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Patient education: Toilet training (Beyond the Basics)

Patient education: Toilet training (Beyond the Basics)
Authors:
Teri Lee Turner, MD, MPH, MEd
Kimberly Ballard Matlock, MD
Section Editors:
Jan E Drutz, MD
Robert G Voigt, MD, FAAP
Deputy Editor:
Mary M Torchia, MD
Literature review current through: Feb 2022. | This topic last updated: Mar 08, 2021.

TOILET TRAINING OVERVIEW — Learning to use the toilet is an important milestone for both caregivers and children. For caregivers, 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 the child is ready, how to help the 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 education: Bedwetting in children (Beyond the Basics)" and "Patient education: Constipation in infants and children (Beyond the Basics)"). 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 can vary from one child to another. Most children are able to stay dry during the day by age two to four years. 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)

Imitate adults and older children

If the 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 education: Constipation in infants and children (Beyond the Basics)".)

Children with chronic illness and/or special health care 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 to complete the toilet training process and there may be more setbacks, but with encouragement and patience, success is possible.

Ask the child's health care provider for advice about toilet training children with special health care needs. Special health care needs is an umbrella term that can be used for a wide range of issues. It includes disorders such as cancer, developmental and learning disabilities, behavioral and mental health issues, and conditions that require special equipment (ie, gastrostomy tubes, tracheostomies, walkers). 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 health care needs, although you may need to make some changes, such as:

Carrying children to the potty chair who cannot walk or crawl

Helping children who cannot use their hands to remove clothing and wipe after a bowel movement

Caregivers of children with autism and related intellectual or other developmental disabilities 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? — Caregivers also need to be ready to start the toilet training process. At least one caregiver 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 caregivers, family members, or teachers, who may expect the child to be toilet trained by a certain age. Toilet training is not a contest. Success with toilet training does not mean that the 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 the 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 that they learn to stay dry during the day. Staying dry at night may take months to years longer. Females usually complete toilet training earlier than males. 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 the child will use these words with other adults and children.

Before you begin training, change the child's diaper frequently so they will learn to prefer dry diapers.

Buy a potty chair with the 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 the child to decorate the potty chair and make it their 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 the child using books or videos. (See 'Other resources' 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 the child is comfortable sitting on the potty chair fully dressed, encourage them 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 they needs to go. Watch for signs that the child needs to go, like squirming or holding the genitals. Go with the child to the potty chair, and praise the child when they go 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 they have accidents or will not use the potty.

Transition to training pants (washable, thick underwear) or cotton underwear after the child is using the potty chair. Do not rush them out of diapers. Allow the child to return to diapers if they are unable to stay dry. A star or sticker chart can be helpful in encouraging potty use.

Once the child has mastered the potty chair, they can be transitioned to an over-the-toilet seat with a step stool. A stool gives the child leverage to push against as they bear 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 the 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 the child in loose, easy-to-remove clothing. 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 the child is not interested, stop toilet training for a while before trying again.

Do not flush the toilet while the child is on it; this can be frightening.

At first, teach males 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 (a total of 720 mL) of milk per day.

The child can transition from diapers to training pants or cotton underwear once they are successful using the potty.

Wait to use underwear at night or during naps until the 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 the 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 the child is not making progress, stop toilet training for two to three months.

Toilet training and child care — If the child attends child care, toilet training will be a shared responsibility between you and your day care provider(s). Caregivers 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 the 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 the child has repeated accidents after they have been toilet trained, contact the child's doctor or nurse. They may want to check for a urinary tract infection.

If the 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 the child is over four years of age, is healthy, and is not toilet trained after several months of trying, talk with the 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 education: Bedwetting in children (Beyond the Basics)".)

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 the child. Tell the child that their poop wants to be in the toilet and it is their 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. Give the child complete control over the process.

Encourage the child to imitate you or their siblings by inviting the child into the bathroom to watch.

Encourage the child to change their own diapers.

Treat hard stools or constipation if needed. Having painful or difficult bowel movements can lead to toilet training setbacks and long-term problems with constipation. (See "Patient education: Constipation in infants and children (Beyond the Basics)".)

Create a star or sticker chart and reward the child for both trying and successfully having a bowel movement on the toilet.

WHERE TO GET MORE INFORMATION — The child's health care provider is the best source of information for questions and concerns related to their medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Bedwetting in children (The Basics)
Patient education: Daytime wetting in children (The Basics)
Patient education: Fecal incontinence in children (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Bedwetting in children (Beyond the Basics)
Patient education: Constipation in infants and children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Constipation in infants and children: Evaluation
Recent-onset constipation in infants and children
Toilet training
Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment
Functional constipation in infants, children, and adolescents: Clinical features and diagnosis

The following organizations also provide reliable health information.

National Library of Medicine

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

American Academy of Pediatrics

(www.healthychildren.org/english/ages-stages/toddler/toilet-training/Pages/default.aspx)

KidsHealth

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

Other resources

Books for children – Caregivers 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 males and females 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

"Potty" by Leslie Patricelli

"The Potty Book" by Alyssa Satin Capucilli and Dorothy Stott (one version for males and one for females)

"P is for Potty" (Sesame Street)

Videos for children

Once Upon a Potty for Her by Alona Frankel (version for males also available)

It's Potty Time, Duke Family Series

Elmo's Potty Time, Sesame Street

Potty Power (for all children)

Potty Time for Bear, Bear in the Big Blue House

Books for caregivers – Many books about toilet training are available for caregivers; 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 the child's health care provider for opinions on methods they think would work best for the 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

"The Potty Journey: Guide to Toilet Training Children with Special Needs" by Judith A. Coucouvanis

Mobile phone or tablet "apps"

Once upon a Potty (one version for males and one for females) by Oceanhouse Media

Potty Training Learning with the Animals by 1tucan

Potty Time with Elmo by Sesame Street

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This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
Topic 1197 Version 17.0

References

1 : Evidence-based toilet training (commentary)

2 : The effectiveness of different methods of toilet training for bowel and bladder control.

3 : Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics.

4 : Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics.

5 : Instruction, timeliness, and medical influences affecting toilet training.