Toileting: Answers

Some epidemiology:  The age at which most children are considered toilet trained varies by culture.  Some general stats in the United States- approximately 25% of children achieve daytime continence by 24 months of age, 85% by 30 months, and 98% by 36 months.  Most children achieve bowel and bladder control by 24 to 48 months (in 1947 most achieved this milestone at 18 months!)  Girls generally complete the toilet training process earlier than boys (2-3 months).

The mother’s concern about expense is a very real one.  Depending on brand, diapers can range in cost from 20 to 40 cents a piece.  Many infants can go through more than 10 diapers a day (averaging a cost to families of >$20/week).  There are sometimes community-based programs that have diaper drives and are a good resource for parents (eg/ local Red Cross).  Buying in bulk at shopping clubs is often cheaper.  The cost should be addressed as a real concern but a discussion that this should not be the inciting factor to toilet training is appropriate.  Inappropriate parental expectations around this topic have been cited as instigating factors in child abuse. 

2.This question addresses the issue of child readiness.  The child's readiness for toilet training is based upon the attainment of certain physiologic, developmental, and behavioral milestones rather than his or her chronologic age. Some experts suggest beginning toilet training three months after the readiness criteria have been met to ensure success. This child-oriented approach to training was introduced by Dr. T. Berry Brazelton in 1962.  It stresses the importance of permitting the child the freedom to master each step at his or her own pace with minimal conflict.  The average age of readiness varies between 22 and 30 months of age. 

Physiologic - A child must have control over his or her sphincter muscle before he or she can be toilet trained.

Developmental -  The achievement of the following motor, language and social milestones signal readiness:

? The ability to walk, sit, and get on/off the potty chair

? Stability when sitting on the toilet

? The ability to remain dry for several hours

? The ability to pull clothes up and down

? Receptive language skills that permit the child to follow a two-step command

? Expressive language skills that permit the child to communicate the need to use the toilet

Behavioral — In addition, specific behavioral signs in the child indicate his/her readiness to begin. They include:

? The ability to imitate behaviors

? The desire to please

? The ability to place things where they belong

? The desire for independence and control of the functions of elimination

? The diminishing frequency of oppositional behaviors and power struggles

Some “concrete” signs that a child may be ready include asking to be changed, telling the caregiver that he/ she is going to pee or poop, staying dry for a few hours, being dry after naps, showing interest in watching parents or older siblings in the bathroom, going to a “private spot” to void or defecate in the diaper

At the two-year visit, you should assess the child's physiologic readiness, motivation to learn, ability to cope, and level of cooperation with tasks. You can ask the child to perform several simple tasks such as pointing to body parts, sitting, standing, walking, and imitating. You also should assess the child's bowel habits, history of constipation, ability to adapt to new situations, attention span, and distractibility. Constipation should be addressed and resolved before the initiation of toilet training.

The parents desire to allow this process to be driven by the child’s motivation, interest, and acquisition of skills is appropriate.  They are correct in their concern that pushing a child who is not ready can lead to failure of the process.  The provider should be concerned about parents with unreasonable expectations.  Anticipatory guidance should include the information that accidents are inevitable and that punishment has no role in this process.  Many parents mistakenly equate toilet training success with intelligence or character.  Therefore, the child who has training difficulty can be perceived as lazy, stubborn, lacking intelligence, or defying parental authority.

One last point, the process should not be undertaken during times of stress or too many changes in a child’s life.  The birth of a new baby, move to a new home, mom returning to work, or beginning of a new daycare are not the times to start and such situations increase the chance for initial failure.

3. Review the big picture of the process with the family – there are a number of steps: discussing, undressing, the actual eliminating, wiping, dressing, flushing, and hand washing.  Using Brazelton’s approach, parents can follow the child’s cues to move from one step to the next.

? Decide on a vocabulary to use consistently (pee, poop whatever but not the sh&$ word!)

? Buy a potty chair – let the child help pick it out, decorate it, put his/her name on it.  Make this fun.  There are different types of potty seats.  Many people find a potty chair is easier to use and less threatening than an over-the-seat model.  The child should be able to have his/her feet touching the ground or a stool (pardon the pun) for leverage

? Accessibility of the potty chair – it should be placed in a convenient location (maybe the room where the child plays).  In multilevel homes, advisable to have one on each level.

? Comfort with the process – encourage the child to sit on the chair fully dressed and look at books or play with toys.  There are many child books and videos that address this topic (many available at public libraries).  Have the child accompany the parent or older sibling to the bathroom to encourage imitation.

? Making the connection – after a few days to a week or so encourage the child to sit on the chair without clothing.  Parents can begin making the connection by placing the soiled diaper or stool in the potty and explaining to the child this is the purpose of the chair.  Eventually one moves to make the connection to the adult toilet.  The toilet flushing can be scary.  Some experts advise allowing the child to first flush just toilet paper and waving bye-bye. (Beware of automatic flushing toilets!  NYTimes article Nov. 12, 2007 describing child anxiety associated with this new technology.)

? Practice and encouragement- praise, praise, praise.  The goal initially may be to “catch” the urine or stool in the potty chair.  Parents should not expect immediate results.  Do not get upset or punish if accidents occur.  If there is resistance- stop the process and restart when the child shows interest.

? Transition to training pants/ pull-ups or underwear- this step can be taken (with flexibility) after about one week of success using the potty.  Some people do not like using training pants or pull-ups during the process (except at night) feeling that it prolongs the process unnecessarily.  Return the child to diapers if he/she is unable to keep dry/ clean at this stage.  Once the child has mastered the potty chair, he/she can transition to the over-the-toilet seat and step stool.

Practical tips:

? Loose, easy to remove clothing are best (overalls not too practical!)

? Don’t flush the toilet when the child is sitting on it.

? Teach boys to urinate first sitting down- teach them to stand eventually but make sure their penis clears the toilet bowl (risk of crush injury if the toilet seat falls down)

? Reminders- remind at times of highest risk for accidents (upon awakening) but do not nag

? Never get in a battle over toilet training- the child will always win as they have ultimate control

? If the child shows resistance- back off and ignore it for a few weeks.

4. This question addresses the issue of resistance or refusal.  The scenario described, a child who has achieved bladder control and has regular bowel movements in their pants or diaper but refuses to defecate in the toilet, occurs in up to 20 % of children. A variety of factors have been suggested as contributing to this and your questions should address these as potential causes:

? Attempting training before the child is ready

? Excessive parent-child conflict

? Fears or anxieties about toilet- real or irrational. 

? Difficult temperament, less-adaptable than peers

? Hard, painful stools from chronic constipation

Given the above possibilities, adjust your care/ advice most appropriately.  Some helpful suggestions:

? Do not punish or nag (recurring theme here?)

? Discontinue training for a few weeks/ months

? Positive feedback system such as star charts

? Encourage child to change his/her own diapers

? Put the diaper in the potty and see if he/ she will stool

? Treat hard stools/ constipation with dietary changes and possible medications

Constipation and stool withholding cycles: sometimes it isn’t constipation that started the process but those children who resist toilet training are at risk of stool withholding which can lead to acute, then chronic constipation followed by encopresis.

5. Enuresis is a topic in and of itself.  In brief, essential information for pediatricians to know is the frequency of primary nocturnal enuresis.  There is much misinformation about what is “normal” at different ages. 

Primary monosymptomatic nocturnal enuresis (nighttime bedwetting) occurs in 16-20 percent of 5 year olds and 10-15 percent of 6 year olds.  Spontaneous resolution of the enuresis then occurs at a rate of 15 percent per year thereafter.  There is a genetic tendency toward nocturnal enuresis.  When one or both parents have a history of prolonged nighttime wetting, approximately one-half and three-quarters, respectively of the offspring are affected.

The evaluation of this child includes a careful history, physical exam, and urinalysis.

History- Ask about the following:

? Presence of daytime wetting

?Family history of nocturnal enuresis

? Frequency of bedwetting occurrences (number of wet nights/ week or month)

? Fluid intake (example- 10 ounces of juice at bedtime would be significant!)

? Stooling history – to determine if associated with constipation or encopresis

? Medical history (example/ sleep apnea, diabetes, sickle cell disease, UTI, gait or neuro abnormalities)

? What interventions has the family tried

Physical Exam- complete physical exam (include checking underwear for wetness, lower lumbosacral spine, perianal irritation or vulvovaginitis)

            The exam of a child with monosymptomatic nocturnal enuresis is usually NORMAL.

Labs: A screening urinalysis is appropriate to rule out medical causes such as diabetes or a urinary tract infection.  Urine culture to be done if indicated from UA result.

The child in this scenario, assuming all else in the history and on physical are normal, does not have a problem outside the norm.  The important issue here is reinforcing with the parents that many children this age are also still bedwetting and it is not the child’s fault.   Engaging the father in a positive way to recall his experience and that it did resolve may be reassuring. 

Advice for the parents:

? Do not get angry- it is not purposeful

? Rubberized/ waterproof mattress protectors

? Get multiple sets of inexpensive sheets so not essential to do laundry every day

? It’s OK to use pull-ups especially in the short term- the mom here is angry and this can alleviate some of her frustration and anger towards her daughter.  Some have concern about this as a long term solution (feeling it facilitates continued bedwetting, the expense).  Suggest it at least in the short term as a pop-off valve!