a little bit more poop to get out, to get things back to normal.


Dr. Mike Patrick: And then, does that same process also account for accidents during the day with poop? So now, we have a medical condition we would call encopresis. So stooling accidentally, is that also caused by constipation?


Dr. Steve Hodges: Yeah, for sure. When I first kind of gotten into this field, I'm not a GI doctor by any stretch of the imagination. But I do a lot of bowel care due to the facts we're discussing. And I was seeing these kids with encopresis and I literally sat down with the GIs from my hospital and said, "Are there any causes for this in healthy kids other than overflow incontinence?"




And they said no. And I said, "Well, you know, why aren't we doing enemas for these kids?" which we'll get into. But yes, so basically, if you fill up the rectum full of poop, and your sensation to a full rectum is the stretching, but you stretched it as far as it can stretch, then the internal sphincter, the thing that hold in the poop, and we're just sitting here, dilates. And then, you can't feel that because it's already stretched and so you have no instinct to withhold it, and the poop just falls out. So it's a difficult problem.


Dr. Mike Patrick: Yeah, absolutely. And we'll talk more about the treatment of constipation. I don't want to steal our thunder that's coming up. But it's easy enough to try treating constipation if that makes the problem go away, then you know that that's what it was. But then you might have to explore other problems if that's not helping.


Dr. Steve Hodges: For sure. Again, just as we're saying, you can't really diagnose constipation with how often they're pooping. You can't assume it's been treated just because you have them pooping more, for sure.




Dr. Mike Patrick: And so then, what do you do then when you have kids who were having accidents after they've been potty trained, whether it be with urine or with stool? I guess you could try treating constipation, but probably your best bet at that point is just talk to your doctor and see how they would recommend you treat the constipation.


Dr. Steve Hodges: Because I think the important reason, number one, is I don't like when some physician says, "Oh, it's just a phase," because there may be a real medical condition even beyond constipation that's causing this. So it's a good reason to see your physician just to make sure there's some rare conditions such as a spinal cord disorder that we missed. There's some congenital problem that we missed.


So just a once-over, a good physical exam to make sure there's nothing obvious that could be causing this. And boys sometimes, you get an ultrasound of the kidneys and bladder because there's a rare condition they can be born with, maybe missed prenatally that can cause these problems.


But once that's done, treating constipation under that direction of physician is the way to go. We'd like to get some imaging as well for the bowels if the parents aren't convinced. An X-ray sometimes will get everyone on the same page and show how significant the constipation is and also give us a baseline so we can measure progress.




Dr. Mike Patrick: And then, what about accidents during the night? So bedwetting, is that also related to constipation?


Dr. Steve Hodges: Yes, so that's my big… I got to get all this work published in a way that's like it's palatable for everyone. But my belief and a firm belief here, is that as your rectum dilates, you get a progressive increase in the bladder reactivity. And that can vary by some physicians and so forth. But if you have a low-level bladder reactivity or bladder spasm, then you cannot stop them only if you're unconscious and that's what bedwetting is.


As during the daytime, you may not have any trouble at all because you can feel the urge and withhold it. So low-level bladder reactivity leads to bedwetting, and that only takes a small amount of rectal dilation and that's the hardest to treat. And then, as that progresses, you start getting daytime symptoms and daywetting and then encopresis. And that's the typical pattern we see.




And so, yes, although there's numerous things published about bedwetting hormones and development we found, but if you look for the constipation and diagnose it, you can treat them and cure them at a very high rate.


Dr. Mike Patrick: That's a really good point. And you know when you think about some of the other explanations for bedwetting that are out there, they can still play a role. But if you have that overactive bladder at baseline, then those things are going to make that overactive bladder more significant.


So example, if we say some kids sleep deeper than others, well, they're less likely to wake up when their bladder is squeezing. We talked about stress. But maybe if you're stressed, you're also sleeping deeper or those kinds of things. You also hear smaller bladder, although that's probably not really a reason.


Dr. Steve Hodges: Yeah, and your point is well taken in that if you take a kid off the street and they show up in the clinic with bedwetting, and you say we'll try desmopressin and alarm, your odds of fixing that are way higher with those tools if you're also treating constipation aggressively.




If they showed up with encopresis and daytime enuresis and bedwetting, and you give them a bedwetting alarm, your odds of success are very low. But if you've aggressively treated the constipation and you've added some augmented therapies such as medications alarm, you have a much higher cure rate.


Dr. Mike Patrick: Yeah, and then you may be able to wean off the medications and off the alarm once you get the constipation for many days.


Dr. Steve Hodges: For sure.


Dr. Mike Patrick: At what age are you worried about bedwetting. So just as we said, there's kind of a young age to start potty training, around age three? Is there an age when bedwetting would still be considered normal or should we always go after that?


Dr. Steve Hodges: Yeah, again, this is slightly controversial as well, but Dr. O'Regan, he first got into this research by curing his own son. His son was only four. There is a high rate of bedwetting, up to 20, 25% of kids up to the age of five. Most people say you don't start treating till then because it drops off at that point.


But I think the big issue is that bedwetting or bladder emptying when you're unconscious is never normal. So once they're potty trained, and you've taken care of other factors like… Because if a child is only three or four, they may not care if they pee in their bed and they may be too scared to get out of bed. They may not be able to get out of their bed. And so, those are factors you have to take in consideration.




But if you have a child who's old enough to get out of bed and go to the bathroom on their own and there's no factors inhabiting that and they're emptying their bladder while they're unconscious, you can fix it at that age for sure.


Dr. Mike Patrick: And I think that's an important point to say it's not really ever normal even though you may be more aggressive about doing something about it when they get to be over four or five years old. But then, when we say is it normal, a lot of families will say, "Well, but it runs in my family. So it is normal for us." Like a parent will say, "Well, I wet the bed. And my grandparent wet the bed." Does it really run in families?


Dr. Steve Hodges: Yes, that's so interesting. And then, they'll wait until maybe the age in which they outgrew and I think that's normal. Like somehow humans evolved bedwetting as some kind of trait. But I think that it definitely runs in families.




But what I think, there are two things that run in the families, number one, and they're related, the propensity to constipation. So some people are just likely, whatever makes up their brain and their personality, that makes them likely to hold or their ability to process food or whatever, that runs in families for sure.


And then, we know subsets of population, their bladders respond differently to constipation. Like there are a lot of kids out there, they're really constipated. They pee and poop normally, you would never know. And so, but certain people, their bladder are really sensitive to these retrodilation.


There are animal studies and human studies that show that variation. So that is definitely inherited. If your bladder is likely to respond to constipation with bedwetting, that will run in your family.


Dr. Mike Patrick: It's a really good point. And I think that a lot of families, you think, "Well, I went through it. My parents went through it. This is just something in our family." But for you and for grandpa, their constipation wasn't treated when they were younger. And so, if we change things a little bit and treat the constipation now, maybe, we can prevent it and make these kids' lives a little bit easier.




Dr. Steve Hodges: Yeah, and you know as well as I do that the psychological ramifications of bedwetting, sometimes, self-esteem, they can't go to sleepovers. And sometimes, you wait, you want to be patient. Next thing you know, the child is 12, 13, 14, 15. College is approaching. So I really do encourage families to jump on this early.


Dr. Mike Patrick: So you're a urologist and you said you're not a GI specialist. And yet, when something in your field is a really significant problem for families like daytime accidents with both urine and stool and also bedwetting, you have to become a GI specialist to some degree in terms of treating constipation, right?


Dr. Steve Hodges: Yeah, and the funny thing is when I first figured this out or kind of put this altogether, I was like, okay, I guess my job is done, I'll just send them over to GI and they will be fixed. And I will send them all to GI and they will send them right back saying these kids were pooping fine.


And so, I realized, number one, GI doctors do a lot more than constipation. They have always complicated rare disorders that they're spending their time and mostly interest in.  And functional constipation to them is not still kind of, I guess, routine that they just use whatever tools they have and don't treat too aggressively.




My goal, to restore normal rectal terms is different than a GI doctor's goal. So it's actually better that these kids get treated by urologist because we have separate kind of end points. And I've learned a lot from GI doctors and they've kind of guide all my therapies. But I've taken that knowledge and applied it in a way that's different than they do it, and I've had better success.


Dr. Mike Patrick: And so a lot of the kids that you see, I would imagine, don't necessarily have any abdominal pain as part of their constipation, whereas the ones that get sent to the GI folks, a lot of times, they have abdominal pain associated with it. So that's another thing.


Dr. Steve Hodges: Yeah, for sure. And then, I use X-rays a lot and that's a whole debate. Can you diagnose constipation in X-rays? And that's more of a semantic thing, too, right? Because can you diagnose functional constipation? No. But can you diagnose a dilated rectum? Yes, you can.




Dr. Mike Patrick: And I will point out, because we do have some medical providers who listen to this podcast, so pediatricians, family practice doctors, nurse practitioners. And in my experience, a lot of times, when you get those X-rays, the radiologist idea of constipation also may be a little bit different than ours.


Dr. Steve Hodges: Oh, that's so true. And you're coming from a place where they may be more in tuned to it but here, it's always, they've learned to say stool in the rectum. But originally, it was normal X-ray. And so parents should say, "They said it was just normal." And yet, actually, we looked at the… Because for them, they're looking at the bones, the gas, and everything looks fine.


Dr. Mike Patrick: Yeah, if the radiologist makes a comment about how much stool there is, then you know there's a lot of poop.


Dr. Steve Hodges: There is a lot of poop. I say that every time. I said, "You know, you're backed up because the radiologist mentioned it." That's funny.


Dr. Mike Patrick: So in terms of constipation, how common is this, especially here in the United States?


Dr. Steve Hodges: I think it's neck in neck with allergies in terms of the most common diagnosis in kids and, probably, I'm sure you see this as well. And again, it's presented like 30%, maybe 50%. But if you actually look at these kids the way we do, it's probably close to almost everybody. Like what child, what human kids poops exactly on time every time? And I would say zero.




And so, I would say most kids have a nature of being a human child delayed defecation at some point. And whether or not that causes problems, that's another issue entirely.


Dr. Mike Patrick: Why is constipation so common in our country?


Dr. Steve Hodges: Well, we discussed in our book several reasons. Maybe the rest are potty trained or kind of modern diet, low fiber content processed foods, school bathrooms where kids are afraid to go. It's just kind of a buttoned-up society where it's a burden to get to the bathroom. You may not have permission to go. It may not be clean.


And a lot of it I think is just throughout the world even, just the nature of a highly evolved mammal with the brain that can decide that you don't want to go to the bathroom right now. You'd rather put it off. And it's amazingly common. And in every country, I've kind of look at it, I found it.




Dr. Mike Patrick: So what then are the symptoms of constipation? And I think this is really important for parent, especially if you have a kid who is having a bowel movement every day. They go in, they have a stool. And so what can give you a clue that constipation is really going on in your child?


Dr. Steve Hodges: So yeah, I think the important thing to point out, is if I diagnose a child with constipation but they're doing okay, you know what, that's a dilemma. You know, how are aggressive are you? You don't have to be too aggressive.


So I look for mostly symptoms such as accidents. If their child's having bedwetting, daytime wetting, encopresis, they are constipated and they need help. If you're trying to prevent this, look for signs early on. The biggest signs, hiding to poop, painful poop obviously, rare poop. But I think the most consistent finding that most parents mention and they don't realize is associate with constipation is large poop.


So if your child is doing this humongous poops and parents like to joke about it, "Oh, it's the size of his arm," that is not a good sign. That's a sign that basically they withheld pooping for long enough that the entire rectum got so packed up with poop and when they let it out, it looked abnormally large. And that's the sign of delayed emptying which is the root cause of all these problems.




Dr. Mike Patrick: Yeah, and I love that you said one symptom are these accidents and bedwetting. You can look at those as primary problems and then we're saying, well, constipation leads to them. But when you flip your thinking and think, well, these are actually symptoms of constipation, then  I think for parents, that really sheds some light on.


Dr. Steve Hodges: Yeah, and it's great. In that way, you use okay, this is actually a medical condition, not like my child just not wanting to be dry. It kind of reframes in a better argument.


Dr. Mike Patrick: Yeah, and I think that's helpful for the kids, too. Because then their parents are going approach this differently than when they think it's just behavior, that there really is condition that's behind it.


Dr. Steve Hodges: Yeah, and then they started thinking back, "Oh, you know what, yeah, I used to have trouble pooping, too." And it makes a lot more sense for sure.




Dr. Mike Patrick: So I guess then the big question is as we think about constipation, and it causing all those accidents and bedwetting, how do we treat it? What's the best way to treat constipation?


Dr. Steve Hodges: Yeah, that's the funny kind of journey is how I've gone along in learning from GI doctors and a lot of people at Nationwide is that I started out with MiraLAX like anybody would, right? It's like, "Oh, I give them MiraLAX," and I found the failings of MiraLAX. Although I do think MiraLAX, you know, or some type of osmotic laxative is very useful early on to keep children pooping regularly.


When I found Dr. O'Regan's work, he used primarily and only enemas. It made so much sense to me that you have this dilated rectum. The problem is at the end of the colon. Let's go right to the root of the problem and so we started this M.O.P protocol, which means the Modified O'Regan Protocol.


So Dr. O'Regan had what started off as a bedwetting treatment which is enemas. One a night for a month, every other night for a month and then twice a week for a month. And he had a very high cure rate, above any of the published cure rates for any other therapies.


As we've gotten deeper into the study, we've got more severe cases. We've started addressing daytime wetting and encopresis. We had to modify that protocol and basically extend it. We vary it.




And so I went from MiraLAX to enemas and combined MiraLAX with enemas. And then, after a recent trip to Nationwide in learning more about Ex-Lax, it's something else I was afraid to use, I've used a lot more Ex-Lax.


And so now, we have combinations of therapies and we just tinker with them and follow their X-ray exams and how empty they're getting until we find the perfect combination of enemas and oral laxative to get children empty. And when we're doing that, they get better most rapidly.


Dr. Mike Patrick: A couple of things come to mind. So you mentioned MiraLAX and it is an osmotic agent. What does that mean?


Dr. Steve Hodges: So basically, it's perfect for kids because what's going on with kids? They put off pooping. So the poop is just sitting in the end of the colon and then water is always being drawn out of the poop in the colon. So it gets drier, drier, and drier. And then it's harder to empty because it's harder poop.




MiraLAX holds water in the poop in the colon. And so, no matter how long your child waits, when it comes out, it will come out soft. So that the osmotic laxatives are ideal for the behavioral problems in kids which are delayed emptying. Because no matter how long the delay is, it still comes up soft.


And also, as you know, when poop is a little softer, you have more urgency to go. So if there's more urge, it's hard to withhold it. So MiraLAX, lactulose, a lot of  magnesium-based laxatives, magnesium citrate and hydroxide all do the same thing. They hold water in the colon via osmosis, so the poop stays softer.


Dr. Mike Patrick: For moms and dad if you think back to your basic biology science class and you'll learn that osmosis is where water travels from where there's less particles to where there's more particles across the semipermeable membrane, just that MiraLAX is particles that the intestine does not absorb. And so they make their way down into the colon. And so now you have more particles and the water moves in and softens that stool.


Dr. Steve Hodges: Yeah, it's perfect. Couldn't have said it better.




Dr. Mike Patrick: Now, I would imagine when you tell a parent that… And the enema thing makes sense because when you think about MiraLAX, you're treating from the top. But the problem is at the bottom, and you want to get that stool out of the rectum. And so that's going after that stool since that's where the problem is makes sense. But I would imagine that parents are a little hesitant to give their kids an enema on a regular basis.


Dr. Steve Hodges: Yeah, it is tough. Some people can try MiraLAX first and I'm totally open to that. It can work for some kids, but a lot of parents come in to my office, having tried MiraLAX for years. And often, as you know, encopresis, if you're really impacted and you just keep some MiraLAX from behind that, it may leak around and make the accidents worse, because it's harder to hold in a loose poop if you fall than it is hard poop.


So they've been through the ringer and most are open to it. And the kids do surprisingly well. Obviously, there are some people that refuse to do them. But as they start doing enemas, as they understand the process, see the X-rays and get moving, and the children actually feel relief when they get empty, they can become really cooperative of the protocol and do very well.




Dr. Mike Patrick: So it's getting over that initial thought of it. But when you think about a child then succeeding and being able to not have accidents both with urine and stool and not bedwetting. And you have an older kid even who's going up to college and they're still having bedwetting, that can cause a lot of anxiety.


And so, maybe just the fact that this is going to get better can be that motivation that you need to get past the hurdle of doing the enemas. What does that look like then? I mean, most parents I think have heard of an enema, but from a procedure standpoint, it sounds messy. Like how do I go about doing it? How do you explain the actual mechanics of doing an enema in kids?


Dr. Steve Hodges: Yeah, I actually had some parents hand it to me and be like show me in the clinic, in the room. And so you want to do it in the bathroom because the urge to go can come on pretty quickly. I always told a joke, don't send me any carpet cleaning bills because I don't want to…. And so you want to do it in the bathroom. If there's small child, you can put them over your lap. If they're larger child, they can lay on their left side, because that's where the colon kind of bends toward.




You put plenty of lubricant, Vaseline, or Aquaphor on their bottom and the tip. And it's simple insertion all the way and squeeze and take out. And once it goes in, the kids do fine. They're obviously tough to relax, but I've done them to my own kids. I'm sure we all have. And I do well with them. And the urge hits them right away. And they kind of look at you funny. And they're on potty and go.


And some huge outputs, some smaller output. It's not going to be any one day that's going to get it all out. But if you do it daily, slow and steady wins the race, and you break down that impacted poop and get them empty.


Dr. Mike Patrick: And then, do you do this with them lying on the floor? Do they have their butt off in the air? Are they sitting on the toilet? What's the… I'm just trying to picture this.


Dr. Steve Hodges: I do them on their side. Well, I recommend them on their side if they're older kids. And if they're very small children, they can be put on your lap, in front of your lap just so you can kind of give them some comfort via that. But on their side has been best for me and then can get up afterwards. That way, they get it in easy.




Some kids, as they get older, they do it themselves. They can do it right on the toilet if they want. You don't want to just… There's this little bit of a waiting period where you want to kind of start working. So you don't want to just spit it out right away. But there's no real reason to fight the urge, the urge comes on strongly.


Dr. Mike Patrick: Yeah, and then in terms of product. So I don't necessarily want to promote particular name brands. But I mean, this is something that you can find that's kid friendly over the counter?


Dr. Steve Hodges: Yeah, we got into a lot of  the variation of the volume. So there's small volume. It's funny the terminology is funny. The small-volume enemas that have a single ingredient like glycerin that are called suppositories. They're called liquid suppositories. And those work really well for some kids.


Then there's your traditional kind of saline enemas that are combination fluid. They're slightly larger volume. And that might work well for some kids.

And then, there's some homemade enemas you can make with a large amount of saline and you add stimulants to it.




Now, even more confusing between the suppository and enema, because most people consider suppository solid versus enema being liquid. The saline enema that you buy in the store in a bottle is not just saline, it's phosphate, a lot of ingredients. As opposed to saline enema, you may make it home which is just salt water with some additives you add.


So really important for parents to make sure they understand which one they're giving in the safety and indications of every one of them.


Dr. Mike Patrick: Yeah, so this is another reason to really do this in cooperation with your child's doctor, so they can advise you on the appropriate items to use. And make sure that you're using pediatric size doses. Is there a youngest age which you will recommend this? How far down can you go?


Dr. Steve Hodges: So most of the over-the-counter enemas allow use at the age of two. Because at the age of two, we have children that are having difficulty with constipation. Younger than that, we usually use partial bits of a suppository, a saline suppository, which is a little bit easier to kind of reduce the dose for. And then osmotic laxatives as needed. But yeah, two years old is the youngest that most published products allow.




Dr. Mike Patrick: Okay. And then, I mentioned, doing this with the advice of your child's doctor. There may be some doctors out there though who this was not really brought up like regular enemas like this during their training. And so, we can all learn from each other and this may be a concept that you introduced to your doctor. Direct them to this podcast.


Dr. Steve Hodges: That's right. Exactly right, and we have some handouts too for physicians we've made to make it easy. Because yeah, no one wants to tell a doctor, maybe tell to them to practice, but yeah, some people might not have experience with this and it's important to use it in the right way.


Dr. Mike Patrick: Yeah, absolutely. We did another podcast on constipation back. It was PediaCast Episode 292. So for folks who are interested in learning more about this, you want to get a little bit deeper into what treatment options are available for constipations, especially when it's significant medical problem and maybe causing abdominal pain and other things. I would encourage you to check out that podcast, and we'll put a link to that episode in the show notes for you over at pediacast.org.




And then, of course, we mentioned this before but I think it bears repeating that if things aren't better with constipation treatment, there may be other medical problems that could still cause daytime and nighttime accidents that we would want to make sure we're not missing.


Dr. Steve Hodges: Yeah, that's the right thing. I don't want to get blinders on and say everything's constipations because there are some significant conditions. There are just some kids that are just never able to able to withhold urine at all. It leaks continually out. There are kids that are born without an anus, so they have to have surgery and there's no good functioning sphincter.


There are children with spinal cord abnormality, spina bifida, or kids with obstruction such as posterior urethral valve. So I'm assuming for treating this constipation, that all these other conditions have been ruled out. And that's another reason to have a doctor on board, to make sure that these conditions have been evaluated.




Dr. Mike Patrick: Now, you've mentioned several times your books. Tell us about your series of M.O.P books.


Dr. Steve Hodges: Sure, yes. We have several books that we have come out with. The very first book was It’s No Accident. That was kind of like a story of how this all came about. And now, we focus mostly on books which can show how to treat these issues. And the M.O.P Book is basically the Modified O'Regan Protocol and we've had various iterations of that.


It's very interesting, you know. As I followed patients over the years, I've learned, just as you learned during your practice, I've learned during my practice and have modified it. So we have various versions, the most recent versions, the one you want to get, it's an anthology now that has our most up-to-date use of enemas, large volume, small volume, as well as Ex-Lax, which we're using a lot more of in addition to the osmotic laxatives.


And then, we had a Pre-M.O.P Book, because we found out it would be nice to prevent this from developing in children in the first place. And the most common complication we discussed is children not being able to poop when they're young. So we have the Pre-M.O.P Book which talks about treating function constipation in little children.




We have M.O.P Teens and Tweens Book because we found a lot of teenagers didn't like kind of being talked to like they were a child, which we made direct things in the M.O.P book towards a younger population.  And then we also put out a couple of books just for children specifically, Bedwetting and Accidents Aren't Your Fault, to help children understand that these accidents happen for a reason and they shouldn't be blamed.


And we also did a Jane and The Giant Poop, a little funny book about constipation that maybe gets kids thinking about pooping a little more regularly.


Dr. Mike Patrick: And all of these things can be found at your website, bedwettingandaccidents.com, right?


Dr. Steve Hodges: Yes, sir. Thank you.


Dr. Mike Patrick: And lots of educational resources including evidence-based research that you point folks to at that website. And then we're going to put links to these books in the show notes so folks can find them easily over at pediacast.org, the show notes for this episode, 481.




And we'll have links to Amazon and Barnes & Noble. And of course, you can get them directly from your website as well.


All right, well, thank you so much. This has been really enlightening and lots of great information for parents. So once again, Dr. Steve Hodges with Pediatric Urology at Wake Forest Baptist Health and also from bedwettingandaccidents.com, thank you so much for stopping by.


Dr. Steve Hodges: Thanks very much. It's been great.




Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that.


Also, thanks to our guest this week, Dr. Steve Hodges, pediatric urologist with Wake Forest Baptist Health and curator of bedwettingandaccidents.com.




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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.






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