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Fifteen-minute consultation: problems in the healthy child—toilet training
  1. Hannah Jacob1,
  2. Ben Grodzinski2,
  3. Caroline Fertleman3
  1. 1UCL Institute of Child Health, London, UK
  2. 2City of London School, London, UK
  3. 3Department of Paediatrics, Whittington Hospital, London, UK
  1. Correspondence to Dr Hannah Jacob, UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK; hcjacob{at}gmail.com

Abstract

Toilet training is a process that all healthy children go through. It is one of the developmental milestones for which parents most often seek medical help. Despite this, many paediatricians feel unconfident managing children presenting with a toilet training problem. We address some common questions arising when assessing and managing such a child, including identifying rare but important diagnoses not to miss.

  • General Paediatrics
  • Paediatric Practice

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When are children usually toilet trained?

As with many developmental milestones, there is a range of ages over which a child may be toilet trained and there is considerable culture variation.1 In Western cultures, children usually begin toilet training between 24 and 36 months. Establishing reliable daytime continence takes around 5 months and is typically achieved 3 months earlier in girls than boys.2 One American study reported a median age for daytime continence of 32 months for girls and 35 months for boys.3 This compares with near-complete continence reported in a cohort of Vietnamese children by 24 months.4 Children are usually out of nappies during the day around 1 year before they are continent at night. Those with learning disabilities are likely to be toilet trained later.5

Box 1 identifies some of the signs that a child may be ready to start toilet training. There is clearly a spectrum of acquisition of these skills and they need not all be present for toilet training to commence.6

Box 1

Signs that a child may be ready to start toilet training

  • Knows when they need to pass urine or stool and may tell parent

  • Interested in other people using toilet or potty

  • Longer gaps between wet nappies (>2 h)

  • Has sufficient language skills to discuss toileting

What advice do parents receive about toilet training?

As with any aspect of parenting, advice about toilet training may come from health visitors and other health professionals as well as family and friends. The NHS Choices website emphasises the importance of waiting until a child is showing signs of being ready and family life is relatively stable.7 It is well documented that attempts at toilet training can be hampered by events such as the arrival of a new sibling, moving house or changing childcare provider.8 Nevertheless, it is important to remember that comparison is inevitable and children as well as parents will be acutely aware of the toilet training skills of their peers.9

Key messages

  • Most children presenting with delayed toilet training are normal and the family needs reassurance, support and time.

  • Delayed toilet training can, rarely, be an indicator of underlying pathology that must be investigated and treated as soon as possible.

  • Advice and support are available from other health professionals such as health visitors and high-quality websites such as NHS Choices.

How do you toilet train a child?

There are a range of methods that can be used to toilet train a child. All involve encouraging the child in a supportive environment to recognise the need to pass urine or stool and then holding on until the potty or toilet is available. All children have accidents and these may occur several times a day at the start of toilet training.

Little evidence exists about the best way to toilet train a child, but it is important to recognise the conflicting advice parents may have received. Some advocate the use of pull-ups, while others suggest switching straight from nappies to cotton underwear. Some recommend building up the periods of time a child spends without a nappy, while others support going straight to whole days nappy free. Some suggest using a potty until full continence is achieved and then transferring to the toilet, while others recommend using the toilet (with child seat) as soon as possible. The method of toilet training is not particularly important. Parents must recognise that toilet training in a low-key, supportive way is the key to success.

What should I ask in my history?

The history should establish what exactly the parent and child feel the problem is and then subsequent questions can be directed at ruling out particular diagnoses. The assessment must include exploring details of bladder and bowel habit, diet and other developmental milestones. Given high parental anxiety about delayed toilet training, it can be helpful to identify features suggesting undue pressure or life events which may have exacerbated the problem. It is also important to establish what the familial and cultural expectations around toilet training are as these can influence the parental perception of delay. Table 1 details some of the causes of delayed toilet training and relevant features in the history.

Table 1

Causes of delayed toilet training and common features in the history

What are the red flags in the history?

Delayed toilet training in the presence of lower limb involvement such as weakness is concerning for involvement of the spinal cord. Abdominal masses or the presence of constitutional symptoms need further exploration for possible malignancy, though faecal matter may be palpable in a child with constipation. Delayed toilet training can, rarely, be a presentation of sexual abuse and children may refer to their genitals in a sexualised manner or report vaginal discharge or genital lesions. A child who previously achieved continence and has gone back to recurrent wetting and soiling may have a behavioural problem or an underlying organic cause such as a tumour.

What should I include in my examination?

All children presenting with delayed toilet training need a thorough examination. Measure and plot the child's weight and height. When examining the abdomen, check for palpable masses, scars and distension. A perineal examination may reveal anal fissures and nappy rash. Check the sacral region for hair, pits or birthmarks. In boys, examine the penis, ensuring the urethral orifice is correctly sited and that there is no inflammation of the foreskin. Note that the foreskin might not be fully retractile; foreskins may not fully retract until 7 years old. In girls, check for vulval inflammation.

What would be concerning on examination?

The presence of any masses or significant weight loss warrants further investigation. Lower limb weakness or paraesthesia could indicate a spinal mass and sacral hair, pits or birthmarks could suggest spina bifida occulta. Vaginal discharge or lesions such as warts may indicate sexual abuse.

How should I investigate a child with delayed toilet training?

Further investigation will be guided by the history together with the examination and may not be necessary at all.

If indicated, some common investigations include:

  • Urine dipstick and microscopy, culture and sensitivities—microscopy and culture may identify a urinary tract infection. The presence of glucose is suggestive of diabetes mellitus.

  • Abdominal/pelvic ultrasound—can assess for incomplete bladder emptying if the history suggests detrusor instability. Important also in a child with a palpable mass or lower limb symptoms.

  • Abdominal X-ray—not recommended unless faecal impaction is suspected and abdominal examination is unreliable or not possible.

  • MRI spine—should be undertaken if underlying neurological abnormality is suspected.

How should I manage a child with delayed toilet training?

All children and parents should be given advice about keeping well hydrated and eating a balanced diet with plenty of fresh fruit and vegetables.10 Fibre and fluid intake need not be more than normal, but it is important to check that existing guidance is being followed by parents.11 Regardless of the cause, it is important parents recognise the need to be supportive of their child and avoid being critical or unduly negative about delayed toilet training. Incentives such as star charts can be employed to good effect. Equally, parents may need reassurance and it can be helpful to explain the wide age range over which children are potty trained.

Beyond this general advice, ongoing management will depend on the cause. Table 2 outlines the management of some common causes of delayed toilet training.

Table 2

Management of some common causes of delayed toilet training

Who should I involve in ongoing management?

Health visitors can be invaluable in the ongoing management of delayed toilet training. They may know the family already and can visit them in their homes, offering advice and support in a non-healthcare environment. General practitioners are often the first port of call for problems such as constipation and should be involved in any planned disimpaction regime. It can be helpful for childcare providers such as nurseries and childminders to be informed about the plan for a child with delayed toilet training, particularly if the parents or child feel pressure about the child achieving continence there. It may be appropriate with the parents’ permission to include childcare providers in the correspondence resulting from a clinic visit.

Are there other sources of information I can provide for parents?

There is a wealth of information about toilet training on the internet, much of which lacks any evidence base despite its authoritative tone. Parents should be directed to NHS or other robust sources, some of which are detailed in box 2.

Box 2

Sources of information about toilet training for parents

Conclusion

Toilet training can be challenging for parents whenever it happens, though most never seek medical attention. When a child presents with delayed toilet training, they must be thoroughly assessed and investigated as appropriate to ensure important diagnoses are not missed. Throughout the process and regardless of the cause, parents and children should be supported, as delayed toilet training can be embarrassing and stressful.

Test your knowledge

  1. Which of the following occur commonly during normal toilet training?

    1. Accidental wetting

    2. Simultaneously achieved daytime and night-time continence

    3. Temporary regression with disruptive life events

    4. Urinary tract infections

    5. Weight loss

  2. Which of these features in the history are red flag signs of underlying pathology?

    1. Constipation

    2. Loss of appetite

    3. Secondary incontinence

    4. Tantrums

    5. Weight loss

  3. Which of these methods have robust evidence for effectiveness in toilet training?

    1. Gradual increase in nappy-free periods

    2. Parental support and encouragement

    3. Pull-up nappies

    4. Star charts

    5. Threats

  4. Which of the following examination features would be concerning when assessing a child with delayed toilet training?

    1. Genital warts

    2. Hard abdominal mass

    3. Leg weakness

    4. Reluctance to be examined

    5. Weight loss

  5. In which of the following conditions may laxative be useful?

    1. Anal fissure

    2. Detrusor instability

    3. Functional constipation

    4. Urinary tract infection

    5. Vulvovaginitis

  • The answers are after the references.

Answers to the multiple choice questions

  1. A, C

  2. B, C, E

  3. B, D

  4. A, B, C, E

  5. A, B, C

Case 1

A 3-year-old girl with normal variant toilet training

Shanelle is a 3-year-old girl seen in a general paediatric clinic with her mother who is concerned that Shanelle is not yet potty trained. All her peers at the drop-in playgroup are out of nappies during the day. She is due to move to a preschool nursery in 2 months and staff have told her parents that she must be potty trained by the time she starts.

Shanelle is generally well, has around five wet nappies and one dirty nappy a day. She has no genital soreness, vaginal discharge or abdominal pain and her stools are soft. She has reached all her developmental milestones so far and when asked, reports feeling scared about starting preschool nursery. On examination, she looks well and is tracking the 25th centile for weight and height. Her abdomen is soft with no masses. Urine dipstick is normal.

Shanelle is diagnosed with normal variant delay in toilet training, likely exacerbated by pressure to be toilet trained in time for preschool nursery. She and her mother are advised about healthy eating, adequate hydration and minimising pressure around toilet training.

At follow up with the health visitor 6 weeks later, Shanelle is out of nappies all day with an accident only once or twice a week.

Case 2

A 3-year-old girl with neuroblastoma

Frances is a 3-year-old girl seen in a general paediatric clinic with her mother who is concerned that Frances is not yet potty trained. Her mother is sure her older sister was using the toilet by this age. Frances’ mother has tried her without a nappy but reports that she often goes all day without doing a wee and may not poo for up to a week at a time. Frances complains of having a tummy ache which she feels is caused by her reluctance to use the potty. She is often tired and this is put down to recently starting at nursery.

On examination, Frances is thin and pale. She has dropped from the 75th centile to 25th centile for weight over the last 6 months. Her abdomen is soft with a palpable mass suprapubically. Urine dipstick is normal but an abdominal ultrasound reveals an 8 cm mass abutting the bladder and rectum. Further imaging and a biopsy reveal that this is a neuroblastoma.

Frances is referred to a paediatric oncologist and undergoes chemotherapy and surgery.

References

Footnotes

  • Contributors HJ drafted the manuscript. BG and CF provided critical review of the draft. All authors approved the final version.

  • Funding HJ is an Academic Clinical Fellow funded by the National Institute for Health Research.

  • Competing interests CF has written two books for lay parents about potty training.

  • Provenance and peer review Commissioned; internally peer reviewed.