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Toilet Training

Solomon Behar, MD, Ann Dietrich, MD, Melissa Winterhalter, MD, and Cody Hostutler, MD
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Learn practical tips on potty training for typical and atypical developing children.

Pearls:

  • The average age for toilet training with daytime dryness is 30 months in the United States.

  • Signs of toilet training readiness include a child having the cognitive capacity to understand urine and stool and the physiologic capabilities to respond to bowel and bladder signals.

  • Constipation plays a large part in toilet training challenges.  Discussing good bowel hygiene with families early on may help prevent some of this.

 

  • When can you start toilet training? While toilet training age varies significantly across cultures, most US pediatricians start anticipatory guidance around 18 months and note that the average age of toilet training has increased in modern society. At the 24 month visit, toilet training specifics are discussed. The average age for a child to be toilet-trained during the day is 30 months. Night time bladder control can be months to years later.  Families should be counseled, however, that these are just averages and there is a lot of variability between children. Families should not get punitive if it takes longer.  

  • What should the pediatrician address in these visits? Before starting toilet training, the child should have the cognitive capacity to understand the concept and the physiologic ability to recognize and respond to bowel and bladder signals. Parents should look for children to have about 2 hours of dry periods in the diapers to assess these signals.  

    • At around 18 months, the family can create positive feelings around the potty and introduce the concepts of wet, dry, bottom etc. Using books and singing songs can be a fun way to discuss these issues. While picking out “big boy” and “big girl” underwear can be exciting for the child, making the transition of out diapers shouldn’t happen immediately as toilet training begins.  At 18 months, the child can start sitting on the potty, even with the clothes and diaper on to get a sense of this.  

      • Remember, though, some kids can get scared of the toilet - the concept that things disappear when flushed can be difficult, as children this age understand object permanence.   Children who have difficulty with loud noise and/or sensory integration may also be scared of the flushing.  For these children, it is nice to gradually desensitize them to these experiences.  Watching an older sibling or parent may help with this.  First children tend to take longer to potty train than subsequent children.

        • If an older sibling is doing the teaching, these should be conversation about the appropriate way to teach and not teach. Some families even use cheerios as targets to pee on in the toilet.  The experience of siblings going potty together can take the stress and isolation out of the training.

        • Given family history plays an important role with regards to enuresis, setting up expectations from the beginning is important.  

  • What methods are used for training? No matter what method is used, the child should be showing signs of readiness.These may include getting excited about the potty and/or already trying to sit on the potty.  

    • For children who are already at this point, it may be possible to train in one weekend. This involves taking the diaper off, giving the child as much as he/she wants to drink of his/her favorite drink and keep sitting them on the toilet.  There are lots of times to practice and there are lots of celebrations when the child uses the toilet. There can even be a “graduation” at the end of the weekend. However, if the child is not ready, then the family runs the risk of making the child pee all the time, he/she doesn’t want to and it becomes a battle and negative associations are formed.

    • A more child-centered approach involves watching for child-led developmental cues such as the child telling the parent when he/she has a dirty diaper and pulling up and down his/her pants. This method, recommended by the AAP, usually takes about 6 months to become fully successful. If the family pushes too soon, the toilet training interval may be longer.  Studies suggest girls potty train 2-3 months sooner than boys. Research shows that for most boys, starting with them sitting to pee on the toilet is more effective.  

      • The family should also be sensitive to other psychosocial changes that may be going on at the same time. For example, when there is a new baby and/or a new house, toilet training should be deferred.

  • What about pull-ups? There isn’t really literature that points one way or another. For many children and families, wearing pull-ups at night can take the pressure off. For some kids, it can be a discriminative stimulus; that is, by wearing the pullups it is telling the body it is OK to pee in a pull up. For most kids, however, if the family is working on good skills and staying dry through the night with a reward system and practice, than the pull ups will not hinder that. More advanced strategies include bedwetting/pull-up wetting alarms; some even have cold packs built into the pull up and get cold when they get wet.  When a child is sick, especially with diarrhea, putting back on the pull-ups makes sense and does not mean the child will regress.

    • To transition out of pull ups, just like any behavioral change, set the child up for success.  Make them feel happy and proud for staying 30 minutes in big kid underwear while dry.  Then make it longer and longer.  For night time, some families will put underwear on under the pull-up to help transition.  

  • What if a family is insistent on training but the child isn’t ready? Instead of simply saying, “Your child isn’t ready” say, “Potty-train the child to do the readiness skills.  Give them rewards and keep track of when they come tell you that their diaper is wet and they need changing. Teach them potty words.  Try moving them into the bathroom to pee in their diaper. These are all skills to help them get ready.”

  • What about setbacks? It is OK to go back to diapers once potty training has begun.  Taking a break for one-three months is reasonable before trying again. The family can look for the same cues of readiness before starting over.

Editor’s note: Regression can be a normal part of toilet training and does not constitute a failure.  While the family may be very frustrated and confused by this, reassurance should be given.

  • When can a child fully clean after using the toilet? Generally by grade school; however, it really depends on the child with respect to maturity, development and supervision. One way to teach good wiping techniques is for the parent to demonstrate for a while, then supervise for a while and then gradually remove him/herself from the process and check the child after the child does the wiping.

  • What about children who refuse to be toilet trained? About 1 in 5 children will refuse to sit on the toilet and the reasons vary. Therefore, it is important to understand why the child is refusing.

    • A child with constipation and hard, painful stool and may confuse this with thinking the toilet caused the pain. In this case, education about what is causing the pain and gradual exposure to toilet sitting may help.  Some kids may even have to poop in their diaper while on the toilet and then cut the diaper to show the child it isn’t the toilet causing the pain.

      • Additionally, placing a stool under the child’s feet may make it psychologically easier to pass stool.

Editor’s note:  Having the child raise their hands above their head while stooling may also helps. This aids in straightening out the recutm.  

      • Managing and educating the families about constipation before toilet training begins should be done.

    • Some children may refuse because they are playing and simply don’t want to stop what they are doing. In this case, making going to the toilet fun and engaging may help.  It is a balance, however, as making the experience too entertaining may make the child lose focus.  

  • How do you approach enuresis? Daytime wetting, enuresis, can be either primary or secondary.  Secondary is more concerning from a medical standpoint and warrants a more thorough investigation. Differential includes, but is not limited to, UTI, diabetes insipidus, diabetes mellitus, significant constipation and/or renal disease.  

Editor’s note: For a full discussion of primary and secondary enuresis, which is a full discussion unto itself, please refer to the segment from June 2015 with nephrologist Dr. Elizabeth Jackson.

  • How do you evaluate encopresis? Again, the function of the behavior should be evaluated.  In some children, painful hard stools associated with constipation leads to withholding behavior leading to encopresis. Families may interpret this as diarrhea, when in reality there is just a lot of overflow. Other children may be afraid of the toilet and/or use stooling “accidents” as an oppositional defiant mechanism.

    • To manage behaviorally, scheduled sits on the toilet 15-30 minutes after meals may be helpful. Constipation should be managed and rewards with stickers and/or celebrations should be considered.

    • Children should not be punished for soiling accidents. One could incorporate honesty into the reward system; so, for example, one sticker for telling the caregiver about the accident, two stickers if they have the bowel movement in the toilet.

      • Remember, chronic constipation can lead to a loss of sensation and a child may have an accident without knowing. However, loss of bowel function in the absence of an obvious constipation, requires prompt attention and further questioning.

    • Other medical conditions that should be considered and evaluated in encopresis include, Hirschsprung’s disease leading to constipation, spina bifida or other neurologic disease like tethered cord, celiac disease and thyroid disease.

      • A good rectal and sacral exam should be performed, assessing tone and for any spinal dysraphisms.  One should assess for spinal anesthesia and an anal wink.

Editor’s Note: Fecal incontinence in children is most commonly associated with constipation.  There are, of course, as stated in the audio, many causes of constipation in children and include, dietary, physiologic, neurogenic (for example, Hirschsprung, CP, spinal cord injury, myelomeningocele), endocrine (for example, thyroid disease, CF, diabetes), anatomic (for example, an anteriorly displaced anus, intestinal obstruction), and other causes (for example, celiac, medications).  All of these should be considered when examining the child with fecal incontinence and specific emphasis should be given to signs of neurologic dysfunction.   

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Mother Of All Bacteria! Full episode audio for MD edition 186:07 min - 87 MB - M4AHippo Peds RAP May 2017 1 MB - PDF

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