Among healthy children, what toilet-training strategy is most effective and prevents fewer adverse events (stool withholding and dysfunctional voiding)?

In many cultures, including North America, successful toilet learning is perceived as a major step in a child's development and independence. It is a topic that is routinely reviewed at well-child appointments, and can create parental anxiety and frustration if independent toileting is delayed or problematic. ‘What is the best way to toilet train my child?’ This is a common question parents ask, and so to help guide families and health care workers with evidenced-based information, a systematic review was recently completed on this topic (1). While a meta-analysis would have been a more powerful study (prevented by heterogeneity of the included studies), practical information was still obtained by this first-ever systematic review on toilet training (TT). Parents often want to know when to start TT and how long the process should take. On average, neuromuscular development of bowel and bladder control is present by 18 months of age; however, other factors amenable to TT (communication and gross motor skills, and temperament) may not yet be appropriately developed. One longitudinal study (2) suggested that children may not be ready for successful TT until two years of age, and yet another study (3) suggested that if TT is started before two years of age, duration of training may be relatively longer. Thus, although both the American Academy of Pediatrics and the Canadian Paediatric Society suggest that TT may commence between 18 and 24 months of age, parents should be informed that TT is a complex skill integrating physiological and behavioural processes (4,5). Girls are successfully trained approximately three months earlier than boys, with both sexes achieving success by approximately three years of age (2,3). In the systematic review (6), there were only four studies directly comparing TT methods among healthy children, one of which had such a small sample size (n=10) that statistical analysis was precluded. Similiar to the Matson and Ollendick (6) study, the Candelora study (7) is now 40 years old; this randomized study found no difference between the Foxx and Azrin (FA) method and the child-oriented (CO) method at follow-up. In one of the larger randomized studies using a CO approach, one group of parents was directed to avoid using negative terms of defecation, while the other group received no such direction. In the directed group, stool toileting refusal was shorter in duration and TT completed sooner (P=0.03 and P=0.04, respectively) (8). While these statistical differences are slightly small, parents should be encouraged to avoid negative terminology (eg, ‘stinky’). Furthermore, dysfunctional voiding may develop if parents are overly aggressive with the bladder routine (eg, making the child strain) (9). While this was a large study, it was limited to a retrospective questionnaire, perhaps introducing a recall bias. Nevertheless, to minimize adverse outcomes, children may benefit from occasional prompting, avoiding punishment and perceived assistance with voiding (running water, making voiding sounds and encouraging straining). In one of the original CO cohorts, training started at 18 months of age was completed by approximately 33 months of age (10). This is in keeping with modern studies (2,3). Foxx and Azrin developed a more aggressive method to facilitate training in less than one day. While 39 of 49 children were trained in only a few hours, the study was limited due to poor follow-up (11). Relying on less powerful levels of evidence, single cohort studies suggested that both the FA and CO methods can be successful. The CO approach, endorsed by the American Academy of Pediatrics and the Canadian Paediatric Society, seems to be effective if started between 18 and 24 months of age, but parents should be prepared for the training duration to take until the child is approximately three years of age. If motivated parents want their child to be toilet trained relatively fast, they can try the FA method, but they must be prepared for an intense, regimented routine, which may not suit every child's temperament. Furthermore, the available evidence does not state how successful this method can be after four months. Future studies should be directed at comparisons between these two TT methods, emphasizing long-term follow-up and adverse events (stool toileting refusal and dysfunctional voiding). The objective is to prevent problems when a child is learning bowel and bladder control. Training must proceed slowly and allow for periods of child disinterest or negativity that can be common in this age group. If there is a breakdown at any time during training, parents are advised to stop training and to reassure the child that it is not their fault and they will learn when ready. The child is ready to begin toilet training when they have appropriate gross motor (walking and sitting) and language skills, and display psychological readiness. The child should desire autonomy and self-mastery, be secure with parents and wish to please them, and wish to identify with and imitate important people in their life. In addition, the parents must be ready to toilet train. At approximately 18 months of age, parents may introduce a potty chair/seat. When the parent uses the toilet, the fully clothed child sits on their ‘potty’ and is allowed to leave it at will. After one to two weeks cooperation, the child's diaper is removed when sitting on the potty. When the child is comfortable with the potty and eliminates in their diaper, the child is taken to the potty and the diaper is emptied into the potty. The parent then explains that bowel movements belong in the potty. If the child appears to understand, the child sits on the potty several times a day. As interest grows, the child's diapers and pants are removed for short periods, placed near the potty and encouraged to use it at will and independently. If the child is progressing, initiate training pants. Nap and night training is accomplished later if it does not occur simultaneously with daytime control. The objective is to teach the child to go to the toilet without reminders or assistance. Training begins at approximately 20 months of age. A child is ready to begin training when they have achieved bladder control, are aware when they are about to urinate, possess physical dexterity to complete toilet training-related tasks and can follow instructions. Pretraining exercises include teaching the child to assist in their dressing and undressing, allowing them to watch others toilet and explain the steps, and teaching them toileting words and how to follow instructions. When the child is capable of following an instruction but chooses not to, the parent must make the child follow the instruction without temper tantrums that may discourage progress. Training is conducted in a room that contains minimal distractions and with a potty that has an easily removable pot. A doll that wets can demonstrate the urination process. The parent provides immediate and varied positive reinforcement (eg, comments, hugs and stickers) for every instance of a correct toileting skill and does not reinforce nontoileting acts. When an accident occurs, the parent delivers a verbal reprimand, omits reinforcement, makes the child change their wet pants and conducts 10 rapid ‘positive practice’ sessions. Positive practice sessions include using the doll to imitate toileting and teach specific actions. The child is then taught to check and identify dry pants from wet pants, and the parent rewards or praises dry pants and performs checks every 3 min to 5 min. The parent should encourage the child to consume liquids to create a strong, frequent desire to toilet. The child is then instructed to walk to the potty, lower pants, sit quietly for several minutes, and stand up and raise pants. The parent watches to see if urination begins, and praises or rewards their child immediately. After urination, the child wipes themselves, and empties and replaces the pot. The parent increases the number of trials. Initially the parent gives prompted potty trials every 15 min and decreases the frequency as the child acquires skill. Dry pants checks are conducted every 5 min. The child sits on the potty for 10 min; after a couple of successful urinations followed by much praise, the child will begin to understand, and prompting and sitting time can be reduced. As the child gains proficiency and performs actions correctly, the parent gives approval only at the end of an action rather than during it. Eventually, the parent reduces to praising only dry pants. For the next several days, the parent checks pants at meals, naps and bedtimes, and praises each time the child's pants are dry. If there is an accident, the child is reprimanded, changes themselves and repeats practice sessions.

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