This week, I have another special treat for you. You’re going to hear an interview that I did on Instagram Live with Dr. Liza Aguiar. Liza is a pediatric urologist, and when we asked you to submit questions for her, you sent us hundreds. In this conversation, we were able to dive deep into some of your questions about circumcisions, daytime potty-training, nighttime potty-training, and bedwetting, and her real thoughts about MiraLAX. Hope you enjoy.
Emily Oster:
Yay. Hello. Okay, so I was saying we’re going to talk about pediatric urology. We’re going to record this. I want to start, I think people who are watching this probably know who I am, or at least some of them, but I would love you to introduce yourself and tell us who you are.
Dr. Liza Aguiar:
Sure. I’m Liza Aguiar. I am a pediatric urologist, so I specialize in kidneys, bladders, the urinary system, and also genitals as well. And I’m a mom. I have a three-year-old boy.
Emily Oster:
I like the way you said that. It’s like, and I have a side project. I have a side project in genitals.
Dr. Liza Aguiar:
Yes, penises. So, I am a mom of a three-year-old boy, and that’s me.
Emily Oster:
Awesome. And you’re my neighbor. I mean, that’s not how we know each other-
Dr. Liza Aguiar:
And I’m your neighbor. Yes.
Emily Oster:
… but it turns out you’re my neighbor. So, it’s a good street. It’s a good street. Okay, so let’s start. We’re going to start by talking… We have like three buckets of questions. The first bucket is penises. The second bucket is daytime potty training, holding pee. And the third is nighttime. So, we’re going to start with penises. And I would say there’s a set of questions about circumcision that people ask all the time, and people sent in a bunch of them. And I think the first one I want to start with is just can you talk about this procedure and is it painful? Which I think is sort of almost where everybody starts. What happens and how should I think about it?
Dr. Liza Aguiar:
Sure. So, by far, the majority of circumcisions happen a few days after life, within the first few days. And what we know about pain and circumcision is that boys do feel pain even as newborns. The nervous system is relatively developed and we know, based on more objective data, their heart rates go up, they cry. So, yes, there’s some pain associated with it, but most kids tolerate it very well. And by the day after, they’re pretty much behaving somewhat normally. And most OBs and pediatricians who do newborn circumcisions offer some local anesthesia, so some lidocaine or numbing cream to make it less painful. It’s, in general, a pretty low risk procedure.
We talk about risks of bleeding and infection, but serious injury to the penis is very rare. And what happens is that most newborn circumcisions, there’s a little bit of a clamp that goes over the tip of the penis. And the foreskin gets clamped off, and then the skin just heals. So, there’s no stitches in a newborn circumcision. And typically, no bandage is necessary, just a lot of Vaseline or A & D Ointment and routine like diaper care.
Emily Oster:
One question people often come to me with is, what is the reason to do this? Okay, so what are the risks? And then, what are the reasons to do this, other than this is sort of an important part of your cultural traditions? But other than that, what are the reasons?
Dr. Liza Aguiar:
So, I get asked that question a lot. Are there any medical benefits to a circumcision? And I’ll add a little bit of context to that, because I get asked specifically about this a lot. So, in 2012, the American Academy of Pediatrics came out with this policy statement about circumcision, and it said that the benefits of circumcision outweigh the risks. And the specific benefits that they mentioned were reducing the risk of three things, urinary tract infection, penile cancer, and transmission of some sexually-transmitted diseases, including HIV. So, like, whoa, that’s big. And of course, as you can anticipate, a lot of phone calls to pediatric urologists saying, “Should I circumcise my son because of this?” And there’s a lot of anxiety and worry. And I don’t think that was their intention, but the headlines obviously promote that.
So, when I talk to parents, I address all three. So, reducing the risk of urinary tract infection, that is a benefit for the first year of life. So, after the age of one, that’s no longer a benefit. And the risk of a urinary tract infection in boys is extremely low at baseline. So, about 1% of boys get a urinary tract infections. So, I don’t use that as a medical reason to recommend circumcision, unless my patient has other congenital abnormalities or medical conditions that would put them at increased risk of urinary tract infection. So, penile cancer. Cancer is a scary word, but the risk of penile cancer is extremely low. About one in 100,000 men get diagnosed with penile cancer every year, and it’s more associated with the inability to retract your foreskin as an adult and hygiene. So, not a medical reason, for me, that I would use to recommend circumcision.
And then, transmission of sexually transmitted diseases. A lot of this data comes from countries where HIV is much more of an issue, and access to care and access to condoms is a problem. So, in the United States where access to appropriate protection is less of an issue, it’s just really not applicable. So, I would never circumcise a boy and say, “You can have unprotected sex.” That would not be okay.
Emily Oster:
All right. So, I want to get to a bottom line question about the circumcision, which it sounds like basically your take on this is that there are not a lot of positive reasons to do this. Is that right?
Dr. Liza Aguiar:
Yeah. So I leave it up to the parents. I say, “It’s a personal decision. It sometimes is a cultural one, a religious one. And if you prefer your kid’s penis to appear circumcised, that’s okay. I’m happy to do it. And if not, then that’s okay too.” So, I leave it up to them.
Emily Oster:
Yeah, it’s interesting because it is one of the things I talk about in crib sheet as an example of something where maybe there are some small costs, maybe there are some small benefits, and it’s also so personal. People say on the internet, “You should do this. You should not do it.” But the lady on the internet doesn’t know what your son’s penis should look like. It’s not really any of her… It’s not a lot of-
Dr. Liza Aguiar:
Some people feel very strongly one way or the other.
Emily Oster:
Yeah. So one thing to ask is actually, I think when I was a kid, circumcision, we were way above half, but now I think we’re down more like 50% in the US.
Dr. Liza Aguiar:
Yeah, about 60% of boys are circumcised, and 40% aren’t, and it kind of varies state to state.
Emily Oster:
If you do not circumcise, are there hygiene things you should be aware of with the foreskin?
Dr. Liza Aguiar:
Yeah, so a newborn uncircumcised penis, the foreskin is covering the tip of the penis and it’s tight. So, that’s called phimosis, and that is very normal during childhood. And with growth of the penis and erections, yes, babies get erections, that tightness loosens up, and eventually kids are able to retract fully. The timing of that varies. So, sometimes kids are able to retract fully by age two, and then other times it takes up until the preteen years. And it is never okay to forcefully retract the foreskin. So, your pediatrician, for example, you should not pull the foreskin back forcefully, causing tears in the skin or bleeding or discomfort. That’s not necessary. It is okay to manipulate the foreskin and pull it back gently, and see how far it goes back over time.
And eventually, you’ll notice that the adhesions underneath, so the stickiness of the skin to the tip of the penis, become less. And you can see more of the tip of the penis, called the glands. And then as you’re able to retract more and more, then it’s appropriate to retract and clean underneath when the foreskin naturally relaxes. And at an age appropriate time, like during potty training or a little bit after, then kids teaching boys to sort of pull back as far as they can comfortably to pee and to wash underneath is part of routine hygiene for an uncircumcised boy.
Emily Oster:
Okay. All right. So, we did the penis. I’m sure there’s many other questions about the penis, but we’re going to move on to the set of questions people had about daytime potty training. And so, one version of this, one thing people ask is just, “My kids holding their pee all the time. How many times do they have to pee? Are they going to be sick if they never pee? What’s a regular amount of times? How many times a day should we pee?”
Dr. Liza Aguiar:
Yeah. So, after potty training, so one of the things that I focus on is potty training’s really important, but what happens after potty training is actually just as important, and sometimes more important. Kids are really good at prioritizing, and they often have much better things to do than go to the bathroom. And holding is very common, but it can get you into trouble. So, holding promotes stasis of urine, urine just sitting there in the bladder. And especially for girls, our urethras are short, bacteria does slip into our bladders, and our job is to flush our bladders out regularly. And same thing for kids.
Kids should be peeing about every one to three hours is normal for a toddler. And then, as you grow and your bladder capacity is more, then every two to four hours is fine. But holding past that does promote bacterial growth, and bladders don’t like to be over distended. The bladder muscle itself doesn’t like to be overstretched, but ignoring those signals is just part of childhood. It does take a little bit of awareness. So, during potty training, parents are often very on top of when their children are peeing and when they’re pooping, and sometimes I see diaries during potty training, but after, they do forget-
Emily Oster:
They write that shit down. They have a spreadsheet. [inaudible] spreadsheet, that’s the best.
Dr. Liza Aguiar:
Yeah, right. But afterwards, we forget about it and we don’t really think about how often our kids are peeing, and then we’re at Target and we’re in the checkout line and then all of a sudden it’s like, “Oh my god, I have to go now.” And those are the habits that I try to work on because it can get you into trouble with urinary tract infections. So, by far, the two most common risk factors for urinary tract infections in children are holding and constipation. So, I often talk about holding and constipation when I see recurrent urinary tract infections in kids. And holding obviously is much more bladder-related, but somewhat related to constipation. And my spiel is like two things need to happen for your bladder to empty in a healthy way. One is your bladder muscle needs to squeeze, and that’s reflexive. We don’t tell our bladders to squeeze. But the second is that our pelvic floor muscles need to relax, and that is something that kids really have.
Emily Oster:
If you’re constipated? I see.
Dr. Liza Aguiar:
Yeah. And it affects pee and poop, right? If kids cannot relax their pelvic floor muscles, they get into the habit of holding. They sometimes have pain with urination. So, if your child has pain with urination and their urine tests are negative, chances are they’re having pelvic floor tightness or spasms. And that’s where we struggle. And shout out to all of my pediatric pelvic floor physical therapists, they work on that with kids who really struggle past baseline recommendations of pee more frequently, spread your legs when you pee, try to relax. They actually, with some older kids, work on that specifically and it really helps.
Emily Oster:
So, somebody has a question very specific. “Can I get a UTI from the bubble bath?”
Dr. Liza Aguiar:
Oh, there’s one paper that suggested that and now I answer-
Emily Oster:
Yeah, I read that paper.
Dr. Liza Aguiar:
… this question all the time. So, really, no. It’s more the irritation that the bubble baths cause externally that can promote stickiness of the tissue to the bacteria. So, I think if you use just gentle soap, it’s not… No. But can you cause some skin rashes and irritation? Yes. But basically-
Emily Oster:
So, you don’t need a bubble bath is what you’re telling me?
Dr. Liza Aguiar:
Yeah, but I get asked this all the time, like, “Oh, they’re wearing their bathing suits for a long time.” That’s really not a cause of urinary tract infections, that can cause yeast infections. But yeah, I think it’s more like habits. It’s more constipation, peeing less frequently than you should. That’s what puts kids at risk.
Emily Oster:
So, one thing I wanted to pull in about the sort of frequency of the pee is a lot of people ask the question with the frame of, “My kid has regressed, and they used to be perfect. And we were potty-trained, and now they don’t know when they need to pee or they’re kind of peeing in other ways.” And I wonder if some of that is this kind of like you were paying so much attention, and then you just stopped paying attention and then they’re developed normally they’d rather play with their trucks than pay attention to when they need to pee.
Dr. Liza Aguiar:
Absolutely. I approach that problem a little differently at different ages. If a parent comes in and their four-year-old or was perfectly potty-trained for eight months and then all of a sudden they regressed, totally normal. If a 12-year-old came in and they were perfectly potty-trained and now just started having accidents, I’m a little bit more investigative and kind of questioning what is going on. By far with little ones, I focus on like, “Okay, let’s talk about habits again and let’s just do a bladder diary. Let’s start keeping track of things.” And most of the time when I describe, “Here’s what a perfect urology patient looks like, let’s try to mimic that for the next two to three weeks and see what happens.” Most of the time parents are like, “Oh, we’re good.” The other thing is constipation can cause decreased signals to the brain. It kind of messes up the signaling. And so, if your child suffers from constipation, I would definitely, “Let’s treat that first and then work on habits.” A lot of poop in the rectum pushes up against the bladder. Also, not a good thing. So, I talk a lot about constipation.
Emily Oster:
I know you’re not a poop doctor specifically, but one of the things people ask a lot about is MiraLAX as a sort of standard treatment for constipation. And there’s this idea going around that it’s poisonous, which I don’t believe to be true-
Dr. Liza Aguiar:
It’s not, no.
Emily Oster:
… but I’d love your opinion.
Dr. Liza Aguiar:
So I think MiraLAX should be in the water. I think it… Yeah, if you have a child-
Emily Oster:
So, you’re not in the poison camp? Okay.
Dr. Liza Aguiar:
No, not in the poison camp. Absolutely not. I give it to my son every day, whether he is constipated or not. No pediatric urologist’s child is constipated. And if you need a little bit of MiraLAX to soften your stools, it’s perfectly safe. So, I’ve talked to my GI friends about this because there was one article to suggest neurocognitive issues and questioning the safety of MiraLAX. Really, it is safe. It is not poisonous, and I think it is perfectly appropriate to increase hydration and increase fiber in the diet. That’s always the right answer to start off with, but it’s okay if your child isn’t drinking the perfect amount of water a day that you add a little bit of MiraLAX in their drinks. And it doesn’t have to be a full cap full, and it can be like a teaspoon or a tablespoon.
Emily Oster:
Yeah. I think the thing people sometimes miss on this, I think you see in the data is that once kids get constipated, then they get afraid, then it’s painful, and then they get afraid. And so, the feedback there is very bad. So, even if you weren’t going to use it for a long period of time, getting past the initial constipation is really crucial.
Dr. Liza Aguiar:
Yes. One of the things that I wish parents knew even prior to potty-training, there are a few things, but one of them is that please do not start potty-training your child if they’re constipated. Because pain with pooping is such a strong trigger for children, and it creates, for some kids, fear of going to the bathroom, and not wanting to poop on the toilet and avoiding pooping and holding in your poop. And it takes a while to retrain and expose them enough to get back to, “Okay, pooping can be comfortable.” So, again, constipation is just a really important thing to consider. I would really aggressively treat that prior to even starting the potty-training process, which is sometimes not an obvious thing.
Emily Oster:
Yeah. No.
Dr. Liza Aguiar:
Oh, and in addition, during potty-training, if your child is prone to constipation, keep the MiraLAX on board or whatever you’re doing for constipation, because I can guarantee you they’re going to get constipated because this is just a whole new thing.
Emily Oster:
Okay. So, our last question is about nighttime potty training because this is, as I understand it, quite different than potty-training during the day, but there are a number of books about potty-training, which are quite specific about the need to do nighttime potty-training at the same time, including the book somebody had in the comments, the book, Oh Crap, says if you don’t potty-train at night by, whatever, three, your child’s muscles will start to atrophy. I mean, I don’t know which muscles, some of them probably urinary-related. So, what is your take on sort of nighttime potty-training, same time, later, do it aggressively?
Dr. Liza Aguiar:
Yeah, I get really confused about these recommendations, and I hear this all the time from parents too. It’s completely separate. It’s just a completely separate box than daytime training. Your child can be perfectly potty-trained during the day and still struggle with nighttime. What I tell parents is nighttime wetting is very common, and 20% of five-year-olds wet the bed, 10% of seven year olds wet the bed. So, it is something that comes later. It’s not something that you can actually train. It’s usually due to… It’s a little bit multifactorial, but it’s usually due to slightly smaller bladder capacity, maybe not having enough hormone in your system to reduce the amount of urine that you make at night, but most of the time it’s because they’re just really sound sleepers. There is a genetic component to all of this. If you have a family history of bedwetting than you’re more likely to be a bed-wetter, your child is more likely to be a bed-wetter. So, I tell parents, “I’m not really going to entertain aggressively treating bedwetting until seven at the minimum age.”
Emily Oster:
So, that’s where I want to be thinking about seven, eight as kind of the place where we start to talk about it.
Dr. Liza Aguiar:
That’s when the referrals process starts. Yeah, that’s when the referral process starts. Most pediatricians are comfortable with reassuring parents that if you have a family history, if you have these risk factors, then it might take a little longer, but really, it’s perfectly appropriate to see a pediatric urologist after that point. And what I talk about, usually, is these are your options. There are medications that help with potty-training, but they’re mostly band-aids, maybe used for sleepovers and/or camps. And then the dreaded bedwetting alarm, which is really the only thing that’s been proven to sort of nip the problem in the bud and get to the root of the problem, which I am not excited about using until there’s some buy-in from the patient. The patient has to be either bothered by the bedwetting and okay with somebody waking them up at night or something waking them up at night.
Emily Oster:
Yeah. I think what’s interesting about this with kids is that you can experience many of us had as parents is my kid was in a pull up until he was pretty old, and then just one day it was just was done. One day he just was like, “Okay, now I’ve kind of understood the idea of waking up,” and it happened two nights in a row and then he never peed in the bed. He never peed again.
Dr. Liza Aguiar:
Yeah, exactly. I mean, I think eventually that arousal system part of your brain gets a little bit more sensitive to your little bladder signal. I do think that there is some evidence to support perfecting… Think about daytime habits. So, there are things that you can’t control. And nighttime wetting is just something that I tell parents, “You really can’t control that.” But you can control daytime habits and there is evidence to suggest that perfecting daytime habits actually doesn’t solve nighttime problems, but sets your child up for success. So, if your child is holding during the day and ignoring those signals, not purposely, but just again, they have better things to do than go to the bathroom, then guess what? When they’re asleep, forget it. They’re never going to respond to those signals when they’re asleep. So, regular bathroom breaks during the day is something that can promote that ability to respond to those signals, and constipation.
Emily Oster:
And constipation. And so, just to reiterate this last point. Your view is basically if my kids wearing a pull-up, if they’re still peeing at night and I want to have them wear a pull-up until they’re five or six, that is a totally reasonable approach to the world?
Dr. Liza Aguiar:
Totally fine. Yeah, absolutely. I think you may want to consider… A lot of parents ask me, “When do I pull that pull-up? When do I take it away?” I would just for the sake of reducing the torture and the laundry load, I think expecting at least 50% dry nights is reasonable, at least just so we’re not going-
Emily Oster:
Doing the laundry every single…
Dr. Liza Aguiar:
… through the ups and downs. And it can be really discouraging for kids. It depends on how your child copes with setbacks and if you think that they’re not going to cope well then just keep the pull-up on, it’s fine.
Emily Oster:
Yeah. All right. Well, I feel like we could talk for a billion years, but I have a 30-minute Instagram Live rule because of people’s attention span. So, I’ll just say thank you so much and we will post this and we will post the audio in the podcast, and so we will have all kinds of ways for people to keep listening.
Dr. Liza Aguiar:
Thank you.
Emily Oster:
Thank you so much.
Dr. Liza Aguiar:
[inaudible].
Emily Oster:
Thank you everybody.
Thanks for listening. If you like what you heard, subscribe to ParentData in your favorite podcast app, and rate and review the show in Apple Podcasts. You can subscribe to the whole newsletter for free at www.parentdata.org. Talk to you soon.
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