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Toilet TrainingPediatric Issues Presentation
Amy Carlson
NSG 625
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Toilet Training
Description of issue
History
Different methods
Epidemiological issues
Readiness
Problems
Treatment Options
References
Handout
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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
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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
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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)
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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
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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
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Epidemiological issues
Age of Toilet Training varies by: Culture Timing Gender
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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.
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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.
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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)
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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.
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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.
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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
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Physiologic readiness
Must have control over sphincter muscles before he or she can be trained (usually after 12 to 18 months of age)
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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
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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
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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
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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
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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.
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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.
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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
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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)
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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.
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Problems
EnuresisDiurnal(daytime)Nocturnal (nighttime)
Resistance/ Refusal
Constipation/Withholding
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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
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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
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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
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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
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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
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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
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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
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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
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