VOL: 98, ISSUE: 43, PAGE NO: 56
June Rogers, BA, RN, RSCN, is paediatric continence adviser, Knowsley Primary Care Trust, and director of PromoConJune Rogers, BA, RN, RSCN, is paediatric continence adviser, Knowsley Primary Care Trust, and director of PromoCon
Trends in toilet training have changed over the past 50-100 years. A study carried out by Bakker and Wyndaele (2000) identified a shift in the age of initiating toilet training from 12-18 months in parents born in the 1920s to 1940s to over 18 months with parents born in 1960-1980. This was felt to be partly due to the labour-saving introduction of disposable nappies.
In the earlier part of the century parents were encouraged to toilet-train their child even earlier. Infant Care, a health education booklet published by the US government in 1932, advised mothers to start toilet training almost immediately after birth and continue until the child was 'trained' at six to eight months (deVries and deVries, 1977). This early intervention is reflected in the Digo tribe in east Africa, who begin training the child a few weeks after birth and expect some day and night dryness at six months, with complete dryness by a year (deVries and deVries, 1977).
A study carried out be Smeets et al (1985) looked at shaping self-initiated toileting in infants. It reported on a programme that was put in place which trained four infants to cue their mothers on the need to empty their bladder and bowels. The infants, aged between three and six-and-a-half months, all completed the training before they were a year-old with no reported side-effects.
Physiology of micturition in infants
Traditionally it has been believed that the infant bladder is controlled by an automatic reflex arc. However, recent studies have shown that voiding occurs in response to various bladder volumes and may involve a sophisticated integration of pre-existing central and peripheral neural pathways and is not therefore mediated by simple spinal reflexes alone (Holmdahl et al, 1996; Yeung. 1995).
However, in order for the child to develop full independent bladder control the normal maturation process of micturition needs to be in place. This involves a compliant bladder which allows filling, an awareness of a desire to void, the ability to postpone voiding until appropriate, the initiation of bladder contraction and sphincter relaxation, the maintenance of urine flow until the bladder has emptied, with the cycle then starting up again (Berk and Friman, 1990). The normal number of voids per day varies from four to nine in children aged between two and three and five to seven in a 10-year-old (Bloom et al, 1993).
Skills required for toilet training
Becoming independently toilet-trained is a complex procedure, with the child needing to acquire several different skills. The child has to recognise the sensation that indicates the need to pass urine and be aware that that signal should take precedent over other activities - for example, playing. The child also needs to be able to perceive the signal correctly so that he or she can postpone micturition until an appropriate receptacle is reached.
Social convention requires that boys stand to pass urine, and they may pass urine in front of other boys but not in front of girls, and most people go behind a shut door to open their bowels. Children have to be able to physically open and close doors, manage clothing, wipe their bottoms and use toilet paper appropriately. They then need to be able to flush the toilet and wash and dry their hands. This is a lot for a small child to accomplish (Rogers, 2001).
When should you toilet-train?
There appears to be no universally accepted correct age at which to begin toilet training, as each society has its own norm. In most European countries children would be expected to be toilet-trained between the ages of two to four years. Historically children were considered to be ready for training when they began to signal they were wet or soiled (Robson and Leung, 1991). However, with the introduction of modern disposable nappies the child never feels wet, so that learning experience is often missed.
Toilet training is best started when the child is not experiencing any other change, such as the arrival of a new sibling or moving house, and it should be introduced in a matter-of-fact way as a normal, everyday activity. Having an open-door policy in the bathroom will allow the child to see other members of the family using the toilet, and there are story books for toddlers about potty training and going to the toilet.
The use of incentive stickers and stars have been found helpful in encouraging some children to get started.
The use of flushable floating 'targets' in the toilet or screwed up toilet paper 'boats' can help a reluctant boy to urinate standing up. Food colouring in the cistern could help encourage the child who enjoys 'flushing' but not defecating in the toilet by only allowing the child to flush after they have used the toilet. An added incentive is for the child to guess what colour the water will be.
Helping the child with difficulties
If a child is having difficulties the first step is to remove the nappy. Reusable pants with built-in absorbent pad are available. These not only look 'normal' and so are suitable for the older school child but will also contain small amounts of urine. They are not, however, particularly suitable for children without bowel control.
For children who have delayed bowel control but have the potential to become continent of urine a disposable pad inserted into normal pants is better than an 'all in one' nappy. Wearing a nappy makes it very difficult for the child to go to the toilet independently to pass urine, and prolonged use of nappies should not be encouraged where possible.
In some cases a 'pull-up' type of nappy may be better to contain looser stools. However, in general these have not been found to be beneficial in the toilet-training process, as to the child they feel no different than a nappy.
Musical potties and musical bowl inserts can help encourage the child to exercise bladder control and provide an instant reward for success. A well-fitting toilet seat reducer will help young children feel more secure sitting on the toilet, as many of them have a fear of falling in.
Supported toilet seating is available for children who have poor sitting balance and allow the child to have some privacy in the knowledge they are securely seated.
For children who 'deny' being wet and appear to have problems responding to the urge to void a body-worn wetting alarm can be used. This consists of a small sensor that is attached to the child's underwear and connected to a sound box pinned to the child's outer clothes. When the child wets the sound box buzzes, which alerts both the child and carer of the need to go to the toilet. This could also be used as part of an assessment to identify when and how often the child voids.
Programmes combining a urine-triggered pants alarm with structured behavioural programmes have been found successful in toilet training children with severe learning difficulties (Azrin et al, 1971; Mahoney et al, 1971; Lancioni and Marcus,1999). Other studies have identified that children with profound learning disabilities can become continent, and therefore toilet training should not be delayed for any child because of a perceived inability to understand the process (Rogers, 2001).
Health care professionals
The professional involved with the family can help the toilet training process by providing support, education and encouragement. To begin the process it is important that the family have an understanding of toilet training, in the context of their child's own development. Written information and booklets will help reinforce advice given and should include information about appropriate diet and fluid intake. Parents should be advised that coercive training is detrimental.
The fact that most children void on waking after sleep or a nap and within an hour of drinking a significant amount will help when deciding the best times to sit the child on the potty/toilet (Robson and Leung, 1991).
Families need to be aware that, although toilet training usually occurs without any major problems, there are a number of children who seem to struggle with the process. They should therefore not feel that any problems experienced by their child is a reflection of a deficit in their parenting skills and should seek help sooner rather than later. There appears to be a similarity between the bladder training process currently used for children with day-time wetting problems and the technique used historically by previous generations to potty-train children. The introduction of a more formal toilet training process may prove to be beneficial to all children and not just those who are experiencing difficulties.
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