12 Elimination Patterns
Gastrointestinal (GI), renal, urinary, and integumentary systems function to eliminate metabolic by-products and body wastes. This chapter discusses normal bowel and bladder function, normal developmental activities such as toilet training, and behaviors that are often self-limited in young children but can require intervention (e.g., encopresis and enuresis). Problems related more directly to GI and renal pathology are presented in Chapters 32 and 34. Dermatologic conditions are discussed in Chapter 36.
Standards
Normal Patterns of Elimination: Bowel and Urinary
Infants
Urinary Patterns
Voluntary bowel and bladder control depends on myelination of the pyramidal tracts in the spinal cord, a process probably completed between 12 and 18 months of age. Infants 9 to 12 months old generally have regular patterns; they may have a bowel movement early in the morning or after feeding or stay dry for several hours and urinate immediately after waking from a nap. Parents may use these regular patterns to begin introducing the toddler to toilet training, and some parents will place the younger child on the “potty” when the child shows elimination cues.
Assessment of Patterns
Health History
Description of Current Status
The patient’s current elimination status can be assessed with the following questions:
• How often does your child urinate? How many wet diapers does your baby have in a 24-hour period?
• How often does your child have a bowel movement? Describe what the stools look and smell like. How does your child act when having a bowel movement?
• Describe anything unusual about your child’s elimination habits. Does your child resist going to the bathroom?
• Describe your child’s toileting habits. For example, at what time of day does your child have a bowel movement?
• Do you use any medications, including over-the-counter preparations or home remedies, to help your child with bowel movements?
• How do you think the process of toilet training will happen (ask of parents of a 9- to 12-month-old child)?
• Is your child toilet trained? When did training begin? Describe the process. How often do “accidents” happen? How do you (parent) feel toilet training is progressing?
• What names do you use in your family for stool and urine, for body parts, and for the process of using the toilet?
Review of Systems
The review of systems should include the following questions:
• Has your child ever been constipated or had diarrhea? How does the parent define constipation and diarrhea? (Box 12-1 summarizes the Rome III criteria for functional constipation. See Box 12-2 for the Bristol Scale of stool quality that reflects colonic transit time.) Is it chronic or occasional? Did it start after a particular incident (e.g., illness, during toilet training, with a certain food or change in diet)?
• Has your child ever had a urinary tract infection (UTI)? Describe. Any workup (e.g., ultrasonography [US], urethrogram), findings, treatment, and follow-up?
• Has your child had any illness, injury, or operation related to the bowel or bladder? Describe.
• Does your child have a physical condition or chronic illness that affects voiding or bowel movements?
• Is there a history of bed-wetting; at what age did it resolve?
BOX 12-1 Rome III Criteria for Functional Constipation: Infants and Children
• Two or fewer defecations per week
• At least one episode of fecal incontinence per week (after child is toilet trained)
• History of excessive stool retention, retentive posturing in children 4 or more years old
• History of painful or hard bowel movements
• History of large-diameter stools, could obstruct toilet
From Rome Foundation: Rome III diagnostic criteria for functional gastrointestinal disorders. Available at www.romecriteria.org/criteria (accessed Aug 9, 2011).
BOX 12-2 Bristol Stool Form Scale
Adapted from Choung RS, Locke GR 3rd, Zinsmeister AR, et al: Epidemiology of slow and fast colonic transit using a scale of stool form in a community, Aliment Pharmacol Ther 26(7):1043-1050, 2007.
| Type 1 | Separate hard lumps, like nuts | Slow colonic transit |
| Type 2 | Sausage-shaped but lumpy | Slow colonic transit |
| Type 3 | Sausage or snakelike but with cracks on surface | Normal colonic transit |
| Type 4 | Sausage or snakelike, smooth and soft | Normal colonic transit |
| Type 5 | Soft blobs with clear-cut edges | Normal colonic transit |
| Type 6 | Fluffy pieces with ragged edges, mushy stool | Fast colonic transit |
| Type 7 | Watery, no solid pieces | Fast colonic transit |
Environment and Psychosocial Issues
Environmental and psychosocial issues should be assessed, using questions such as:
• How do you, as a parent, feel about the issue of toileting?
• How do you interact with your child around toileting issues?
• How do you deal with toileting “accidents” (including bed-wetting)?
• What plans do you have for managing toilet training?
• Describe your child’s typical diet.
• Tell me about the toileting facilities at your child’s house, daycare, and school. How do you think they affect your child’s toileting habits?
Management Strategies for Normal Patterns
Toilet Training
When to begin toilet training is a perennial question of parents. Providers can emphasize that every child is unique, and readiness cues should ultimately be used to decide when to begin training. Physiological readiness develops by about 18 months. True voluntary sphincter control is a function of psychological and social development as well, so most children are not usually ready for independent toilet training until 24 months or even older. Guidelines for assessing toilet-training readiness include physical, cognitive, interpersonal or psychological, and parental skills (Table 12-1).
TABLE 12-1 Guidelines for Assessing Readiness to Toilet Train
| Skills to Assess | Criteria |
|---|---|
| Child’s physical skills | Has voluntary sphincter control |
| Stays dry for 2 hours, may wake from naps still dry | |
| Is able to sit, walk, and squat | |
| Assists in dressing self | |
| Child’s cognitive skills | Recognizes urge to urinate or defecate |
| Understands meaning of words used by family in toileting | |
| Understands what the toilet is for | |
| Understands connection between dry pants and toilet | |
| Is able to follow directions | |
| Is able to communicate needs | |
| Child’s interpersonal skills | Demonstrates desire to please parent |
| Expresses curiosity about use of toilet | |
| Expresses desire to be dry and clean | |
| Parental skills | Expresses desire to assist child with training |
| Recognizes child’s cues of readiness | |
| Has no compelling factor that will interfere with training (e.g., new job, move, family loss or gain) |
Over the past 4 decades, the median age to begin toilet training in the U.S. has increased from less than 18 months to between 21 and 36 months; some studies show no benefit to beginning training before 27 months (Choby and George, 2008). Internationally, the age of initiating toilet training has also increased (Mota and Barros, 2008; Vermandel et al, 2008). In the U.S., race and socioeconomic status may influence the decision about when to begin toilet training, with one study showing that higher-income Caucasian parents view 25.4 months as an appropriate age in contrast to African-Americans (18.2 months) and other racial groups (19.4 months) (Horn et al, 2006). In some cultures, early assisted toilet training (in contrast to independent toilet training in which the child learns self-management) may be the norm, with some Asian and African-American families beginning toilet training between 1 and 3 months old. This method requires that the caregiver be highly motivated to note and respond to infant elimination cues; initially the caregiver takes responsibility for placing the child on the toilet when necessary. As the child matures, he or she takes more self-responsibility (Rugolotto et al, 2008; Sun and Rugolotto, 2004). As families from various cultural groups immigrate to the U.S., health care providers need to understand these practices and be open to developing mutually agreed-on approaches to toilet training.
• Showing an interest in using the toilet: girls, 24 months; boys, 26 months
• Telling parents of their need to use the toilet: girls, 26 months; boys, 29 months
• Staying dry for at least 2 hours: girls, 26 months; boys, 29 months
• Staying dry during the day: girls, 32.5 months; boys, 35 months
There is little evidence regarding which toilet training strategy (e.g., early assisted; Brazelton’s child-oriented approach [Brazelton and Sparrow, 2004]; operant conditioning such as Azrin and Foxx’s Toilet Training in Less Than a Day [1974]) is most effective. When children and parents are ready to begin toilet training, several management techniques can be helpful (Box 12-3). If children resist training, the effort should be put on hold for a few weeks before trying again. If toddlers seem to be toilet trained for a brief period and suddenly regress to wetting and soiling consistently, they should be placed back in diapers and the process begun again within a few weeks. It is extremely important that parents and children do not become engaged in a “battle for control” over toilet training. Ultimately it is the child’s responsibility to control bowel and urinary function, and toilet training is only one of the many tasks toddlers master on their way to independence. Parents have the responsibility to assist in the process by providing a positive environment and opportunities, teaching the techniques, and setting a positive example. It appears that a structured yet flexible approach that is responsive to the child’s cues is likely to be most successful.
BOX 12-3 Management of Toilet Training
Altered Patterns of Elimination
