Patient information: Toilet training

TOILET TRAINING OVERVIEW

Learning to use the toilet is an important milestone for both parents and children. For parents, it means freedom from diapers and new worries about accidents. For a child, it is a step toward independence and self-sufficiency.

Before you begin toilet training, it is important to know if your child is ready, how to help your child, and what to do if there are problems along the way.

This article will address some of the most common questions about toilet training and will let you know when to seek help. Articles about other common toileting issues are available separately. (See "Patient information: Bedwetting in children" and "Patient information: Constipation in infants and children".) More detailed information about toilet training is available by subscription. (See "Toilet training".)

IS MY CHILD READY?

Developmental skills — The age when a child is ready to learn to use the toilet depends upon a number of factors, and this can vary from one child to another. Most children are able to stay dry during the day by age two to four years, while staying dry at night may happen at the same time or may take months or years longer.

Most experts agree that before starting toilet training, a child should be able to do the following:

• Walk to the toilet
• Sit up on the toilet
• Stay dry for several hours or wake up dry after a nap
• Pull clothes up and down
• Follow simple instructions
• Communicate the need to go to the toilet
• Demonstrate independence by saying "no"
• Show interest in toilet training
• Express a desire to please (give gifts, enjoy praise)
• Imitates adults and older children

If your child has trouble with constipation, experts recommend getting that under control before starting to toilet train. Chronic constipation can lead to painful bowel movements, which can lead to withholding stool and refusal to use the toilet. (See "Patient information: Constipation in infants and children".)

Children with special needs — Children who have chronic illnesses, such as asthma or sickle cell disease, do not necessarily need to start toilet training later than a healthy child. It may take longer for an ill child to complete the toilet training process and there may be more setbacks, but with encouragement and patience, success is possible.

Ask your child's healthcare provider for advice about toilet training your special needs child. You may need to observe more closely for patterns and cues that signal the child is ready to eliminate. The tasks involved in toilet training do not differ for children with special needs, although you may need to make some changes, such as:

• Carrying a child to the potty chair who cannot walk or crawl
• Helping a child who cannot use his or her hands to remove clothing and wipe after a bowel movement

Parents of children with autism and related disorders may wish to read the book "The Potty Journey: Guide to Toilet Training Children with Special Needs," by Judith A. Coucouvanis. This book provides strategies to make the training process easier in this special group of children but promises no "quick fixes."

Am I ready to help? — Parents also need to be ready to start the toilet training process. At least one parent will need to devote time and emotional energy to toilet training on a daily basis for at least three months. This usually means giving lots of positive reinforcement, preparing for accidents, and doing additional laundry.

Consider delaying toilet training if you are preparing for a new child, moving to a new home, returning to work, or if the child is entering day care; making too many changes at once can make toilet training more difficult and increase the chances of frustration and failure.

It can be hard to resist pressure from other parents, family members, or teachers, who may expect your child to be toilet trained by a certain age. Toilet training is not a contest. Success with toilet training does not mean that your child is more intelligent or advanced than other children. Additionally, having trouble with toilet training or starting at a later age does not mean that your child is lazy, stubborn, defiant, or a slow learner. And remember — accidents are going to happen.

How long will it take to learn? — The average time it takes a child to learn to stay dry during the day is six months, and most children learn to control their bowels before or at the same time. Staying dry at night takes months to years longer. Girls usually complete toilet training earlier than boys. First children usually take longer than subsequent children to complete toilet training.

STARTING TOILET TRAINING

Toilet training involves many steps: talking, undressing, sitting, wiping, dressing, flushing, and hand washing. Going through these steps every time helps to reinforce proper toileting skills.

• Decide what words you will use to describe toileting and try to be consistent; examples include pee, poop, potty. Keep in mind that your child will use these words with other adults and children.
• Before you begin training, change your child's diaper frequently so that he or she will learn to prefer dry diapers.
• Buy a potty chair with your child. In the beginning, a potty chair is easier to use compared with an over-the-toilet seat. Consider buying more than one chair if you have a multi-level home. Allow your child to decorate the potty chair and make it his/her own special chair.
• Place the potty chair in a convenient location, such as the child's playroom or bedroom. Easy access is important.
• Encourage the child to sit on the potty chair, fully dressed, to look at books or play with toys.
• Talk about toilet training with your child using books or videos. (See 'Books for children' below.)
• Make regular trips ("practice runs") to the potty chair, particularly after first waking up in the morning and after meals, when a child is more likely to have a bowel movement.
• After your child is comfortable sitting on the potty chair fully dressed, encourage your child to sit on the chair without a diaper. Place a wet or dirty diaper in the chair to help the child understand the chair's purpose.
• Encourage the child to tell you when s/he needs to go. Watch for signs that your child needs to go, like squirming or holding the genitals. Go with the child to the potty chair, and praise the child when s/he goes in the chair. Be patient because it may take days or weeks before the child is successful. And remember that setbacks are common.
• Do not punish, threaten, or speak harshly to the child if s/he has accidents or will not use the potty.
• Transition to training pants (washable, thick underwear) or cotton underwear after your child is using the potty chair. Do not rush your child out of diapers. Allow the child to return to diapers if s/he is unable to stay dry. A star or sticker chart can be helpful in encouraging your child to use the potty.
• Once your child has mastered the potty chair, s/he can be transitioned to an over-the-toilet seat with a step stool. A stool gives the child leverage to push against as s/he bears down to move the bowels. The stool also helps the child to feel more stable while sitting on an adult-sized toilet.

Tips — As you work with your child, keep the following tips in mind:

• Try to keep a positive and loving attitude and avoid becoming angry when the child has accidents.
• Keep your child in loose, easy-to-remove clothing (or naked, if you prefer). Avoid clothing with complicated snaps and buttons during the training period.
• Keep an extra set of clothing with you and wherever an accident might happen (at school, in the car, at relatives' houses).
• Avoid battles over toilet training. If your child is not interested, stop toilet training for a while before trying again.
• Do not flush the toilet while your child is on it; this can be frightening.
• At first, teach boys to urinate while sitting on the potty chair. Teach them to urinate while standing after they have learned to have bowel movements in the potty chair.
• Keep stools soft by offering plenty of high-fiber foods and limiting dairy products to no more than the equivalent of three eight-ounce cups of milk per day.
• The child can transition from diapers to training pants or cotton underwear once he or she is successful using the potty.
• Wait to use underwear at night or during naps until your child is consistently dry during the day. Consider forgoing disposable pull-ups because these products keep the child feeling so dry that the child may not be aware they have wet.
• Remind your child to use the toilet after first waking up in the morning, and at other times throughout the day. However, try not to over-remind.
• If your child is not making progress, stop toilet training for two to three months.

Toilet training and child care — If your child attends child care, toilet training will be a shared responsibility between you and your day care provider(s). Parents and child care providers should communicate frequently about successes and setbacks, as well as techniques that have been helpful. Ask child care providers and other caregivers to use toilet training methods similar to those you use at home to avoid confusing the child.

In addition, reusable (cloth) training pants are not recommended in a child care setting because of the risk of spreading germs to other children.

TOILET TRAINING PROBLEMS

Toilet training can be a challenging process, full of both successes and failures. The most common problems that occur during the toilet training process include temporary setbacks, bedwetting, and refusing to use the toilet. We'll address each of these issues here.

Temporary setbacks — It is completely normal for a child to have accidents, especially early in the toilet training process. Remind your child to slow down and take a potty break when needed, especially while playing, after meals, before a car trip, and before going to bed.

Even after a child has been completely toilet trained, changes in the child's daily routine can lead to accidents. Occasional accidents can happen, even after the child is completely toilet trained.

If your child is not making progress with toilet training and is between two and four years old, it is reasonable to take a break for two to three months. If your child is over four years of age, is healthy, and is not toilet trained after several months of trying, talk with your child's doctor or nurse.

Bedwetting — Bedwetting is a common problem that affects 20 percent of five-year-olds and 10 percent of six-year-olds. You can read more about bedwetting in a separate article. (See "Patient information: Bedwetting in children".)

Refusing the toilet — Up to 20 percent of children will refuse to use the toilet. Some children are willing to use the toilet to urinate but will not use it for bowel movements. Instead, the child may hide and have a bowel movement in their diaper.

There are a number of possible reasons why a child might refuse to use the toilet. Most experts recommend the following:

• Have one last talk about toilet training with your child. Tell your child that his poop wants to be in the toilet and it is his job to help the poop come out.
• Do not punish or nag the child.
• Stop toilet training for a few weeks or months. Stop reminding the child to use the toilet. He or she has complete control over the process.
• Encourage the child to imitate you or your other children by inviting the child into the bathroom to watch.
• Encourage the child to change his/her own diapers.
• Treat hard stools or constipation if needed. Having painful or difficult bowel movements can lead to toilet training set backs and long-term problems with constipation. (See "Patient information: Constipation in infants and children".)
• Create a star or sticker chart and reward your child for both trying and successfully having a bowel movement on the toilet.

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed every four months on our web site (www.uptodate.com/patients).

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information

Patient information: Bedwetting in children
Patient information: Constipation in infants and children

Professional level information

Constipation in children: Etiology and diagnosis
Prevention and treatment of acute constipation in infants and children
Toilet training
Treatment of chronic functional constipation and fecal incontinence in infants and children

The following organizations also provide reliable health information.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/toilettraining.html)

• American Academy of Pediatrics

      (www.aap.org/healthtopics/toilettraining.cfm)

• KidsHealth

      (http://kidshealth.org/parent/emotions/behavior/toilet_teaching.html)

Books for children — Parents and children may find the following books helpful in the toilet training process:

• No More Diapers by JG Brooks
• Your New Potty by Joanna Cole
• Once Upon a Potty by Alona Frankel (versions for boys and girls available)
• All By Myself by Anna Grossnickle Hines
• Going to the Potty by Fred Rogers
• KoKo Bear's New Potty by Vicki Lansky
• The Princess and the Potty by Wendy Cheyette (The Prince and the Potty also available)
• It Hurts When I Poop! A Story for Children Who Are Scared to Use the Potty by Howard Bennett
• The New Potty by Gina Mayer and Mercer Mayer

Videos for children

• Once Upon a Potty for Her by Alona Frankel (version for boys also available)
• It's Potty Time, Duke Family Series

Books for parents — Many books about toilet training are available for parents; we have listed a few that we have found helpful. Some other books tout a strategy that will allow older children to potty training faster. However, these methods put too much pressure on some children to achieve dryness in a short time. Consult your healthcare provider for opinions on methods s/he thinks would work best for your child's personality and habits.

• Toilet Training the Brazelton Way by TB Brazelton
• The American Academy of Pediatrics Guide to Toilet Training by Mark Wolraich
• Parents Book of Toilet Teaching by Joanna Cole

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