Toilet Training

Dear Lisa,

My 3 year old will not be potty trained. The school she attends is also trying but in a 4 hour period she will not go on the toilet but will wet her clothes up to six times. There is no increase in fluid intake. Urinalysis and cultures are negative, blood sugars are normal. She has been on low dose abx for urinary reflux for @ 2 years. Are there any other things that she should be tested for?

“Mother of Three”

Dear “Mother of Three”,

There is a broad range in age that a child is expected to potty train, from 2 years old to almost 4 years old. There are some developmental milestones that need to be reached before a child is ready to use the potty. First of all a child should have the gross and fine motor skills needed to pull down their pants and physically sit on a potty. A child with motor delays or insufficient abdominal strength, which is found in children with Cerebral Palsy, may have problems learning to toilet train. (1) A child also needs the verbal skills to communicate to their caregiver that they need to go to the bathroom. (2) A certain level of Intellectual ability or cognitive awareness is also necessary in order for a child to understand what it means to go potty and to understand what a potty is for. (2) Lastly, attention to sensation is necessary for a child to feel the sensation that they “have to go”. Children with Attention Deficit Disorder have higher rates of wetting themselves because they may not possess the concentration level or attention to sensation at a level that is needed in order to potty train. (1)

Once a child is developmentally able to potty train, a parent must then consider the child’s readiness. A child that is ready to toilet train shows interest in going on the potty, likes to watch others use the potty and shows a desire to please their parents. (3) If your child is not showing interest in these areas then an evaluation of the home and school environment may be necessary. The questions that should be explored include: Is my child refusing to make this step because she is seeking attention? Has there been a change in the family such as a new sibling or new home that is upsetting her? Is my child holding on to the diaper because she likes the individual attention that she gets during diapering? Is my child refusing to potty train because there is a fear of the toilet? These issues may need to be addressed, before potty training can be mastered. If this is the case, your child may need you to spend time with her to explain what is expected and to help alleviate her fears.

Other signs of readiness include a child that holds the urine for more than 1 1/2 hours, a child that wakes from a nap dry, a child who finds a special place to go and a child who is uncomfortable in a dirty diaper. (3) If a mother notices signs of readiness it is a good idea to become a little more assertive with a schedule and level of expectation. A child that falls within the normal age for potty training, and developmentally able may need a little encouragement and direction from mom.

In some cases a baby is ready to potty train but the caretakers are not. To some mothers potty training “the baby of the family” is a sign that their child is growing up and the end of the baby years. To many mothers this transition may be difficult to accept. In other cases, moms with experience realize how much time and energy is takes to potty train a child. Potty training may be put off because of other household commitments or commitments outside of the home that would interfere with the process. Not only does a child need to be ready, but a Mom needs to be ready to potty train too. It is better for a child to potty train when they are ready because it will prevent them from becoming confused or developing habits that will be hard to break when they are older.

For families that are ready to potty train there are a few steps that can be taken to help the process run more smoothly. The first step is to help your child become aware of the sensation that she has to go to the bathroom. The best way to do this is to discontinue the use of diapers or Pull-ups and put underwear on your child. Underwear does not absorb moisture and will keep the cold wet feeling of urine and stool close to the skin. This way the child will associate a negative sensation with going to the bathroom in their pants. This negative feeling will encourage the child to use the potty in order to feel warm, comfortable and dry. If a child continues to wear diapers they will not experience this discomfort because the diaper absorbs the moisture and keeps the urine and stool away from the skin. A child wearing a diaper has no incentive to stop playing to go on the potty if they can just go in their diaper and stay comfortable.

When a child wearing underwear has an accident it is more noticeable to the caregiver, who should interrupt the child’s play and make her get changed when she soils. This is especially helpful in a child who has difficulty sensing the need to use the toilet. If the caregiver brings it to the child’s attention right away, the child will learn to pay attention to the wetness or coldness of the underwear. The child will learn that they will have to stop playing anyway and that it is quicker and easier to use the potty then clean and change into new clothes.

It is also a good idea to pick up on the gestures and cues that a child displays when a child needs to go to the bathroom. When a caregiver notices these clues of wiggling, sitting in the chair differently, rocking back and forth or touching the private area she can bring it to the child’s attention. The child should stop what she is doing and sit on the toilet. By bringing these cues to the child’s attention it teaches them to become more in tuned to their body and its feelings. This is sometimes difficult in a daycare setting when a caregiver doesn’t have the time to give one child individual attention. This may better be accomplished in the home setting during a vacation or with the help of a relative or friend if the mom has to work.

In addition to picking up on early cues and putting a child in underwear, a child should be put on a bathroom schedule. Since a child that is not potty trained is expected to urinate every 1  1/2 to 2 hours, they should sit on the potty automatically every 1  1/2 to 2 hours during the day. This should start in the morning when a child wakes and the child should sit whether they feel if they have to go to the bathroom or not. It is very important to praise the child for sitting, even if they do not urinate or have a stool.

Once potty training begins, it takes a lot of time, a lot of effort and a lot of patience. It is normal for children to have accidents which can be very frustrating for the caregivers. A parent can help their child by having a “you can do it” expectant attitude, rather than a “when are you ever going to learn” attitude. A very matter of fact attitude towards potty training with the avoidance of punishment will prevent the child from using potty training as a tool to get their parent’s attention. A positive attitude will help a child who is having difficulty and will give them the encouragement that they need. (2)It is important to remember that it can take up to 6 months to potty train a child, and many times children take a few steps forward and then a step backwards.

If you have given potty training a concentrated effort and are still finding no success it would be important to evaluate what is going on when your daughter is at school. You mentioned that your daughter will not go on the toilet at school. Does the staff bring her to the bathroom every 1 ½ to 2 hours on a schedule? If she goes on the toilet at home and not at school, is there something that she is afraid of or uncomfortable with at school? Is she afraid of the toilet at school because it is different or makes noises? Or is it that she is just too busy playing that she doesn’t want to stop to go on the toilet. How does the staff handle it when she has an accident? It would be a good idea to figure out what the issue is at school by talking to the staff and your daughter. You can ask your daughter to show you how she goes to the bathroom at school by using a doll or puppet. You may get more information from her this way.

If you give your child sufficient time and she still can’t seem to master the task of potty training then other areas may need to be explored. It is a good idea to discuss your concern with your daughter’s Pediatrician. Your Doctor may want to evaluate your daughter to make sure there are no anatomical reasons or complicating factors that are contributing to her inability to control her urine and stool. Testing the urine for a urinary tract infection and the blood for diabetes is part of the work-up which was reported normal in your daughter’s case.

Other areas may also need to be investigated, such as her ability to hold her urine and her ability to sense the need to urinate. A physical examination including a complete neurological evaluation by your daughter’s pediatrician will be able to tell you if there is an issue in this area. The evaluation typically includes a visual inspection of the genital and rectal area to make sure there are no anomalies that prevent a child from controlling their bladder and or bowels. The skin on the lower back, sacrum and gluteal cleft should be inspected for signs of an occult problem. Findings such as a port wine stains, tufts of hair, congenital nevi (moles), gluteal cleft deviation(asymmetry of the but crack) or deep sacral dimples may be a sign of an underlying problem which may affect sensation. (4) In addition the Pediatrician may evaluate your child’s stooling pattern because children with constipation have more problems with controlling their urine. The hard stools can cause pain, interfere with feelings or sensation of having to void and cause the child to withhold the stool because of the fear of painful defecation. (4)

Since you mentioned that your daughter has vesicoureteral reflux (urinary reflux) she may already have seen an urologist and had testing of her kidney and her bladder. In some cases a Pediatrician may recruit the expertise of a Urologist and request further testing if a child has difficulty controlling her urine. Typical testing includes an ultrasound of the bladder. This test can tell you if your daughter’s inability to potty training is due to a problem with her bladder. A post-voiding residual volume can be checked by doing an ultrasound of the bladder. It can tell you if the bladder is large, distended and unable to be emptied or if it is very small, leading to overflow incontinence. (4) In cases where a child has persistent problems controlling her urine as well as her stool an MRI may be needed. An MRI examines the lower spine for abnormalities which may interfere with bowel and bladder control. (4)

If your daughter is approaching four years old, it is better to discuss your concerns with your pediatrician sooner rather than later. Instead of assuming that your daughter is just not ready, it is better to have her evaluated for confounding factors. Institution of behavior modification early on for dysfunctional voiding can result in the reversal of symptoms which is not necessarily the case if you wait too long. (4)

I wish you luck and your daughter success in this difficult endeavor!

References:
(1)Howard BJ. Toileting Problems of Young Children. Audio-Digest Pediatrics. 2000.46(02).
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:219-221.
(3)Rosenthal M. Suggestions to help parents change their toddler’s behavior outlined. Infectious Diseases in Children. 2006. Mar:44.
(4)Listernick R. AThirteen-Year-Old Girl with Anemia. Pediatric Annals. 2003. 32(3):139-145.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents