Toilet Training Pediatric Issues Presentation Amy Carlson NSG 625
Toilet Training Description of issue References History Handout Different methods Epidemiological issues Readiness Problems Treatment Options
Description of issue Toilet training is an important milestone for both parents and children This area of pediatric care presents a critical opportunity for anticipatory guidance Parents need guidance in: Recognition of readiness Helping their child achieve necessary skills Addressing problems when they occur
History Early 1900’s- stressed physiologic readiness, involving the child as a passive participant 1920’s & 30’s- early training and rigid scheduling were recommended 1940’s- pediatric experts began advocating parents wait until they observed signs of developmental readiness 1960’s- 2 major theories emerged: 1. The Parent Oriented Approach 2. The Child Directed Approach
Parent Oriented Training Developed by Azrin & Foxx, 1972 Consists of speed training using 4 basic concepts: 1. Increased fluid intake 2. Regularly scheduled toilet times 3. Positive reinforcement for correct elimination 4. Overcorrection for accidents (eg, verbal reprimands or time out from positive reinforcement) Mean time of training: 3.9 hours (range 0.5 to 14 hours)
Child-Oriented Training 1962- Dr. T. Berry Brazelton Begin toilet training only after certain physiologic and behavioral criteria and readiness are met Stressed importance of letting the child master each step at his or her own pace with minimal conflict Associated with: High rates of continence Fairly rapid training time Low long-term regression rates Many current toilet training methods are based upon this approach
Comparison of the two Methods Both parent-oriented and child-oriented approaches resulted in quick, successful toilet training among healthy children The two methods have not been directly compared- so we cannot make any definitive decisions of method superiority
Epidemiological issues Age of Toilet Training varies by: Culture Timing Gender
United States 26% of children achieve daytime continence by 24 months of age 85% by 30 months 98% by 36 months Most children achieve bowel and bladder control by 24- 48 months. In 1947 most U.S. children achieved this by 18 months old.
Cultural Differences in US Most African Americans believe potty training should be started at age 18 months. Caucasians more commonly propose 24 months as a starting time. 50% of African American parents, compared to 4% of Caucasian parents agree that it is important to be trained by two years of age.
Timing The average length of time required to achieve toilet training is: 6 months for daytime urinary continence 6-11 months for stool continence Earlier initiation of toilet training (<27 months old) is assoc. with longer duration First born children take longer than subsequent siblings (2 months longer)
Gender Girls generally achieve nighttime dryness before boys. Age 4 25% of boys wear nighttime diapers 12% of girls wear nighttime diapers Age 6 5% of boys wear nighttime diapers 2% of girls wear nighttime diapers Nighttime dryness should be achieved by age 7.
Developing Continence Continence depends on: Complete and functioning renal system Maturation of nervous system Opportunity/support given to the child to void Cultural expectations Maturation of control mechanisms usually take up to 5-7 years for healthy children to be dry in the day and overnight Older age of the child, non-Caucasian race, female sex, and a single parenthood were significant predictors of toilet-training completion.
Readiness AAP recommends only beginning training when a child is developmentally ready At the 2-year visit clinicians should assess the child’s readiness, motivation to learn, ability to cope, and level of cooperation with tasks Ask the child to perform several tasks- such as pointing to several body parts, sitting, standing, walking and imitating 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
Physiologic readiness Must have control over sphincter muscles before he or she can be trained (usually after 12 to 18 months of age)
Developmental Readiness The ability to ambulate to the toilet Stability when sitting on the toilet The ability to remain dry for several hours 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 Readiness Ability to imitate behaviors Ability to place things where they belong Demonstration of independence by saying “no” Expression of interest in toilet training The desire to please The desire for independence and control of the functions of elimination Diminishing frequency of oppositional behaviors and power struggle
Parental Readiness Start the discussion at age 12 months with parents. Parents should be informed of the important developmental milestones for toilet training: Children become aware of accidents by 15 months Children call attention to their soiled diapers and can verbally distinguish between urine and feces by 18 to 24 months Children announce need to eliminate by 24 months Children begin to ask to be taken to the toilet for elimination by 30-36 months Children achieve the adult pattern of elimination by 48 months
Parental Readiness Clinician should ask the parents about: expectations the existence of pressure for toilet training from other family members or day care providers Whether they have any negative memories relating to their own toilet training Parents should postpone training until they can allow it to be driven by the child’s motivation, interest, and acquisition of skills One caregiver should be able to devote time and emotional energy necessary to be consistent on a daily basis for a minimum of 3 months
Parental Readiness Training should be delayed if parents are motivated by: Anticipated birth of a new child in the home Moving to a new home Mother returning to work Specific daycare requirementsToo many changes in a child’s life make it more difficult totrain and thus increase risk of initial failure.
Parental Readiness Parents must understand that accidents are inevitable and that children should not be punished during the process. Toilet training can set the stage for abuse. Parents who are easily frustrated, impatient, or not supportive of their children during office visits should be instructed to wait until at least 30 months to start training.
Guidelines for Toilet Training Steps involved: Communicating the need to go Undressing Eliminating Wiping Re-dressing Flushing Hand washing Going through these steps consistently helps reinforce proper toileting skills
Guidelines for Parents Use consistent vocab for body fluids Buy a potty chair with your child. Place it in a convenient location. Encourage the child to sit in the potty chair fully clothed, and look at books or play. Talk about the potty with books or videos. Make regular practice trips to the potty chair after waking, meals After your child is comfortable sitting in the chair dressed, encourage him to sit in the chair with no diaper. Encourage the child to tell you when they need to go Do not punish, threaten or speak harshly Transition to training pants (washable, thicker underwear)
Tips Keep a positive, loving attitude Keep the child in loose, easy-to-remove clothing Keep an extra set of clothing on hand at all times Do not flush the potty with the child on it Teach boys to urinate while sitting first, once they have bowel control they can switch to standing Keep stools soft by modifying diet Wait to use underwear at night till the child is consitently dry during the day Remind the child several times during the day to use the potty If the child is not making progress, stop for 2-3 months, then restart.
Nocturnal EnuresisCommon Experience in early childhood Dx made when the involuntary passage of urine, during sleep, occurs in a child ages 5 years or more, in the absence of any congenital or acquired defects of the nervous system 20% of 5-year-olds, 10% of 6-year-olds, and 7% of 7-year-olds wet the bed at night Organic causes of primary nocturnal enuresis are found in only 2-3% of children
Diurnal Enuresis Children older than 4-years-old who have primary or secondary diurnal enuresis should be evaluated for organic etiologies Most cases can be determined through: History taking Complete PE UA/C&S Looking for glucose, WBC’s or RBC’s
Treatment Options Bedwetting Alarms Successful in 2/3 of all cases Approx. 3 month commitment DDAVP (desmopressin) Average of 1.4 fewer wet nights/week The recommended starting dose for the tablet is 0.2 mg, and the drug can be titrated as necessary to a maximum of 0.6 mg Tricyclic antidepressants usual dose, taken 1-2 hours before bedtime, is 25 mg for patients aged 6-8 years and 50-75 mg for older children and adolescents
Resistance or Refusal Children with toilet refusal have achieved bladder control but not bowel continence. Up to 20% of developmentally normal children have this problem Possible causes: Attempting training too early Excessive parent-child conflict Irrational fears or anxiety about toileting Difficult temperament Hard, painful stools from chronic constipation
Tips for Toilet Refusal for Parents Do not punish or nag the child Discontinue training for a few weeks Encourage the child to imitate parents/siblings Continue to discuss training with the child Treat constipation with dietary changes, medications Create positive feedback system, such as a star chart Regression lasting >6months should be brought to clinicians attention
Resources For children: “No More Diapers” by JG Brooks “Your New Potty” by Joanna Cole “Once Upon a Potty” by Alona Frankel “All by Myself” by Anna Grossnickle Hines “Going To The Potty” by Fred Rogers “KoKo Bear’s New Potty” by Vicky Lansky For Parents: “Toilet Training the Brazelton Way” by TB Brazelton “The American Academy of Pediatrics Guide to Toilet Training” “The Potty Journey: Guide to Toilet Training Kids with Special Needs” by JA Coucouvanis
References1. Klassen, T., Kiddoo, D., Lang, M., Friesen, C., Russell, K., Spooner, C., & Vandermeer, B. (2006). The effectiveness of different methods of toilet training for bowel and bladder control. Evidence Report/Technology Assessment, (147), 1-57.2. MacGregor, J. (2008). Introduction to the anatomy and physiology of children: A guide for students of nursing, child care and health. New York, NY: Routledge.3. Mersch, J. (March 10, 2010). In Potty Training (Toilet Training). MedicineNet.com. Retrieved April 1, 2012, from http://www.medicinenet.com/script/main/art.asp?articlek ey114293.4. Turner, T., & Matlock, K Toilet Training. In: UpToDate, Torchia, M.M.(Ed), UpToDate, Waltham, MA, 2012