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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 toilet training, potty training.
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
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
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
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
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,
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.
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
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