OK, here I go. I’m about to weigh in — as a dad and a pediatric urologist — on the Kristen Bell/diaper brouhaha.
To recap: In her latest episode of Momsplaining, the Frozen star mused about the differences in potty training her two girls, revealing that her younger daughter, Delta, “is 5 ½ and still in diapers.”
Naturally, the universe went berserk.
Many folks did not hold back in lambasting Bell.
“If a 5 yr old is still in diapers,” one grandma tweeted, “that is a lazy or negligent mother.”
Others praised Bell’s honesty and patience.
“Thank you for educating others about developmental differences,” one mom wrote.
Following the initial hysteria, Bell clarified that Delta only wears diapers at night, a scenario she described as “such a non issue in my family” and “pretty normal for a 5 yr old whose tiny bladder cant take the 10 hr challenge yet."
Bell’s clarification only fueled the fire. “Well yeah, she's 5,” one mom tweeted. “What about when she's 14?”
I scrolled through dozens of the tweets and can report that medically speaking, most everyone — the supportive folks and the trolls — had their facts wrong.
This includes Bell, who has my sympathy and is worshipped by every member of my family.
Let’s assume that Delta is, as Bell clarified, wearing diapers only at night. I wish I could agree with Bell and the supportive Twitterverse that bedwetting at age 5 ½ is a non-issue and is caused by a “tiny bladder” that’s just not ready for the long haul.
Alas, that’s not the case.
Bedwetting has nothing to do with an underdeveloped bladder. Nor is it related to deep sleep, a hormonal shortage, anxiety, or an immature “bladder-brain connection” — all popular misconceptions.
Bedwetting, known as nocturnal enuresis, is caused by chronic constipation.
In other words: Over time, stool piles up in the rectum, which stretches to accommodate the growing mass. The stretched rectum presses against and aggravates the nearby bladder nerves, causing the bladder to hiccup and empty without warning.
You can see the stool pile-up in a plain x-ray. You can quantify its severity by measuring the diameter of the child’s rectum. In a child who wets the bed, the rectum will measure 2 to 3 times wider than normal.
In 99% of my otherwise healthy patients, no other cause of enuresis exists. (Here, I discuss the exceptions, the rare medical conditions that should be ruled out.) Odds are, an x-ray of Delta Bell Shepard’s rectum would show it’s stretched by stool and encroaching upon her bladder.
In most cases, the constipation itself has no underlying medical cause. In our culture, chronic constipation is exceedingly common, for a half-dozen reasons that pertain to life in the 21st century.
But this does not mean a stool-clogged rectum is normal or healthy or that its consequences, including bedwetting, should be shrugged off.
I treat bedwetting starting at age 4, and I treat it aggressively, with a regimen that combines enemas and laxatives.
You won’t hear that from most physicians. Parents are typically told that up until age 7, even beyond, bedwetting is normal. The common refrain is: “Don’t worry, she’ll outgrow it.”
Now, it’s true that bedwetting at age 5 is common. About 16% to 20% of 5-year-olds (and 10% of 7-year-olds) need pull-ups overnight.
But “common” should not be confused with “normal.”
Just because a typically developing 5-year-old has a common condition does not mean the child will outgrow the condition or should go untreated.
Normalizing bedwetting deprives kids of timely treatment and allows a fixable condition to worsen, as it often does.
I have loads of tween and teen patients with nocturnal enuresis.
One mom told me: “Every year, through age 5, 8, 10, 14, the pediatrician kept saying, ‘Don’t worry, he’ll grow out of it.” Her son was 16 when he came to my clinic.
A mom in my private bedwetting support group posted: “A pediatrician told my 7-year-old not to be concerned until age 11 or 12 because there are such great pull-up-type products available nowadays.” (Ten-year-old love wearing pull-up-type products!)
Another mom lamented: “I’ve been told consistently, ‘He’ll grow out of it.’ I now have a 16-year-old who wets the bed nightly. Hoping for college. I’m so angry about how long we waited.”
I’ve heard this thousands of times.
The advice to “be patient” is, in part, based on the idea that overnight dryness is a developmental issue, a misconception echoed by many supporters of Kristen Bell.
On mom tweeted: “When your kid is on a different developmental track than others, it can feel like you’re the only mom in the world going through it and that you failed somehow.”
Bell herself tweeted, “Everyone is different.”
I relate to this sentiment! I have three daughters, and they all walked, talked, and learned to read at different ages. I know parents are subjected to a crazy amount of judgment when their kids don’t follow the curve.
But I also know that bedwetting at age 5 ½ should be treated, not ignored.
This is especially true if the child also has daytime pee or poop accidents. Research shows the kids least likely to outgrow bedwetting are those who wet the bed every night and/or have daytime accidents, too.
Health organizations like the American Academy of Pediatrics cite the adult enuresis figures — 1% to 3% — as assurance that the condition is destined to disappear. But we’re talking about millions of kids who, without treatment, will not outgrow their condition!
One of Kristen Bell’s trolls tweeted at her: “What about when she's 14?” to which Bell responded: “Don't you worry, she won't sleep in diapers at 14 :).”
In truth, Bell has no way of knowing that. Parents of my tween and teen patients held that very same belief when their kids were 5.
In one regard, Bell is absolutely right: “There's nothing ‘humiliating’ to wear diapers at five years old.”
Bell added that Delta is “confident & goofy & doesn't see anything about her beautiful unique self to apologize for."
I’m glad Delta is confident! Bedwetting children shoulder tremendous shame and blame (as do their parents) and certainly have nothing to apologize for. I emphasize this point in my children’s book Bedwetting and Accidents Aren’t Your Fault.
Bell described Delta’s bedwetting as a “non issue” at their house, and I appreciate her determination to shield her daughter from shame.
But ignoring bedwetting in a 5-year-old can have its own consequences.
Even kids who eventually outgrow bedwetting can remain plagued through adulthood by the effects of constipation. That alone is reason to treat the rectal clogging at the root of enuresis.
What’s more, children who spontaneously stop bedwetting at age 8 or 10 could have achieved overnight dryness before kindergarten, if they’d been treated appropriately. (Think of all the unnecessary pull-ups purchased and sleep lost!)
Virtually all my teen patients were wetting the bed in kindergarten and showed signs of chronic constipation by age 3. But these signs, often subtle and not well-known, were missed or disregarded. No alarm was raised, no treatment offered.
Many of these kids struggled with potty training, which, itself is a sign of constipation. And many had daytime accidents after toilet training, a giant red flag.
When Bell first revealed that Delta wore diapers, everyone assumed she was referring to daytime. (After all, most parents would use the term “pull-ups” in reference to nighttime.)
Some folks felt relieved they weren’t alone. One mom tweeted:
"Thank you @KristenBell for being so open. I was feeling horrible about my 4 year old in diapers and I am afraid he won’t be ready anytime soon.”
I don’t want any parent, ever, to feel horrible about having a 4-year-old in diapers. On the other hand, if a child this age needs daytime diapers, “readiness” isn’t the issue. Constipation is.
These kids need to be fully cleaned out every day (with enemas or glycerin suppositories) so the stretched rectum can shrink back to size, stop bothering the bladder, and regain the tone and sensation necessary to fully evacuate daily without help.
What I recommend for kids who have nighttime and/or daytime accidents is the Modified O’Regan Protocol. What I recommend for kids struggling to potty train is the Pre-M.O.P. regimen.
What I recommend for parents who thrive on potty shaming: Cut it out! You have no idea what you’re talking about.