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Toilet Training

Sara D. Henderson, MD

A child has achieved bladder control when there no longer is involuntary leakage of urine. Enuresis (involuntary leakage of urine) is categorized as diurnal (daytime) versus nocturnal (during sleep) and primary versus secondary. Primary diurnal enuresis should be evaluated if the child is older than four years of age.

Secondary diurnal enuresis implies that bladder control has been consistent for at least 3 months. In the preschooler who recently acquired urinary control, diurnal enuresis should prompt a review of psychosocial stressors. Common reasons for secondary enuresis include urinary tract infection and diabetes mellitus. Additional causes of diurnal enuresis include constipation, congenital or acquired neurogenic bladder, urethral obstruction, and ectopic ureter.

Primary nocturnal enuresis (PNE) is common, with 20% of 5-year-olds never having been dry consistently. One year later, 50% of these children are consistently dry through the night. However, the rate of spontaneous resolution of PNE slows after age 6. Approximately 15% of the remaining children who have PNE become dry each year. Most parents seek help and a medical evaluation for their children between the ages of 5 and 7 years. 

Bowel control is achieved when there is no longer the involuntary leakage of stool from the rectum. Although many children acquire bowel control prior to bladder control or both at the same time, at least 10% of children have a gap between initially acquiring bladder control and then bowel control.

The age at which parents have begun working on their children's toileting skills has changed over the years. Most American children achieve control of bladder and bowel function between 24 and 48 months of age. Approximately 25% are toilet trained at 24 months of age, 85% at 30 months of age, and 98% at 36 months of age. Girls tend to achieve control slightly sooner than boys.

A child-directed approach to toilet training continues to be the mainstay of advice shared by pediatricians today. This approach takes into account both physiologic and behavioral readiness.

In the first year of life, the bladder reflexively empties about 20 times daily. At 9 to 12 months of age, reflex sphincter control can be elicited, and between 12 and 18 months of age, the extrapyramidal tracts are myelinated. Both sphincter control and extrapyramidal tract myelinization are required for bladder and bowel control. A greater challenge is to balance these physiologic features with the psychological maturational features of an individual child; variables important to all aspects of parenting come into play. These variables include the family's daily routine and environment, parental expectations, setting of limits, and the ability of the parents to follow through with expectations and limits. In addition to parenting skills, the child's temperament is a crucial variable. Toddlers who are 18 to 24 months of age still demonstrate "negativism" in some interactions with others. "Strong-willed" toddlers are more difficult to toilet train.

Readiness for toilet training varies from child to child and should take into account the points noted in table 1. These seven items encompass motor, language, and social milestones as well as the child's demeanor and relationship with the parent. By approaching toilet training from this perspective, the parent can adapt his or her expectations and process to the physical and behavioral development of the child. In other words, rather than approaching toilet training simply as a function of a child's chronologic age, we should approach it based on the motor, cognitive, and psychosocial development of the child and the relationship of the child with the primary caregiver.

Several decades ago, in the era of parent-directed toilet training, infants and toddlers were perched over the receptacle periodically throughout the day. There were multiple verbal prompts throughout the day encouraging use of the potty. More coercive methods also were used with strong negative reinforcement. Data on the effects of this approach are limited, but they suggest that although the age at which toilet training was initiated was younger with the parent-directed approach, the age at which the child successfully achieved independent toileting skills was not dramatically earlier than with the child-directed approach. Unfortunately, because studies use different end-points (independent control versus child indication of need with caregiver attending to the need), they cannot be compared directly.

Toilet training should begin with an assessment of parental expectations at the 12-month health supervision visit . Educational materials should be provided to familiarize parents with toileting readiness skills and developmental expectations. Additional materials outlining a child-directed approach should be provided at the 15- or 18-month visit.

The parent should follow the child's cues for moving from one stage to the next. Initially, the child simply is exposed to the potty-chair. During the same interval the child should be allowed to watch the parent use the toilet. Frankly, most parents freely admit to losing bathroom privacy when there is a toddler in the home. During this phase the parents should use a matter-of-fact terminology for anatomy as well as urine and stool. Words that imply shame (eg, "dirty") should be avoided.

Next, the child is encouraged to sit on the potty while fully dressed. He or she may be encouraged to look at books or play with a toy. Initially, most children feel more comfortable using a potty-chair than being perched on an adult-sized toilet; the child will be more stable with both feet firmly on the floor. The next step is to have the toddler sit on the potty after a wet or soiled diaper has been removed. The wet or soiled diaper may be placed in the potty to demonstrate the function of the potty-chair. This is followed by the child being led to the potty several times a day and encouraged, but not forced, to sit on the potty without wearing a diaper. When the child expresses a spontaneous interest in sitting on the potty-chair, he or she should be praised irrespective of whether voiding or defecation has occurred. A few minutes on the potty are ample; the parent should not encourage prolonged sessions. Finally, a child may be guided toward a routine of sitting on the potty after waking in the morning, after meals or snacks, and before naps and bedtime.

Using this method, a child usually will gain control of bladder and bowel function in a few weeks. Positive reinforcement often is coupled with this step-by-step program. Food or candy rewards should be discouraged because this provides an unhealthy message to reward positive behavior with food. The reward must be immediate because toddlers and preschoolers have difficulty with delayed gratification. A calendar on which stickers or stars can be placed may be posted in a visible and accessible place to remind the child of his or her successes.

Developing a toileting routine should be coupled with teaching proper hygiene. Girls should be taught to wipe gently from front to back to avoid vaginal and urethral contamination with perirectal flora. Additionally, all children should be prompted to wash their hands after using the potty.

A child who has demonstrated a week or more of consistent success may be ready to try training pants or cotton underpants. This provides a good opportunity for positive reinforcement. Conversely, the child who has a series of wetting or soiling accidents soon after trying training pants or cotton underpants should have the option of returning to diapers without shame or feeling

that he or she has disappointed anyone.

Azrin and Foxx have outlined a method for more rapid progression of learning potty skills. They note that children older than 20 months of age who have appropriate developmental skills can grasp the essentials of toilet training in a few hours. Their approach mandates an intense one-on-one day with the toddler. The day is filled with practice, reinforcement, imitation, and praise. A few studies have suggested that this method may be successful for those who have received adequate training using the technique, but it may be problematic for many parents who have not received specific training in these techniques.

There are only a few areas in life where a toddler has a significant amount of control. Ultimately it is difficult and counterproductive to force a child to eat. Similarly, it is difficult and counterproductive to try to force a child to void or produce a bowel movement on command. Hence, parents must be advised to avoid engaging in "toileting battles" because they are not productive and are potentially damaging. Such battles may damage the parent-child relationship and the child's self-image and likely will hinder progress in acquiring toileting skills. Ultimately, there is significant risk of stool withholding as a demonstration of control on the child's part, which may lead to acute, then chronic constipation followed by encopresis. As a child withholds stool, the stool may become harder, dryer, and larger. Children then may withhold the stool to avoid the discomfort of passing a larger, harder stool. Parents also may note a transient change in posture or gait as the child tries to prevent passage of an uncomfortable stool. The child also may establish a favorite place to pass the stool that avoids the immediate prompting of the caregiver.

Children demonstrating toileting resistance or refusal tend to have more difficult temperaments. Additional information suggests that stool toileting refusal is more common if parents have a general difficulty in setting limits with the child. The overall child-parent relationship and limit-setting should be addressed as part of the evaluation of toileting refusal . Parents of children who resist or refuse toilet training should be advised to recognize that the child has ultimate control of this situation. ALL reminders and pressures to toilet train must cease for a period of 1 to 3 months. This includes pressure from parents, grandparents, child care providers, or other caregivers.

Attention to the stool texture and size is very important. Dietary measures such as decreasing fat intake (eg, how much whole milk is in the diet?) and increasing fluid and fiber are an initial step. Laxatives or a more aggressive "clean-out" with enemas may be required. The parent may have an advantage when a child has a consistent place to go to have a bowel movement. A simple and gentle statement of, "I see that you know when you need to have a bowel movement because you usually go and sit behind the couch for a few minutes. It's great that you know that you have to go! When you are ready to let me know so you can have your bowel movement in the potty, I will be glad to help you." However, even this gentle statement should not be shared until any constipation issues are addressed.

If the preschooler continues to resist toilet training after 3 months, a positive feedback system such as a star chart may be appropriate to use. If the child continues to show no interest in toilet training, there has been a good faith effort to transfer control to the child, the child is older than 4 years of age, and findings on physical and neurodevelopmental examinations are normal, a referral to a mental health specialist may be required to explore parenting techniques and other facets of the parent/child relationship.

This topic is covered in Pediatrics in Review. 1998;19:23. If a toddler has a history of constipation prior to demonstrating interest in toilet training, constipation and encopresis must be addressed and resolved before initiating toilet training. The constipated toddler may resist passing a large-caliber stool because of the associated dyschezia. This resistance leads to a larger, harder bowel movement and greater discomfort when trying to pass the stool, setting up a negative feedback cycle. If the constipation is ongoing, the child may develop acquired megacolon. Therefore, the child may not sense a full rectum, resulting in overflow of liquid stool. A thorough history and physical examination should be performed to look for clues to an organic versus functional etiology.

Functional constipation should be addressed early with established follow-up. Initially a diet history should be used to evaluate the fat (especially whole cow milk) versus fiber content of the intake. Excessive whole cow milk (32 oz per day) may provide too much fat, which will slow gut motility, and may satiate the child without adequate intake of water, fruit, and vegetable fiber that promotes softer stools. If dietary manipulation does not remedy the situation quickly, administration of a laxative and careful attention to adequate water intake are required . Prior to recommending a laxative, a rectal examination should be performed to rule out fecal impaction. If fecal impaction is present, enemas should be used to relieve the impaction to avoid excessive abdominal pain and cramping. A pediatric enema twice a day for 2 to 3 days (until the stool results are essentially watery) should be followed by a clearly outlined plan for the use of laxatives. If the constipation is chronic and acquired megacolon and encopresis are considerations, careful follow-up is essential. Parents need to understand the chronic nature of the condition and the amount of time (3 to 12 mo) needed to treat acquired megacolon as a result of chronic constipation. The parents and child will need a significant amount of support and reassurance. A clear plan must be in place if the child returns to a pattern of more than 48 hours without a bowel movement.

Toilet training is a milestone anticipated by all parents, who will benefit from anticipatory guidance relative to the timing and process. The process may need alterations to suit children who have special physical or emotional needs or to encourage a positive experience based on the child's temperament. As with nearly everything in parenting, the whole picture must be taken into account. In addition to the physical, neurodevelopmental, and emotional development of the child, it is wise to consider the parent/child relationship and cultural influences.

References

1. Azrin NH, Foxx RM. Toilet Training in Less Than a Day. New York, NY: Simon and Schuster; 1974  

2. Berk LB, Friman PC. Epidemiologic aspects of toilet training. Clin Pediatr. 1990;29:278-282  

3. Brazelton TB. A child-oriented approach to toilet training. Pediatrics. 1962;29:121-128  

4. deVries MW, deVries MR. Cultural relativity of toilet training readiness: a perspective from East Africa. Pediatrics. 1977;60:170-177  

5. Luxem M, Christopherson E. Behavioral toilet training in early childhood: research, practice and implications. J Devel Behav Pediatr. 1994;15:370-378  

6. Maizels M, Gandhi K, Keating B, Rosenbaum D. Diagnosis and treatment for children who cannot control urination. Current Problems in Pediatrics. 1993;23:402-450