Toilet Training

Robert S. Michel
Pediatrics in Review 1999;20;240
DOI: 10.1542/pir.20-7-240

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 ARTICLE

Toilet Training
Robert S. Michel, MD*
should be considered encopretic
OBJECTIVES until proven otherwise.
After completing this article, readers should be able to:

1. List the age-appropriate factors related to toilet training. Epidemiology

2. Name the age by which the majority of American children are toilet
trained.
3. Delineate what percent of 5-year-old children experience primary
nocturnal enuresis despite daytime bladder control.
4. Describe antecedants to toilet training refusal.
5. Describe the potential consequences of stool withholding.
Introduction
Acquiring toileting skills is a nearly
universal developmental milestone,
but the path to toilet training has
changed substantially over the past
century. Parents need guidance in
recognizing when their child is
ready to acquire toileting skills, how
to help their child acquire those
skills, and how to address problems
in toilet training. Problems may
include toileting refusal, stool with-
holding, and constipation with or
without encopresis. It is important to
recognize that current views on toi-
let training are based on the physical
and psychosocial development of the
child, including culture differences,
which should be noted.
Definition
A child has achieved bladder control
when there no longer is involuntary
leakage of urine. Enuresis (involun-
tary leakage of urine) is categorized
as diurnal (daytime) versus noctur-
nal (during sleep) and primary ver-
sus secondary. Primary diurnal
enuresis should be evaluated if the
child is older than 48 months of age.
Other indications for evaluation of
primary diurnal enuresis at any age
are concerns of dysuria, gross
changes in the appearance or odor
of the urine, or abnormalities in the
urinary stream.
Secondary diurnal enuresis
implies that bladder control has been
consistent for at least 3 months. In
*Associate Professor of Pediatrics,
University of Virginia Childrens Medical
Center, Charlottesville, VA.
the preschooler who recently
acquired urinary control, diurnal
enuresis should prompt a review of
psychosocial stressors. Secondary
diurnal enuresis always should be
evaluated with a thorough history
and physical examination. Common
reasons for secondary enuresis
include urinary tract infection and
diabetes mellitus. Additional causes
of diurnal enuresis include constipa-
tion, congenital or acquired neuro-
genic bladder, urethral obstruction,
and ectopic ureter. (A complete
review of diurnal enuresis can be
found in Pediatrics in Review.
1997;18:407.)
Primary nocturnal enuresis (PNE)
is common, with 20% of 5-year-olds
never having been dry consistently.
One year later, 50% of these chil-
dren are consistently dry through the
night. However, the rate of sponta-
neous resolution of PNE slows after
age 6. Approximately 15% of the
remaining children who have PNE
become dry each year. Most parents
seek help and a medical evaluation
for their children between the ages
of 5 and 7 years. (A thorough
review of PNE can be found in
Pediatrics in Review. 1997;18:183.)
Bowel control is achieved when
there is no longer the involuntary
leakage of stool from the rectum.
Although many children acquire
bowel control prior to bladder con-
trol or both at the same time, at
least 10% of children have a gap
between initially acquiring bladder
control and then bowel control.
Bowel control is not categorized as
daytime and nighttime control.
Indeed, the older child who has per-
sistent nocturnal stool incontinence
The age at which parents have
begun working on their childrens
toileting skills has changed over the
years. There also are important cul-
tural influences. Most American
children achieve control of bladder
and bowel function between 24 and
48 months of age. Approximately
25% are toilet trained at 24 months
of age, 85% at 30 months of age,
and 98% at 36 months of age. Girls
tend to achieve control slightly
sooner than boys. These findings are
consistent with other industrialized
western cultures.
Among the Digo people in East
Africa, toilet training is begun in the
first weeks of life, with the expecta-
tion that urinating and stooling on
command will be achieved by 4 to
5 months of age (see deVries in
Suggested Reading). The method
employed by the Digo people
depends on nearly continuous con-
tact with the caregiver, placing the
burden on the caregiver, often an
older sister, to recognize subtle cues
given by the infant prior to voiding
or stooling.
When examining toilet training, it
is important to address the defined
end-point as well as when and how
the issue is addressed initially by
caregivers. Is the end-point consis-
tent dryness or is it the autonomous
use of the bathroom by the child
with no prompts by the caregiver? It
is difficult to compare studies look-
ing at age of toilet training because
of different definitions of end-points.
Therefore, it is most important to
assess the primary caregivers
expectations early in the course of
health supervision examinations.
Readiness for Toilet
Training
In 1962, Brazelton suggested a more
child-directed approach to toilet
training, which continues to be the
mainstay of advice shared by pedia-
tricians today. This approach takes

240 Pediatrics in Review Vol. 20 No. 7 July 1999

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 PSYCHOSOCIAL
Toilet Training

into account both physiologic and
behavioral readiness. At the begin-
ning of the 1900s, there was a
laissez-faire approach to toilet train-
ing in the United States. In the
1930s, training involved the child as
a passive participant of reflex condi-
tioning, stressing physiologic readi-
ness alone. Indeed, the parent-
directed approach may have been
early from even the physiologic
perspective.
In the first year of life, the blad-
der reflexively empties about
20 times daily. At 9 to 12 months of
age, reflex sphincter control can be
elicited, and between 12 and 18
months of age, the extrapyramidal
tracts are myelinated. Both sphincter
control and extrapyramidal tract
myelinization are required for blad-
der and bowel control. A greater
challenge is to balance these physio-
logic features with the psychological
maturational features of an individ-
ual child; variables important to all
aspects of parenting come into play.
These variables include the familys
daily routine and environment,
parental expectations, setting of lim-
its, and the ability of the parents to
follow through with expectations
and limits. In addition to parenting
skills, the childs temperament is a
crucial variable. Toddlers who are
18 to 24 months of age still demon-
strate negativism in some interac-
tions with others. Strong-willed
toddlers are more difficult to toilet
train.
Readiness for toilet training var-
ies from child to child and should
take into account the points noted in
Table 1. These seven items encom-
TABLE 1. Signs of Toilet
Training Readiness
The ability to ambulate to the
potty.
Stability while sitting on the
potty.
Ability to remain dry for
several hours.
Receptive language skills that
allow the child to follow one-
and two-step commands.
Expressive language skills that
allow the child to
communicate the need to use
the potty with words or
reproducible gestures.
The desire to please based on
a positive relationship with
caregivers.
The desire on the childs part
for independence and control
of bladder and bowel
function.
pass motor, language, and social
milestones as well as the childs
demeanor and relationship with the
parent. By approaching toilet train-
ing from this perspective, the parent
can adapt his or her expectations
and process to the physical and
behavioral development of the child.
In other words, rather than
approaching toilet training simply as
a function of a childs chronologic
age, we should approach it based on
the motor, cognitive, and psychoso-
cial development of the child and
the relationship of the child with the
primary caregiver.
Toilet Training Procedures
(Table 2)
Several decades ago, in the era of
parent-directed toilet training, infants
and toddlers were perched over the
receptacle periodically throughout
the day. There were multiple verbal
prompts throughout the day encour-
aging use of the potty. More coer-
cive methods also were used with
strong negative reinforcement. Data
on the effects of this approach are
limited, but they suggest that
although the age at which toilet
training was initiated was younger
with the parent-directed approach,
the age at which the child success-
fully achieved independent toileting
skills was not dramatically earlier
than with the child-directed
approach. Unfortunately, because
studies use different end-points
(independent control versus child
indication of need with caregiver
attending to the need), they cannot
be compared directly.
The introduction of disposable
diapers may have contributed to the
acceptance of Brazeltons child-
centered approach. By the 1970s,
most families used disposable dia-
pers. Indeed, the use of cloth diapers
is uncommon today. Gone are the
pressures to toilet train the toddler
to relieve the caretaker from rinsing
stool-filled cloth diapers in the com-
mode and to get rid of the nasty
diaper pail! Some wonder whether
the child-directed approach leads to
urine and stool continence at a later

TABLE 2. Steps to Potty Training

1. Decide on the vocabulary for referring to bodily fluids, functions, and anatomy. Deal with potty training
matter-of-factly.
2. Select a potty-chair and place it in a convenient place for the child to have ready access; allow the child to
watch parents use the toilet.
3. Encourage the child to tell the parent when he or she needs to urinate or have a bowel movement. Give
praise upon success or even for the child telling the parent after the fact. Learn the childs behavioral cues
when he or she is about to urinate or have a bowel movement.
4. Encourage the child with praise. Do not expect immediate results. Do not get upset with mistakes. There is
no role for punishment or negative reinforcement.
5. After repeated success, suggest the use of cotton underwear or training pants. Make this a special moment.
Adapted from Toilet Training Guidelines for Parents, American Academy of Pediatrics parent education publications, 1993.

Pediatrics in Review Vol. 20 No. 7 July 1999 241

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 PSYCHOSOCIAL
Toilet Training

age, although it is difficult to find
data to substantiate this hypothesis.
If this is true, there might be public
health implications. The large num-
ber of children in child care and
preschool settings at earlier ages
offers opportunities for the spread of
hepatitis and other enteric pathogens
that would be lessened if the chil-
dren involved had mastery of toilet-
ing and handwashing skills.
Toilet training should begin with
an assessment of parental expecta-
tions at the 12-month health supervi-
sion visit (Table 3). Educational
materials should be provided to
familiarize parents with toileting
readiness skills and developmental
expectations. Additional materials
outlining a child-directed approach
should be provided at the 15- or
18-month visit.
Using Brazeltons approach, the
parent follows the childs cues for
moving from one stage to the next.
Initially, the child simply is exposed
to the potty-chair. During the same
interval the child should be allowed
to watch the parent use the toilet.
Frankly, most parents freely admit
to losing bathroom privacy when
there is a toddler in the home. Dur-
ing this phase the parents should use
a matter-of-fact terminology for
anatomy as well as urine and stool.
Words that imply shame (eg,
dirty) should be avoided.
Next, the child is encouraged to
sit on the potty while fully dressed.
He or she may be encouraged to
look at books or play with a toy.
Initially, most children feel more
comfortable using a potty-chair than
being perched on an adult-sized toi-
let; the child will be more stable
with both feet firmly on the floor.
The next step is to have the toddler
sit on the potty after a wet or soiled
diaper has been removed. The wet
or soiled diaper may be placed in
the potty to demonstrate the function
of the potty-chair. This is followed
by the child being led to the potty
several times a day and encouraged,
but not forced, to sit on the potty
without wearing a diaper. When the
child expresses a spontaneous inter-
est in sitting on the potty-chair, he
or she should be praised irrespective
of whether voiding or defecation has
occurred. A few minutes on the
potty are ample; the parent should
not encourage prolonged sessions.
Finally, a child may be guided
toward a routine of sitting on the
potty after waking in the morning,
after meals or snacks, and before
naps and bedtime.
Using this method, a child usu-
ally will gain control of bladder and
bowel function in a few weeks. Pos-
itive reinforcement often is coupled
with this step-by-step program. Food
or candy rewards should be discour-
aged because this provides an
unhealthy message to reward posi-
tive behavior with food. The reward
must be immediate because toddlers
and preschoolers have difficulty
with delayed gratification. A calen-
dar on which stickers or stars can be
placed may be posted in a visible
and accessible place to remind the
child of his or her successes.
Developing a toileting routine
should be coupled with teaching
proper hygiene. Girls should be
taught to wipe gently from front to
back to avoid vaginal and urethral
contamination with perirectal flora.
Additionally, all children should be
prompted to wash their hands after
using the potty.
A child who has demonstrated a
week or more of consistent success
may be ready to try training pants or
cotton underpants. This provides a
good opportunity for positive rein-
forcement. Conversely, the child
who has a series of wetting or soil-
ing accidents soon after trying train-
ing pants or cotton underpants
should have the option of returning
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

242 Pediatrics in Review Vol. 20 No. 7 July 1999

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 PSYCHOSOCIAL
Toilet Training

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.

Pediatrics in Review Vol. 20 No. 7 July 1999 243

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 PSYCHOSOCIAL
Toilet Training
TABLE 4. Commonly Used Agents for Treating Constipation
Enemas
Fleet
Mineral oil
Milk and Molasses
Laxatives
Milk of Magnesia
Haleys MO (75% M.O.M.
25% mineral oil)
Senekot
Mineral oil
movement and greater discomfort
when trying to pass the stool, setting
up a negative feedback cycle. If the
constipation is ongoing, the child
may develop acquired megacolon.
Therefore, the child may not sense a
full rectum, resulting in overflow of
liquid stool. A thorough history and
physical examination should be per-
formed to look for clues to an
organic versus functional etiology.
Functional constipation should be
addressed early with established
follow-up. Initially a diet history
should be used to evaluate the fat
(especially whole cow milk) versus
fiber content of the intake. Exces-
sive whole cow milk (32 oz per
day) may provide too much fat,
which will slow gut motility, and
may satiate the child without ade-
quate intake of water, fruit, and veg-
etable fiber that promotes softer
244
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1 oz/10 kg body weight
Maximum, 4.5 oz
2 oz/10 kg body weight
Maximum, 4.5 oz
50:50 mixture
Maximum, 6 oz
1 mL/kg per dose
Maximum, 60 mL bid
1 mL/kg per dose
Maximum, 60 mL bid
,6 y, 5 to 10 mL/d
.6 y, 10 to 15 mL/d
1 to 4 mL/kg per day divided bid
Maximum, 60 mL bid
stools. If dietary manipulation does
not remedy the situation quickly,
administration of a laxative and
careful attention to adequate water
intake are required (Table 4). Prior
to recommending a laxative, a rectal
examination should be performed to
rule out fecal impaction. If fecal
impaction is present, enemas should
be used to relieve the impaction to
avoid excessive abdominal pain and
cramping. A pediatric enema twice a
day for 2 to 3 days (until the stool
results are essentially watery) should
be followed by a clearly outlined
plan for the use of laxatives. If the
constipation is chronic and acquired
megacolon and encopresis are con-
siderations, careful follow-up is
essential. Parents need to understand
the chronic nature of the condition
and the amount of time (3 to
$12 mo) needed to treat acquired
Pediatrics in Review
megacolon as a result of chronic
constipation. The parents and child
will need a significant amount of
support and reassurance. A clear
plan must be in place if the child
returns to a pattern of more than
48 hours without a bowel
movement.
Summary
Toilet training is a milestone antici-
pated by all parents, who will bene-
fit from anticipatory guidance rela-
tive to the timing and process. The
process may need alterations to suit
children who have special physical
or emotional needs or to encourage
a positive experience based on the
childs temperament. As with nearly
everything in parenting, the whole
picture must be taken into account.
In addition to the physical, neurode-
velopmental, and emotional develop-
ment of the child, it is wise to con-
sider the parent/child relationship
and cultural influences.
SUGGESTED READING
Azrin NH, Foxx RM. Toilet Training in Less
Than a Day. New York, NY: Simon and
Schuster; 1974
Berk LB, Friman PC. Epidemiologic aspects
of toilet training. Clin Pediatr. 1990;29:
278 282
Brazelton TB. A child-oriented approach to
toilet training. Pediatrics. 1962;29:
121128
deVries MW, deVries MR. Cultural relativity
of toilet training readiness: a perspective
from East Africa. Pediatrics. 1977;60:
170 177
Luxem M, Christopherson E. Behavioral toi-
let training in early childhood: research,
practice and implications. J Devel Behav
Pediatr. 1994;15:370 378
Maizels M, Gandhi K, Keating B, Rosen-
baum D. Diagnosis and treatment for chil-
dren who cannot control urination. Current
Problems in Pediatrics. 1993;23:402 450
Vol. 20 No. 7 July 1999
 PSYCHOSOCIAL
Toilet Training

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.

Pediatrics in Review Vol. 20 No. 7 July 1999 245

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 Toilet Training
Robert S. Michel
Pediatrics in Review 1999;20;240
DOI: 10.1542/pir.20-7-240

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