By Steve Hodges, M.D.
If you’re a preschool teacher with a room full of potty-trained 3- or 4-year-olds, you might think: Fantastic— they’re out of diapers! That makes my job easier.
Not so fast!
Changing diapers may not be convenient, but it’s pretty easy. What’s difficult is teaching toilet-trained children to pee and poop when they feel the urge — not two hours, or two days, later. This job is terribly important, both for teachers and parents of preschoolers, but it’s often overlooked.
A child’s graduation from diapers means it’s time for parents and teachers to pay more attention — not less! — to the child’s pooping and peeing behavior. That’s because preschool is prime time for children to become poop and pee holders. Once it takes root, the holding habit is difficult to reverse and can persist for years, damaging the child’s bladder and rectum and leading directly to enuresis (daytime and nighttime pee accidents), encopresis (poop accidents), and recurrent urinary tract infections.
Even children with no history of holding pee or poop often develop these habits in the preschool years. (Why? I explain here.) So it’s critical for parents and preschool teachers to take proactive steps rather than just react to what children do.
For example, when we see kids doing the “potty dance,” crossing their legs and curtsying, we insist they head to the toilet. When we notice they haven’t pooped in a while, we tell them to try. But we don’t explain why.
Preschoolers are capable of understanding what happens to the bladder and colon when they hold their pee and poop. So let’s tell them! Likewise, teaching what healthy poop looks like should be part of every preschool curriculum. So should proper pooping posture.
As best you can, monitor your class for the subtle signs of pee holding and constipation, report these signs to parents, and urge them to take immediate action. You may need to educate parents about the red flags and the importance of treating constipation aggressively.
We adults often consider toilet training a skill that is locked in once things “click.” But potty training isn’t like riding a bike. Things can go awry two or three years after the child appears to have mastered the toilet. When your preschoolers go off to elementary school they may well be faced with bathroom restrictions or offered rewards for ignoring their bodies’ urges. That’s when problems that began in preschool really come to a head.
It can take a few years for the holding habit to catch up to children, but when it does — look out. Bedwetting and accidents are fixable problems, but in the interim are very stressful for children and parents.
Here are 8 important steps to take with your preschool class so they can avoid the toileting troubles that have become epidemic among our children. A free PDF of our Teaching the Toilet infographic is available on our Downloads page.
1. Explain what happens when you keep poop inside.
Everyone loves Everyone Poops, but what’s missing from that classic book is an explanation for why everyone poops — and what exactly happens if you go even one day without pooping.
Yes, one day! It’s a myth that some kids only need to poop three or four times a week; everyone needs to poop every day. Otherwise, poop starts piling up at the end of colon, aka the rectum. This pile-up forces the rectum to stretch. The image of a rat in a snake’s belly tends to resonate with kids.
Another way to demonstrate the point: Cut the toe off a long sock to create a tube (your intestine), and fill the tube with rolled-up socks (poop). Explain that every time you eat, more socks go into the tube. If you don’t keep pooping them out, the tube stretches. Eventually the stretched-out tube presses against the bladder and can make pee leak out. Press this overstuffed tube against a filled water balloon, and your class will get the idea!
Also explain that this poop pile-up can give you a stomachache. What’s more, if the tube is stretched often enough, it becomes droopy or floppy, the way a t-shirt gets stretched when you sit with your knees inside of it. When the tube becomes floppy enough, it can’t hold poop inside your bottom when you want it to, and poop might just fall out.
2. Explain what happens when you hold pee.
Preschoolers may not be able to grasp that holding pee makes the bladder wall thicken, the way your biceps thicken when you lift weights. However, in my experience young children do understand that when you hold pee often enough, your bladder becomes irritated, mad, cranky, grouchy — whatever term you feel is meaningful to your class.
And sometimes a cranky bladder starts hiccupping. It may even empty before you have a chance to get to the toilet. You can keep the bladder happy by peeing every time your body feels the urge.
3. Have children sit on the toilet about every 2 hours.
Most preschools do a good job with this one, setting a regular toilet schedule for the whole class. It’s definitely not enough to give children the opportunity to pee; teachers must set the expectation that every child sits on the toilet and gives it a try. (Children are much more amenable when they are told why this is important!)
Make sure there are no barriers to using the bathroom, like a toilet that’s too loud, and that there’s always plenty of toilet paper.
Try to notice whether the children in your class pee regularly. If they don’t, do your best to find out what’s holding them back. Inform their parents, so Mom and Dad can reinforce why it’s important to let pee out.
4. Watch closely for signs of constipation.
If you’re a teacher who only sees your students for 3 or 4 hours a day, can you really tell whether they’re constipated?
Actually, yes! In fact, pooping frequency is not even a reliable indicator of constipation; there are other, more telling, signs.
Certainly a child who poops three times a week is clogged, but many chronically constipated children poop multiple times a day because they don’t empty completely. So if you have a child who poops often, don’t automatically place the child in the “not constipated” category.
The signs of constipation in children can be subtle and are not well known. Many children in my practice harbor softball-sized masses of stool in the rectums — masses that went undetected even by their physicians because they focused on pooping frequency.
Here are the telltale signs of constipation in children:
•pee or poop accidents in toilet-trained children
•extra-large poops
•poops shaped like pellets or logs
•stomachache
•urgent need to pee
•frequent need to pee
•itchy bottom
•underwear skid marks
I recommend handing out 12 Signs a Child is Constipated to all parents and teachers at your preschool.
5. Teach children and parents to identify healthy poop.
Three-year-olds may not be the most reliable sources when it comes to reporting what their poop looks like, so it’s best if an adult peers into the toilet to get a first-hand glimpse. (Gross, yes!) But that’s not always feasible, and children should know what to look for, anyway.
As our How’s Your Poop? chart indicates, healthy poop is super mushy, like soft-serve ice cream, thin snakes, or soft blobs. Pudding, a fresh cow patty, hummus — all good, too!
On the other hand, poop formed like pellets, logs, or bumpy sausages indicates a child’s colon is backed up.
6. Teach good potty posture.
Children should lean forward while pooping, elbows on knees, legs apart, shoulders rounded but spine straight, and tailbone pushed out rather than tucked. Yes, that sounds like some complicated yoga pose, but it’s actually pretty simple.
Sitting in this position stretches the abdominal cavity, giving the colon more room to pump stool to the rectum for emptying. It also helps the pooping muscles relax and places the rectum in a more vertical position, giving the child the benefit of gravity.
Preschool-age boys should sit while peeing. When they stand, they often park themselves too far from the toilet and compensate by jutting their pelvis forward. In this position, they squeeze their butt cheeks and their peeing muscles are not relaxed enough to fully empty.
7. Have children poop with feet on a tall stool.
Toilet stools aren’t just for climbing onto the toilet; they’re even more important for placing the child in the ideal pooping position.
Fact is, humans were designed to squat while pooping. In the squatting position, the rectum straightens, allowing poop to exit more easily. If you’ve ever pooped in the woods, you know what I’m talking about. By contrast, sitting upright is like trying to poop uphill.
Also, with their feet dangling while pooping, children clench their inner thighs, which also makes pooping more difficult.
All preschool toilets should have a child-sized seat to help children relax their peeing and pooping muscles.
8. Teach that accidents are never a child’s fault!
It can be mortifying for children to have accidents at school, so be sure to handle accidents discreetly, and reassure children they are not to blame. A hiccuping bladder is something children have zero control over. End of story!
At pick-up, avoid announcing how many accidents a child had that day. I know: This should go without saying. But it happens more often than you might think and causes families great distress.
If a child has recurrent accidents, understand — and make sure the parents understand — that constipation is likely the culprit and that an abdominal X-ray can provide confirmation. Our children's book, Bedwetting and Accidents Aren't Your Fault, can help children understand and feel better about their situation.
Finally, when children have frequent accidents, don’t assume these kids are not fully toilet trained. Most children who have accidents have long been trained, by very attentive parents. Sending theses kids home for an extra week or two of training is like sending a dyslexic child home for an extra week of reading. It won’t remotely fix the problem (Here’s what will.) Show compassion to these families as they work to restore the child’s bladder and rectum to good health. Be patient, as this can take months.
Steve Hodges, M.D., is an associate professor of pediatric urology at Wake Forest University School of Medicine and coauthor, with Suzanne Schlosberg, of It's No Accident, The M.O.P. Book, and Bedwetting and Accidents Aren't Your Fault.