CHAPTER 48

Toilet Training

Jung Sook (Stella) Hwang, DO, FAAP, and Lynne M. Smith, MD, FAAP

The age at which toilet training is carried out is culturally determined. Some cultures train children at a very early age. For example, among the Digo, an East African tribe, some children between 2 and 3 months of age are conditioned to urinate or defecate when placed in certain positions. In the United States, the cultural emphasis is on the learning aspects of toilet training rather than the conditioning aspects. Training based on the learning aspects focuses on the cognitive development of children and children’s readiness to learn the complexity of the task.

Toilet training is potentially a rewarding and frustrating experience for children and parents alike. Parents may have unrealistic expectations of their child’s capability or may be quite intolerant of normal accidents that occur in the training process. It is important for the physician to introduce the topic of toilet training early on to prevent these unrealistic expectations. Refusal by a child to toilet train or accidents related to toilet training are often cited as a precipitating event for child physical abuse. It is recommended that the physician introduce to parents the issue of toilet training and provide anticipatory guidance by the time a child is 18 to 24 months of age to help parents develop reasonable expectations.

Epidemiology

The age at which children are toilet trained varies depending on social considerations and pressures. Before the 1920s, the approach to toilet training in the United States was permissive. After this attitude changed, the training methods became more rigorous, requiring that children be trained at an earlier age. In 1947, only 5% of children in the United States were not trained by 33 months of age, but by 1975 this figure had increased to 42%. Currently, approximately 25% of typically developing US children are daytime toilet trained at 24 months of age and 98% by 36 months of age.

The renewed interest in earlier toilet training in the United States has been attributed to 3 societal factors: the lower cost and increased options for child care and schooling associated with children after they are toilet trained, concerns about contagious illnesses (eg, hepatitis and infectious diarrhea in child care facilities in which diapers are changed), and the adverse environmental effects of nonbiode-gradable disposable diapers.

Generally, girls are trained a bit earlier than boys, but only by a matter of a few months. Additionally, younger siblings often require less time to achieve daytime continence than firstborn children. Most children (80%) are trained simultaneously for bladder and bowel control. Approximately 12% are trained first for bowel control, with approximately 8% trained first for bladder control. Girls achieve nighttime continence at a younger age than boys.

Pathophysiology

Toilet training involves the ability to inhibit a normal reflex release action and then relax the inhibition of the involved muscles. For the process to be successful, a certain degree of neurologic and biological development is essential. Although a recent literature review found no consensus on which or how many readiness signs are ideal to start toilet training, several factors affect a child’s toilet training readiness. Myelination of the pyramidal tracts and conditioned reflex sphincter control are necessary. Voluntary control is evidenced by myelination of the pyramidal tracts by age 12 to 18 months. Conditioned reflex sphincter control occurs by 9 months of age, and voluntary cooperation occurs between 12 and 15 months of age. In assessing the neurologic development of children, walking is viewed as 1 of the milestones that indicate motor readiness for toilet training. Appropriate motor skills, including getting to the bathroom, being able to remove clothing, and sitting on the toilet, are also key skills required for successful toilet training.

Toilet training depends on physiologic and psychological readiness. Cognitive development is assessed by a child’s ability to follow certain instructions and understand what the potty is used for. Two years of age has been suggested as the appropriate age to initiate toilet training in most children given that the developmental and physiologic skills necessary for successful toilet training begin maturing at this time. Toilet training usually takes 2 weeks to 2 months to master. Achieving nighttime continence is often separate from daytime continence. Although opinions about nighttime wetting are culturally dependent, it is considered normal in the United States up to 6 years of age.

A child’s temperament can also affect the success of toilet training. Children who struggle with inflexibility, are less persistent, or have a more negative mood often experience delays in toilet training. Unlike physiologic or psychological readiness, temperament is not likely to change after a 2-month delay in training; understanding a child’s temperament can better assist parents in supporting their child through the process of toilet training. In addition to the child’s temperament, the child’s emotional readiness is influenced by parental attitudes and parent-child interactions.

Differential Diagnosis

The differential diagnosis of toilet training difficulties focuses on factors that contribute to a delay in acquisition of skills. The physician should look for associated symptoms, such as dysuria, a weak urinary stream, constantly wet underwear, or fecal soiling when assessing a child who continues to manifest signs of urinary or stool incontinence. Additionally, it is important to determine if children are essentially toilet trained but are having intermittent accidents.

Dysfunctional voiding involves an abnormal voiding pattern stemming from a problem with the bladder filling or emptying. Such voiding is characterized by urine leakage, an increase in urgency, and an increase in frequency, and it often results in frequent urinary tract infections (UTIs). The most common cause of isolated daytime wetting in previously trained children is UTI (see Chapter 112). Although UTI is not associated with age at the onset of toilet training, earlier toilet training is associated with later onset of UTIs. No association exists between toilet training methods and dysfunctional voiding. Chemical urethritis may also be associated with urinary incontinence. Stress incontinence, which has also been called “giggle incontinence,” may result in wetting. Urgency incontinence occurs when children delay going to the bathroom and then are unable to hold urine any longer. Some children have ectopic ureters, which can empty into the lower portion of the bladder, vagina, or urethra and cause a constant dribble of urine. Labial fusion with vaginal reflux of urine may also be associated with daytime wetting. Urine pools behind the fused labia or labia that do not separate sufficiently to allow natural egress during voiding, and when the child stands up the urine exits. The child with a neurogenic bladder may also have symptoms of daytime enuresis.

Stool-related accidents may be associated with chronic constipation and overflow incontinence or with congenital megacolon (ie, Hirschsprung disease; see Chapter 56). Stool toileting refusal occurs when a child is trained to urinate in the toilet but refuses to defecate in the toilet for at least 1 month. Although many parents perceive stool toileting refusal as insignificant, it is often associated with developing encopresis, constipation, painful bowel movements, and delayed completion of toilet training. If a child has persistent constipation, the child may develop megacolon and may not be able to sense a full rectum, thereby causing overflow of loose stools. A complete history and physical examination are required to differentiate functional constipation from organic causes. The physician should recognize and address functional constipation early to avoid acquired megacolon, because it takes 3 to 12 months to treat megacolon caused by chronic constipation. Children who prefer to stand in a corner to defecate should be commended for recognizing their physiologic urge. However, parents should be aware that children who hide while passing stool in their diaper are more likely to exhibit stool toileting refusal and be constipated. Successful management of constipation may decrease the incidence of toileting refusal.

Evaluation

History

Typically developing toddlers should be assessed for their physiologic and psychological readiness to initiate toilet training, as well as for any underlying medical conditions that may affect their ability to learn toileting skills at the customary age. The physician should provide anticipatory guidance to parents about toileting readiness. Affirmative answers should be obtained to the following 3 questions:

1. Does the child exhibit bladder control as evidenced by periods of dryness that last up to 2 hours and facial expressions that show the child’s physiologic response to the elimination process?

2. Does the child have the motor skills necessary to get around? This essentially involves the child’s ability to walk and remove their clothing.

3. Does the child have the cognitive ability to understand the task at hand?

Cognitive ability can be assessed by giving a child 10 one-step tasks to determine whether the child can complete at least 8 of the 10 tasks (Box 48.1). The ability to carry out these tasks does not ensure a willingness to be toilet trained, however. When language readiness is apparent (ie, use of 2-word phrases and 2-step commands), training can commence. In addition to language readiness, understanding of the cause and effect of toileting, desiring independence, and having sufficient motor skills and body awareness are helpful for successful training.

Stress in the home may negatively affect a toddler’s ability to master the task of toilet training. The physician might counsel a family to delay toilet training if the family has moved recently, the birth of a new baby is expected, or a major family crisis has occurred, such as a death or serious illness.

The child who has had difficulties with toilet training must undergo a similar assessment.

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