Beruflich Dokumente
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Robert S. Michel
Pediatrics in Review 1999;20;240
DOI: 10.1542/pir.20-7-240
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Toilet Training
Robert S. Michel, MD*
should be considered encopretic
OBJECTIVES until proven otherwise.
After completing this article, readers should be able to:
into account both physiologic and the relationship of the child with the
behavioral readiness. At the begin- TABLE 1. Signs of Toilet primary caregiver.
ning of the 1900s, there was a Training Readiness
laissez-faire approach to toilet train- The ability to ambulate to the Toilet Training Procedures
ing in the United States. In the
potty. (Table 2)
1930s, training involved the child as
a passive participant of reflex condi- Stability while sitting on the Several decades ago, in the era of
tioning, stressing physiologic readi- potty. parent-directed toilet training, infants
ness alone. Indeed, the parent- Ability to remain dry for and toddlers were perched over the
directed approach may have been several hours. receptacle periodically throughout
early from even the physiologic the day. There were multiple verbal
perspective. Receptive language skills that prompts throughout the day encour-
In the first year of life, the blad- allow the child to follow one- aging use of the potty. More coer-
der reflexively empties about and two-step commands. cive methods also were used with
20 times daily. At 9 to 12 months of Expressive language skills that strong negative reinforcement. Data
age, reflex sphincter control can be allow the child to on the effects of this approach are
elicited, and between 12 and 18 communicate the need to use limited, but they suggest that
months of age, the extrapyramidal the potty with words or although the age at which toilet
tracts are myelinated. Both sphincter reproducible gestures. training was initiated was younger
control and extrapyramidal tract with the parent-directed approach,
The desire to please based on
myelinization are required for blad- the age at which the child success-
a positive relationship with
der and bowel control. A greater fully achieved independent toileting
caregivers.
challenge is to balance these physio- skills was not dramatically earlier
logic features with the psychological The desire on the childs part than with the child-directed
maturational features of an individ- for independence and control approach. Unfortunately, because
ual child; variables important to all of bladder and bowel studies use different end-points
aspects of parenting come into play. function. (independent control versus child
These variables include the familys indication of need with caregiver
daily routine and environment, attending to the need), they cannot
parental expectations, setting of lim- be compared directly.
its, and the ability of the parents to pass motor, language, and social The introduction of disposable
follow through with expectations milestones as well as the childs diapers may have contributed to the
and limits. In addition to parenting demeanor and relationship with the acceptance of Brazeltons child-
skills, the childs temperament is a parent. By approaching toilet train- centered approach. By the 1970s,
crucial variable. Toddlers who are ing from this perspective, the parent most families used disposable dia-
18 to 24 months of age still demon- can adapt his or her expectations pers. Indeed, the use of cloth diapers
strate negativism in some interac- and process to the physical and is uncommon today. Gone are the
tions with others. Strong-willed behavioral development of the child. pressures to toilet train the toddler
toddlers are more difficult to toilet In other words, rather than to relieve the caretaker from rinsing
train. approaching toilet training simply as stool-filled cloth diapers in the com-
Readiness for toilet training var- a function of a childs chronologic mode and to get rid of the nasty
ies from child to child and should age, we should approach it based on diaper pail! Some wonder whether
take into account the points noted in the motor, cognitive, and psychoso- the child-directed approach leads to
Table 1. These seven items encom- cial development of the child and urine and stool continence at a later
age, although it is difficult to find Words that imply shame (eg, bowel function in a few weeks. Pos-
data to substantiate this hypothesis. dirty) should be avoided. itive reinforcement often is coupled
If this is true, there might be public Next, the child is encouraged to with this step-by-step program. Food
health implications. The large num- sit on the potty while fully dressed. or candy rewards should be discour-
ber of children in child care and He or she may be encouraged to aged because this provides an
preschool settings at earlier ages look at books or play with a toy. unhealthy message to reward posi-
offers opportunities for the spread of Initially, most children feel more tive behavior with food. The reward
hepatitis and other enteric pathogens comfortable using a potty-chair than must be immediate because toddlers
that would be lessened if the chil- being perched on an adult-sized toi- and preschoolers have difficulty
dren involved had mastery of toilet- let; the child will be more stable with delayed gratification. A calen-
ing and handwashing skills. with both feet firmly on the floor. dar on which stickers or stars can be
Toilet training should begin with The next step is to have the toddler placed may be posted in a visible
an assessment of parental expecta- sit on the potty after a wet or soiled and accessible place to remind the
tions at the 12-month health supervi- diaper has been removed. The wet child of his or her successes.
sion visit (Table 3). Educational or soiled diaper may be placed in Developing a toileting routine
materials should be provided to the potty to demonstrate the function should be coupled with teaching
familiarize parents with toileting of the potty-chair. This is followed
proper hygiene. Girls should be
readiness skills and developmental by the child being led to the potty
taught to wipe gently from front to
expectations. Additional materials several times a day and encouraged,
outlining a child-directed approach but not forced, to sit on the potty back to avoid vaginal and urethral
should be provided at the 15- or without wearing a diaper. When the contamination with perirectal flora.
18-month visit. child expresses a spontaneous inter- Additionally, all children should be
Using Brazeltons approach, the est in sitting on the potty-chair, he prompted to wash their hands after
parent follows the childs cues for or she should be praised irrespective using the potty.
moving from one stage to the next. of whether voiding or defecation has A child who has demonstrated a
Initially, the child simply is exposed occurred. A few minutes on the week or more of consistent success
to the potty-chair. During the same potty are ample; the parent should may be ready to try training pants or
interval the child should be allowed not encourage prolonged sessions. cotton underpants. This provides a
to watch the parent use the toilet. Finally, a child may be guided good opportunity for positive rein-
Frankly, most parents freely admit toward a routine of sitting on the forcement. Conversely, the child
to losing bathroom privacy when potty after waking in the morning, who has a series of wetting or soil-
there is a toddler in the home. Dur- after meals or snacks, and before ing accidents soon after trying train-
ing this phase the parents should use naps and bedtime. ing pants or cotton underpants
a matter-of-fact terminology for Using this method, a child usu- should have the option of returning
anatomy as well as urine and stool. ally will gain control of bladder and to diapers without shame or feeling
TABLE 3. Suggested Timeline for Addressing Toilet Training At Health Supervision Visits
VISIT ACTION
12-month visit Assess parental expectations
Discourage active toilet training
Tell parents that you will address this issue at future health supervision visits
15-month visit Discuss readiness criteria as outlined in Table 1
18-month visit Review readiness criteria
Provide written information on the process of toilet training
24-month visit Assess readiness criteria
Assess plan and process underway
Congratulate if already toileting independently
Discuss nocturnal enuresis for those who have diurnal control
36-month visit Assess plan and progress
Congratulate if toileting independently
Assess and discuss refusal issues
Establish reasons for follow-up prior to 48-month visit
Discuss nocturnal enuresis issues
48-month visit If refusing to seek diurnal urine and stool control, seek behavioral medicine consultation
Discuss nocturnal enuresis issues
that he or she has disappointed setting limits with the child. The you. However, even this gentle
anyone. overall child-parent relationship and statement should not be shared until
Azrin and Foxx have outlined a limit-setting should be addressed as any constipation issues are
method for more rapid progression part of the evaluation of toileting addressed.
of learning potty skills. They note refusal (Figure). Parents of children If the preschooler continues to
that children older than 20 months who resist or refuse toilet training resist toilet training after 3 months,
of age who have appropriate devel- should be advised to recognize that a positive feedback system such as a
opmental skills can grasp the essen- the child has ultimate control of this star chart may be appropriate to use.
tials of toilet training in a few hours. situation. ALL reminders and pres- If the child continues to show no
Their approach mandates an intense sures to toilet train must cease for a interest in toilet training, there has
one-on-one day with the toddler. period of 1 to 3 months. This been a good faith effort to transfer
The day is filled with practice, rein- includes pressure from parents, control to the child, the child is
forcement, imitation, and praise. grandparents, child care providers, older than 4 years of age, and find-
A few studies have suggested that or other caregivers. ings on physical and neurodevelop-
this method may be successful for Attention to the stool texture and mental examinations are normal, a
those who have received adequate size is very important. Dietary mea- referral to a mental health specialist
training using the technique, but it sures such as decreasing fat intake may be required to explore parent-
may be problematic for many par- (eg, how much whole milk is in the ing techniques and other facets of
ents who have not received specific diet?) and increasing fluid and fiber the parent/child relationship.
training in these techniques. are an initial step. Laxatives or a
more aggressive clean-out with
enemas may be required. The parent Constipation and
Toileting Refusal may have an advantage when a Encopresis
There are only a few areas in life child has a consistent place to go to This topic is covered in Pediatrics
where a toddler has a significant have a bowel movement. A simple in Review. 1998;19:23. If a toddler
amount of control. Ultimately it is and gentle statement of, I see that has a history of constipation prior to
difficult and counterproductive to you know when you need to have a demonstrating interest in toilet train-
force a child to eat. Similarly, it is bowel movement because you usu- ing, constipation and encopresis
difficult and counterproductive to try ally go and sit behind the couch for must be addressed and resolved
to force a child to void or produce a a few minutes. Its great that you before initiating toilet training. The
bowel movement on command. know that you have to go! When constipated toddler may resist pass-
Hence, parents must be advised to you are ready to let me know so ing a large-caliber stool because of
avoid engaging in toileting battles you can have your bowel movement the associated dyschezia. This resis-
because they are not productive and in the potty, I will be glad to help tance leads to a larger, harder bowel
are potentially damaging. Such bat-
tles may damage the parent-child
relationship and the childs self-
image and likely will hinder
progress in acquiring toileting skills.
Ultimately, there is significant risk
of stool withholding as a demonstra-
tion of control on the childs part,
which may lead to acute, then
chronic constipation followed by
encopresis. As a child withholds
stool, the stool may become harder,
dryer, and larger. Children then may
withhold the stool to avoid the dis-
comfort of passing a larger, harder
stool. Parents also may note a tran-
sient change in posture or gait as the
child tries to prevent passage of an
uncomfortable stool. The child also
may establish a favorite place to
pass the stool that avoids the imme-
diate prompting of the caregiver.
Children demonstrating toileting
resistance or refusal tend to have
more difficult temperaments. Addi-
tional information suggests that stool
toileting refusal is more common if
parents have a general difficulty in FIGURE. Algorithm for addressing toileting refusal.
PIR QUIZ
Quiz also available online at 16. Most American children are toilet
www.pedsinreview.org. trained by which age?
A. 1 year.
13. A 4-year-old girl has been
B. 2 years.
completely toilet trained for the past
C. 3 years.
year. For the past week she has had
two to three episodes of day- and D. 4 years.
night-time wetting. Her mother E. 5 years.
reports that she has normal bowel 17. All of the following are signs of
movements and is drinking her toilet training readiness except:
usual amount of fluid. The most
likely cause of her secondary A. Ability to ambulate to the potty.
enuresis is: B. Ability to remain dry for 1 hour.
A. Constipation. C. Desire to please based on a
B. Diabetes insipidus. positive relationship with
C. Diabetes mellitus. caregivers.
D. Non-neurogenic bladder. D. Receptive language skills,
E. Urinary tract infection. allowing the child to follow
one- and two-step commands.
14. The pediatrician should be prepared E. Stability while the child sits on
to discuss parents toilet training the potty.
expectations at which health super-
vision visit?
A. 6 months.
B. 12 months.
C. 15 months.
D. 24 months.
E. 30 months.
15. A 5-year-old boy has been
completely toilet trained for the past
2 years. However, in the past
6 months his bowel movements
have become infrequent and quite
large, often blocking the toilet. His
parents report leakage of soft stool
in his pants when he returns from
school in the afternoon. Your evalu-
ation reveals constipation and a
dilated colon. Management plans
should include large bowel
clean-out with enemas, a program
of positive reinforcement, reduced
milk intake, increased fiber
consumption, and stool softeners,
with ongoing follow-up for a period
of at least:
A. 1 month.
B. 2 months.
C. 3 months.
D. 5 months.
E. 6 months.
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References This article cites 4 articles, 2 of which you can access for free at:
http://pedsinreview.aappublications.org/content/20/7/240#BIBL
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