Toilet TrainingPediatric Issues Presentation

Amy Carlson

NSG 625

Toilet Training

Description of issue

History

Different methods

Epidemiological issues

Readiness

Problems

Treatment Options

References

Handout

Description of issue

Toilet training is an important milestone for both parents and children

This area of pediatric care presents a critical opportunity for anticipatory guidance

Parents need guidance in:Recognition of readinessHelping their child achieve necessary skillsAddressing problems when they occur

History

Early 1900’s- stressed physiologic readiness, involving the child as a passive participant

1920’s & 30’s- early training and rigid scheduling were recommended

1940’s- pediatric experts began advocating parents wait until they observed signs of developmental readiness

1960’s- 2 major theories emerged:1. The Parent Oriented Approach

2. The Child Directed Approach

Parent Oriented Training

Developed by Azrin & Foxx, 1972

Consists of speed training using 4 basic concepts:1. Increased fluid intake

2. Regularly scheduled toilet times

3. Positive reinforcement for correct elimination

4. Overcorrection for accidents (eg, verbal reprimands or time out from positive reinforcement)

Mean time of training: 3.9 hours (range 0.5 to 14 hours)

Child-Oriented Training

1962- Dr. T. Berry BrazeltonBegin toilet training only after certain physiologic

and behavioral criteria and readiness are metStressed importance of letting the child master each

step at his or her own pace with minimal conflictAssociated with:

High rates of continence Fairly rapid training time Low long-term regression rates

Many current toilet training methods are based upon this approach

Comparison of the two Methods

Both parent-oriented and child-oriented approaches resulted in quick, successful toilet training among healthy children

The two methods have not been directly compared- so we cannot make any definitive decisions of method superiority

Epidemiological issues

Age of Toilet Training varies by: Culture Timing Gender

United States

26% of children achieve daytime continence by 24 months of age

85% by 30 months

98% by 36 months

Most children achieve bowel and bladder control by 24-48 months.

In 1947 most U.S. children achieved this by 18 months old.

Cultural Differences in US

Most African Americans believe potty training should be started at age 18 months.

Caucasians more commonly propose 24 months as a starting time.

50% of African American parents, compared to 4% of Caucasian parents agree that it is important to be trained by two years of age.

Timing

The average length of time required to achieve toilet training is:

6 months for daytime urinary continence 6-11 months for stool continence

Earlier initiation of toilet training (<27 months old) is assoc. with longer duration

First born children take longer than subsequent siblings (2 months longer)

Gender

Girls generally achieve nighttime dryness before boys.Age 4

25% of boys wear nighttime diapers 12% of girls wear nighttime diapers

Age 6 5% of boys wear nighttime diapers 2% of girls wear nighttime diapers

Nighttime dryness should be achieved by age 7.

Developing Continence

Continence depends on: Complete and functioning renal system Maturation of nervous system Opportunity/support given to the child to void Cultural expectations

Maturation of control mechanisms usually take up to 5-7 years for healthy children to be dry in the day and overnight

Older age of the child, non-Caucasian race, female sex, and a single parenthood were significant predictors of toilet-training completion.

Readiness

AAP recommends only beginning training when a child is developmentally ready

At the 2-year visit clinicians should assess the child’s readiness, motivation to learn, ability to cope, and level of cooperation with tasks

Ask the child to perform several tasks- such as pointing to several body parts, sitting, standing, walking and imitating

Assess the child’s bowel habits, history of constipation, ability to adapt to new situations, attention span, and distractibility

Constipation should be addressed and resolved before the initiation of toilet training

Physiologic readiness

Must have control over sphincter muscles before he or she can be trained (usually after 12 to 18 months of age)

Developmental Readiness

The ability to ambulate to the toilet

Stability when sitting on the toilet

The ability to remain dry for several hours

Ability to pull clothes up and down

Receptive language skills that permit the child to follow a two-step command

Expressive language skills that permit the child to communicate the need to use the toilet

Behavioral Readiness

Ability to imitate behaviors

Ability to place things where they belong

Demonstration of independence by saying “no”

Expression of interest in toilet training

The desire to please

The desire for independence and control of the functions of elimination

Diminishing frequency of oppositional behaviors and power struggle

Parental Readiness

Start the discussion at age 12 months with parents.

Parents should be informed of the important developmental milestones for toilet training:

Children become aware of accidents by 15 months Children call attention to their soiled diapers and can

verbally distinguish between urine and feces by 18 to 24 months

Children announce need to eliminate by 24 months Children begin to ask to be taken to the toilet for

elimination by 30-36 months Children achieve the adult pattern of elimination by 48

months

Parental Readiness

Clinician should ask the parents about: expectations the existence of pressure for toilet training from other

family members or day care providers Whether they have any negative memories relating to

their own toilet training

Parents should postpone training until they can allow it to be driven by the child’s motivation, interest, and acquisition of skills

One caregiver should be able to devote time and emotional energy necessary to be consistent on a daily basis for a minimum of 3 months

Parental Readiness

Training should be delayed if parents are motivated by:Anticipated birth of a new child in the homeMoving to a new homeMother returning to workSpecific daycare requirements

Too many changes in a child’s life make it more difficult to train and thus increase risk of initial failure.

Parental Readiness

Parents must understand that accidents are inevitable and that children should not be punished during the process.

Toilet training can set the stage for abuse. Parents who are easily frustrated, impatient, or not supportive of their children during office visits should be instructed to wait until at least 30 months to start training.

Guidelines for Toilet Training

Steps involved: Communicating the need to go Undressing Eliminating Wiping Re-dressing Flushing Hand washing

Going through these steps consistently helps reinforce proper toileting skills

Guidelines for Parents

Use consistent vocab for body fluids

Buy a potty chair with your child. Place it in a convenient location.

Encourage the child to sit in the potty chair fully clothed, and look at books or play.

Talk about the potty with books or videos.

Make regular practice trips to the potty chair after waking, meals

After your child is comfortable sitting in the chair dressed, encourage him to sit in the chair with no diaper.

Encourage the child to tell you when they need to go

Do not punish, threaten or speak harshly

Transition to training pants (washable, thicker underwear)

Tips

Keep a positive, loving attitude

Keep the child in loose, easy-to-remove clothing

Keep an extra set of clothing on hand at all times

Do not flush the potty with the child on it

Teach boys to urinate while sitting first, once they have bowel control they can switch to standing

Keep stools soft by modifying diet

Wait to use underwear at night till the child is consitently dry during the day

Remind the child several times during the day to use the potty

If the child is not making progress, stop for 2-3 months, then restart.

Problems

EnuresisDiurnal(daytime)Nocturnal (nighttime)

Resistance/ Refusal

Constipation/Withholding

Nocturnal EnuresisCommon Experience in early childhood

Dx made when the involuntary passage of urine, during sleep, occurs in a child ages 5 years or more, in the absence of any congenital or acquired defects of the nervous system

20% of 5-year-olds, 10% of 6-year-olds, and 7% of 7-year-olds wet the bed at night

Organic causes of primary nocturnal enuresis are found in only 2-3% of children

Nocturnal Enuresis Causes/Factors

Neurological Developmental Delay

Genetics

ADHD

Caffeine

Constipation

Infection

Insuffiecient Anti-diuretic Hormone production

(ADH)

Physical Abnormalities

Psychological

Sleep problems (sleep apnea, sleepwalking)

Stress

Diurnal Enuresis

Children older than 4-years-old who have primary or secondary diurnal enuresis should be evaluated for organic etiologies

Most cases can be determined through:History takingComplete PEUA/C&S

Looking for glucose, WBC’s

or RBC’s

Treatment Options

Bedwetting Alarms Successful in 2/3 of all cases Approx. 3 month commitment

DDAVP (desmopressin) Average of 1.4 fewer wet

nights/week The recommended starting dose for the tablet is

0.2 mg, and the drug can be titrated as necessary to a

maximum of 0.6 mg

Tricyclic antidepressants usual dose, taken 1-2 hours before bedtime, is 25 mg for

patients aged 6-8 years and 50-75 mg for older children and adolescents

Resistance or Refusal

Children with toilet refusal have achieved bladder control but not bowel continence. Up to 20% of developmentally normal children have this problem

Possible causes: Attempting training too early Excessive parent-child conflict Irrational fears or anxiety about toileting Difficult temperament Hard, painful stools from chronic constipation

Tips for Toilet Refusal for Parents

Do not punish or nag the child

Discontinue training for a few weeks

Encourage the child to imitate parents/siblings

Continue to discuss training with the child

Treat constipation with dietary changes, medications

Create positive feedback system, such as a star chart

Regression lasting >6months should be brought to clinicians attention

Resources

For children: “No More Diapers” by JG Brooks “Your New Potty” by Joanna Cole “Once Upon a Potty” by Alona Frankel “All by Myself” by Anna Grossnickle Hines “Going To The Potty” by Fred Rogers “KoKo Bear’s New Potty” by Vicky Lansky

For Parents: “Toilet Training the Brazelton Way” by TB Brazelton “The American Academy of Pediatrics Guide to Toilet Training” “The Potty Journey: Guide to Toilet Training Kids with Special

Needs” by JA Coucouvanis

References

1. Klassen, T., Kiddoo, D., Lang, M., Friesen, C., Russell, K., Spooner, C., & Vandermeer, B. (2006). The effectiveness of

different methods of toilet training for bowel and bladder control. Evidence Report/Technology Assessment, (147), 1-57.

2. MacGregor, J. (2008). Introduction to the anatomy and physiology of children: A guide for students of nursing, child care and health. New York, NY: Routledge.

3. Mersch, J. (March 10, 2010). In Potty Training (Toilet Training). MedicineNet.com. Retrieved April 1, 2012, from

http://www.medicinenet.com/script/main/art.asp?articlekey114293.

4. Turner, T., & Matlock, K Toilet Training. In: UpToDate, Torchia, M.M.(Ed), UpToDate, Waltham, MA, 2012