INTRODUCTION — The mastery of toilet training is an important developmental milestone for children and caregivers. This area of pediatric care presents a critical opportunity for anticipatory guidance; caregivers need guidance in recognizing signs of readiness, in helping their child achieve the necessary skills, and in addressing problems when they occur [1,2].
The approach to toilet training and common problems in toilet training are reviewed here. The diagnosis and management of enuresis and encopresis are discussed separately. (See "Nocturnal enuresis in children: Etiology and evaluation" and "Nocturnal enuresis in children: Management" and "Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation" and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
HISTORICAL PERSPECTIVE — The methods used for toilet-training children in the United States have evolved over the last century. In the early 1900s, techniques for toilet training stressed physiologic readiness, involving the child as a passive participant [1]. During the 1920s and 1930s, early training and rigid scheduling were recommended [3]. A 1929 "Parents" magazine claimed that most healthy babies could be trained by eight weeks of age [4]. By the 1940s, pediatric experts, including Dr. Benjamin Spock, began to advocate that caregivers wait to begin toilet training until they observed signs of developmental readiness in their children. They believed that rushed, rigid training would be unsuccessful and lead to behavioral problems [5]. In the early 1960s, two major theories on toilet training emerged: the parent-oriented approach, the major contributors for which were Azrin and Foxx; and the child-directed approach, developed by T Berry Brazelton [1,2,4].
The age at which children begin to toilet-train has increased over time. In a survey study, individuals in Belgium were asked about the toileting habits of children they had trained. The researchers divided the respondents into three groups according to their age: >60 years, 40 to 60 years, and 20 to 40 years. Initiation of daytime toilet training began at less than 18 months of age in 88 percent of the children of respondents who were >60 years of age, 50 percent of respondents in the 40 to 60 age range, and 22 percent of respondents in the 20 to 40 age group. There was no statistically significant difference in the duration of training among the children in any of the three groups. In this study, methods of training also appear to have changed over time, with trainers in the youngest cohort using more than one method to train their children, in comparison to a single method (diaper removal) used by respondents in the >60 age group [6].
A systematic review of the effectiveness of different methods of toilet training revealed that both the parent-oriented and child-oriented training approaches resulted in quick, successful toilet training among healthy children [7]. The two methods have not been directly compared, and therefore definitive conclusions regarding the superiority of one method over the other cannot be made; however, the American Academy of Pediatrics guidelines most closely reflect the child oriented training model [8].
Epidemiology — The age at which most children are considered toilet trained varies by time, culture, and definition of the endpoint of toilet training [9]. The more stringent definitions require children to be continent of bowel and bladder during both day and night and to be able to perform their toileting independently. Less stringent definitions consider children toilet trained when they are continent of urine during the day or when they are able to express their need to eliminate, whether or not they do so independently.
In the United States, 26 percent of children achieve daytime continence by 24 months of age, 85 percent by 30 months, and 98 percent by 36 months of age [10]. Most children achieve bowel and bladder control by 24 to 48 months of age; in 1947, most children achieved this milestone at 18 months [1,11,12]. Similar findings were noted in a report of 320 Swiss children; complete bowel and bladder control were found in 5 percent of two-year-olds, 11 percent of three-year-olds, 77 percent of four-year-olds, and 91 percent of six-year-olds [13].
In comparison, the Digo people in East Africa begin toilet training their infants during the first weeks of life, relying on nearly continuous contact with the caregiver and dependence on the caregiver to recognize subtle cues given by the infant prior to elimination [14]. They achieve stooling and urination on command by the time the child is four to five months old.
Most children achieve bowel control before or at the same time as daytime bladder control; bladder control is achieved first in 10 percent of children [1,13]. Nighttime bladder control is achieved months to years later and is not expected until five to seven years of age.
The average length of time required to achieve toilet training is six months for daytime urinary continence and six to seven months for stool continence [1,2]. Earlier initiation (before 27 months of age) is correlated with a longer duration of toilet training [15]. Females complete the toilet-training process earlier than do males (eg, two to three months earlier in a large retrospective study) [10,12,16,17]. First children take longer to toilet train than do subsequent siblings (eg, two months longer in a large retrospective study) [10].
In a prospective longitudinal study, three factors were identified that consistently were associated with toilet training completion at a later age: initiation of training at an older age, presence of stool toileting refusal, and presence of frequent constipation [18].
Parent-oriented training — The parent-oriented approach is based upon structural-behavioral training and operant conditioning. The complete method was published in 1974 in "Toilet Training in Less Than a Day" and consists of speed training, using four basic concepts [19]:
●Increased fluid intake
●Regularly scheduled toilet times
●Positive reinforcement for correct elimination
●Overcorrection for accidents (eg, verbal reprimands or time out from positive reinforcement)
The method was first used on institutionalized intellectually disabled adults, then repeated on 34 children who were older than 20 months [19]. The children were toilet trained in a mean time of 3.9 hours (range: 0.5 to 14 hours). Subsequent studies reported behavioral problems, including tantrums and unsuccessful toileting outcomes, unless the use of the book was accompanied by group training, lectures, written instructions, and close supervision [4]. The major drawbacks of this method are the risk of inadvertently conditioning the child to perform incorrect behaviors (eg, wetting in clothing or on the floor) and the possibility of physical abuse occurring during the overcorrection component [20].
Two variations of parent-oriented methods of toilet training (timed potty training and a daytime wetting alarm) were compared in a randomized controlled trial in 39 children aged 20 to 36 months [21]. Children in the timed potty-training group were brought to the potty four times per day and encouraged to void. Parents of children in the alarm group were instructed to put them on the potty when the moisture-sensitive alarm sounded and encourage them to finish voiding. Parents of both groups were asked to use positive reinforcement and refrain from negative reinforcement. More children in the alarm than in the timed group were completely dry after five days of training and one month later (78 versus 41 percent and 89 versus 53 percent, respectively). These suggest that training based on awareness of body signals may be more effective than being rewarded for voiding at prescheduled times unrelated to "having to go" [22].
Several studies have reviewed the success rates of training protocols for achieving continence in children with autism spectrum disorders and other developmental disabilities [23]. Almost all of these are based on the original rapid toilet training (RTT) method described by Azrin and Foxx. Many of these methods focus on abbreviating the original RTT protocol while also reducing the complexity and professional training involvement needed for success. These studies are limited by their small sample sizes and lack of generalizability, as well as protocols that would be difficult for caregivers to carry out without significant training and assistance.
Child-oriented training — In 1962, Dr. T Berry Brazelton introduced the child-oriented approach to toilet training. This approach suggests beginning toilet training only after certain physiologic and behavioral criteria of readiness are met. It stresses the importance of permitting children the freedom to master each step at their own pace with minimal conflict [1,2,10]. (See 'Readiness' below.)
Brazelton's method is associated with high rates of continence, fairly rapid training time, and low long-term regression rates [10]. Toilet-training recommendations are based upon Brazelton's child-oriented approach. (See 'Guidelines for toilet training' below.)
READINESS — The American Academy of Pediatrics recommends that the process of toilet training begin only when the child is developmentally ready or shows signs of readiness [8]. Pediatric health care providers must be able to recognize and understand the importance of readiness for both the caregiver and the child (see 'Caregiver readiness' below). They should discuss toilet training with caregivers at each health supervision visit beginning at age 12 months (table 1) [2].
Child readiness — The child's readiness for toilet training is based upon the attainment of certain physiologic, developmental, and behavioral milestones, rather than chronologic age [2]. A 2012 literature review identified 21 different toilet training readiness signs [24]. It remains unclear how many of the readiness signs need to be present before starting toilet training and whether any of these signs are more important than others. Some experts suggest beginning toilet training three months after the readiness criteria have been met to ensure success [2,25]. Delays in toilet-training mastery can occur if children are not toilet trained while they are ready and interested [2]. The age of readiness varied between 22 and 30 months in one longitudinal survey of the acquisition of toilet-training skills in a cohort of 267 Milwaukee-area children [12]. Initiation of toilet training before 27 months of age is not associated with earlier completion of toilet training, suggesting little benefit to beginning training before this age [15].
Physiologic — Children must have control over their sphincter muscle before they can be toilet trained (figure 1). Local conditioning of reflex sphincter control can be elicited at 9 to 12 months of age. Voluntary coordination of sphincter control is accomplished by 12 to 15 months of age. Myelinization of pyramidal tracts to the sphincters is complete by 12 to 18 months of age.
Developmental — The achievement of the following motor, language, and social milestones signals readiness [1]:
●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 — In addition, specific behavioral signs in the child indicate their readiness to begin. They include [10]:
●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 struggles
The clinician should take a proactive role in discussing the initiation and process of toilet training with the caregiver. In an observational study, 41 percent of parents relied on the internet for toilet training information and fewer than 50 percent discussed toilet training with their primary care provider [26]. Parents used a variety of toilet training strategies, most of which were inconsistent with recommendations from the American Academy of Pediatrics, suggesting that caregivers and children would benefit from more clinician guidance. By the two-year visit, the clinician should assess the child's physiologic readiness, motivation to learn, ability to cope, and level of cooperation with tasks. The clinician can ask the child to perform several simple tasks, such as pointing to body parts, sitting, standing, walking, and imitating [2]. The clinician also should 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. (See 'Constipation and withholding behavior cycles' below.)
Child with chronic illness — Toilet training is a crucial milestone for the with chronic illness; in this setting, the attainment of regular developmental milestones maintains an important sense of normalcy [27]. Thus, toilet training should not be delayed because of caregiver protectiveness for the child or lack of priority within the framework of the child's illness. All cognitively ready children who have no physical or anatomic conditions that would interfere with the toilet training process should begin training at the same age as that of their healthy peers. In addition to the readiness criteria described above, particular attention should be paid to medication effects, developmental delay, anomalies in organ systems involved in the toileting process, periods of bed rest, and consequences of the illness that could hamper the process. A systematic review concluded that toilet-training programs for children with Hirschsprung disease or anal atresia are enhanced by a multidisciplinary team approach [7].
Children with chronic illnesses may require additional time to complete the toilet-training process. Setbacks should be expected and treated with consideration and patience. Children with special health care needs may need to be observed more closely for patterns and cues that signal the child is ready to eliminate. Additional changes that may be necessary include:
●Carrying children who cannot walk or crawl to the potty chair
●Helping children who cannot use their hands to remove clothing and wipe after a bowel movement
Caregiver readiness — Caregivers must be prepared for the toilet-training process before they begin. The clinician should discuss toilet training with caregivers at each health supervision visit beginning at age 12 months (table 1) [2]. Caregivers should know how to tell when their child is ready to begin training and should have realistic expectations about duration of training, accidents, and setbacks.
Caregivers will be better able to assess the readiness of their child if they know 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 their need to eliminate by 24 months
●Children begin to ask to be taken to the toilet for elimination by 30 to 36 months
●Children achieve the adult pattern of elimination by 48 months
The clinician should ask the caregivers about their expectations, the existence of pressure for toilet training from other family members or day care providers, and whether they have any negative memories relating to their own toilet training. Many caregivers mistakenly equate toilet-training success with intelligence or character, thus believing that toilet-training difficulty means their child is lazy, stubborn, hostile, lacking intellectual ability, or defiant of caregiver authority [2].
The clinician should ask the caregivers about their motivation to begin toilet training [2,3]. Toilet training should be delayed if the caregivers are motivated by the anticipated birth of another child, move to a new home, mother's returning to work, or specific day care requirements. Too many changes in a child's life make toilet training more difficult and increase the chance for initial failure [2,27].
Caregivers should postpone the training process until they can allow it to be driven by the child's motivation, interest, and acquisition of skills [2,10]. Caregivers should plan toilet training when at least one caregiver is able to devote the time and emotional energy necessary to be consistent on a daily basis for a minimum of three months [2,3].
Caregivers must understand that accidents are inevitable and that punishment has no role during the toilet-training process [28]. Toilet training can set the stage for child abuse [20]. Caregivers who are easily frustrated, impatient, or not supportive of their children during office visits should be advised to wait until their child is at least 30 months old to begin toilet training. They should be counseled against using methods of toilet training that involve negative reinforcement.
GUIDELINES FOR TOILET TRAINING — Toilet training involves many steps: communicating the need to go, undressing, eliminating, wiping, dressing, flushing, and hand washing. Going through these steps consistently reinforces proper toileting skills [2]. Using Dr. T Berry Brazelton's approach, the caregiver follows the child's cues for moving from one step to the next:
●Deciding on a vocabulary for bodily fluids that will be used consistently
●Buying a potty chair – The potty chair is easier to use than is the over-the-toilet seat and provides the appropriate leverage for elimination. Children should be encouraged to take ownership of the chair by helping to pick it out, decorating it, or placing their name on it.
●Accessibility of the potty chair – The chair should be placed in a convenient location, such as the child's playroom. In multilevel homes, it is advisable to have a potty chair on each level [3,10].
●Becoming comfortable with the process – The child should be encouraged to sit on the chair fully dressed and look at books or play with toys. Beginning when the caregivers or siblings are using the toilet encourages imitation.
●Making the connection – After a week of sitting on the potty fully clothed, the child should be encouraged to sit on the chair naked. Caregivers can then begin to make the connection between elimination and the potty chair by placing the soiled diaper or stool in the potty and explaining to the child that this is the purpose of the chair. Once this connection is made, demonstration of disposal of the feces or the urine into the "adult" toilet can be undertaken. Because toilet flushing or the disappearance of feces can be frightening to children, the child should first be permitted to flush pieces of toilet paper or wave "bye-bye" to the feces.
●Practice and encouragement – Praise should be used to encourage the child to tell the caregiver when the child needs to go. The child should be led to the chair and invited to use it whenever the caregivers are able to anticipate the child's need for elimination. The goal of this stage is to "catch" the urine or stool in the potty chair and praise any successful attempts. Caregivers should not expect immediate results, nor should they get upset or punish when accidents occur.
●Transition to training pants or cotton underwear – Children can transition from diapers to training pants or cotton underwear after at least one week of success using the potty. Children should not be rushed out of diapers, nor should they be forced to wear soiled diapers for extended periods of time as a form of negative reinforcement. They should return to diapers if they are unable to remain dry at this stage. A sticker or star chart can be used as positive reinforcement for successful attempts [1-4,10,27]. Once children have mastered the use of the potty chair, they can be transitioned to the regular toilet with an over-the-toilet seat and step stool [3].
Some tips to keep in mind [2,10]:
●Adopt a positive, loving approach to toilet training
●Keep the child in loose, easy-to-remove clothing
●Avoid battles over toilet training
●Avoid flushing the toilet while the child is on it
●Avoid over-reminders
●Teach males to urinate sitting first; teach them to stand after successful bowel training is complete
●Keep stools soft by increasing dietary fiber and reducing dairy products
●Use training pants as part of the transition from diaper to underwear, not as the first step
●Nighttime and nap training should wait until the child is consistently dry during the day
●Children should be reminded to void upon awakening to avoid accidents
●If the child is not making progress, training should be discontinued for two to three months
SPECIAL CIRCUMSTANCES
Day care — Many children go through the toilet-training process in the day care or child care setting, as approximately 60 percent of American children younger than five years receive day care outside the home [29]. Toilet training in the day care setting has advantages and disadvantages [27]. Day care providers are in a unique position to recognize the signs of readiness and participate in the toilet-training process. Day care provides an environment where interaction with peers who are successfully toilet trained can boost a child's interest and desire to imitate. This desire to learn and imitate can enhance and expedite mastery of toilet-training skills.
On the other hand, children who are toilet-training may receive inadequate supervision and assistance if the day care center is understaffed. In addition, children may become confused if caregivers and day care staff use different methods to teach toileting skills [2]. Caregivers and day care providers must communicate to develop a consistent sequential plan for both environments. Caregivers should receive regular information concerning their child's developmental progress through the toilet-training process.
Potty chairs are not practical in the day care setting because of the risk of contamination and spread of infectious disease [2]. They also may cause setbacks for a child who has been successfully trained. Child-sized toilets, step aids, or modified toilet seats (when only adult-sized toilets are available) should be made easily accessible. Nondisposable training pants should be discouraged because of the risk of infectious disease. Diapers or disposable training pants offer containment, comfort, and ease of use [2].
Child with autism spectrum disorder or intellectual disability — Recommendations for training children with autism spectrum disorder (ASD) or intellectual disabilities most often draw upon operant conditioning principles [30]. A number of training protocols have been used with children who have developmental disabilities. Almost all of these protocols are derivatives of the parent-oriented training approach (see 'Parent-oriented training' above). In a survey of 100 parents of individuals with ASD (mean age 19.5 years), individuals with both ASD and severe to profound intellectual disability took longer to achieve daytime bladder control than those with ASD without intellectual disability (approximately 3 versus 1.2 years) [31]. Those with ASD and lack of verbal skills also took longer to achieve daytime bladder control than those with ASD and verbal skills (2.7 versus 1 year). In addition, those with lower cognitive levels had higher rates of toileting regression.
Key steps in training a child with ASD and/or intellectual disability that deserve special emphasis or may differ from those in training children without these disorders include [23]:
●Baseline monitoring to identify toileting patterns and cues
●Scheduled bathroom visits based on identified patterns of voiding using graduated guidance and prompting
●Developing a nonverbal "toileting language" that both the caregiver and child can use to signify toileting needs (eg, pictures, sign language, or gestures)
●Increasing fluid intake to increase urinary frequency and provide opportunities for practicing of skills may be helpful in some children
●Providing reinforcement/rewards for appropriate behaviors
●Treating and preventing constipation, which may provide negative reinforcement resulting in toilet refusal or withholding (see "Recent-onset constipation in infants and children" and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment")
As the child's toileting skills improve, prompts and/or scheduled bathroom visits can be gradually decreased over time. Caregivers should be reminded that patience, persistence, and a supportive learning environment are the key components for success. Toileting training for the child with ASD or intellectual disability is a journey, not a race. At each well child visit, health care providers should discuss the caregivers' expectations about toileting and ask about the caregivers' successes and frustrations with the process.
PROBLEMS AND SETBACKS — Toilet training is a challenging process that is frequently accompanied by problems and setbacks. Temporary setbacks, nocturnal enuresis, and toileting refusal are the most common problems in healthy children. Temporary setbacks are a normal part of the toilet-training process and do not constitute failure; they are expected in times of acute illness, a family move, new child care arrangements, or a family crisis [2,27].
Enuresis — Enuresis, the involuntary leakage of urine, is characterized as diurnal (daytime) or nocturnal (nighttime). Problems with elimination should be treated early to encourage normal psychosocial development [7].
Nocturnal enuresis — Primary nocturnal enuresis occurs in 15 percent of five year olds. It resolves spontaneously at a rate of approximately 15 percent per year. Organic etiologies are uncommon [32]. The evaluation and management of primary nocturnal enuresis are discussed separately. (See "Nocturnal enuresis in children: Etiology and evaluation", section on 'Evaluation' and "Nocturnal enuresis in children: Management".)
Diurnal enuresis — Children older than four years of age who have primary or secondary diurnal enuresis should be evaluated for underlying organic etiologies (eg, urinary tract infection, diabetes mellitus, congenital spinal malformations, acquired neurologic problems) [33,34]. Most cases of daytime voiding dysfunction can be determined by taking a thorough history, performing a complete physical examination, and obtaining a few noninvasive tests, such as a urinalysis and urine culture.
Children with stress or giggle incontinence, urgency incontinence, weak urinary stream, or constantly damp underwear also should be evaluated. (See "Etiology and clinical features of bladder dysfunction in children" and "Evaluation and diagnosis of bladder dysfunction in children".)
Resistance or refusal — Children with toilet refusal have achieved bladder control and have regular bowel movements in their pants or in a diaper, but refuse to defecate in the toilet; they may or may not have achieved bowel continence before developing refusal behavior. Up to 20 percent of developmentally normal children have this problem [17].
A variety of factors are hypothesized to be associated with toilet-training refusal:
●Attempting training at too early an age
●Excessive caregiver-child conflict
●Irrational fears or anxieties about toileting
●Difficult temperament, such as negative persistence or poor adaptability
●Hard, painful stools from chronic constipation [35]
One case-control study found that children who had stool toileting refusal had more difficult temperaments and higher rates of constipation than did their age- and sex-matched peers [36]. In a cross-sectional study of children referred to a specialty clinic for toileting difficulties, children who were difficult toilet trainers were more likely to be less adaptable, more negative in mood, and less persistent than control patients [37]. They were also more likely to be constipated, to hide stool, and to ask for pull-ups in which to have a bowel movement. Parenting styles, however, did not differ between the two groups, nor did the groups differ in behavior problems. Another prospective study found an association between toileting refusal and the presence of younger siblings or the inability of parents to set limits [17].
In a large prospective longitudinal study, children with stool toileting refusal were more likely to have experienced hard bowel movements, frequent hard bowel movements, and painful defecation. The majority of the children who experienced both stool toileting refusal and hard bowel movements (93 percent) demonstrated constipation before the onset of the stool toileting refusal. Also, children with frequent hard bowel movements had a longer duration of stool toileting refusal. It has been postulated that earlier and more effective treatment of constipation may be a potential treatment option for decreasing the incidence and/or duration of stool toileting refusal [38].
Children who are toileting refusers complete their toilet training at a later age than that of those who are not (73 percent of the children who completed their training after four years of age had problems with toileting refusal versus 14 percent of children who completed training by three years) [17].
Toileting resistance may develop in children who are trying to exert their independence or control in a power struggle with their caregivers [1,39]. Returning control of the toilet-training process to these children is the key to successful management. In one prospective study, one-half of the children with stool toileting refusal began stooling independently within three months of the discontinuation of toilet-training efforts by their parents and the return to diapers [17].
If a child is resistant to toilet training, the following are helpful suggestions to offer caregivers [40]:
●Do not punish or nag the child.
●Discontinue training for a few weeks or months.
●Encourage the child to imitate caregivers and siblings by inviting the child into the bathroom.
●Continue to discuss toilet training with the child. This can be facilitated by books or videos on toilet training. Remind the child that toilet training is the child's responsibility.
●Encourage the child to change soiled diapers.
●Treat hard stools and constipation through dietary changes and, if necessary, with medications.
●Create a positive feedback system, such as a star chart.
Referral to a developmental-behavioral pediatrician may be necessary for the child older than four years of age with normal physical and neurologic examinations [1]. Group treatment involving both the child and the family may be beneficial [41]. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
Constipation and withholding behavior cycles — Children who refuse or resist toilet training are at significant risk of stool withholding, which can lead to acute, then chronic, constipation followed by encopresis [1,42]. Toileting refusal, stool withholding, and constipation are more common among children who hide during defecation than those who do not (29 versus 16 percent, 29 versus 12 percent, and 62 versus 40 percent, respectively) [43]. Initiation of toilet training before 27 months of age does not increase the risk of developing these problems [15]. (See "Constipation in infants and children: Evaluation" and "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
Children of toilet-training age are susceptible to constipation for a variety reasons. Their normal dietary intake is low in fiber and high in milk. The excessive consumption of whole cow's milk (32 oz [960 mL] per day) can slow intestinal motility and satiate the child, thereby diminishing the intake of foods that promote soft stools, such as water, fruits, and vegetables [1]. In addition, children using adult-sized toilets may not have sufficient leverage to successfully evacuate their stools.
Young children who have severe chronic constipation withhold stools to keep hard fecal matter out of contact with the sensitive portions of the gastrointestinal tract. Withholding sets up a vicious cycle of fecal impaction, pain, and more withholding. This cycle can have a profound effect on toilet use and can lead to encopresis. To maximize long-term outcomes in these children, correcting constipation and stool withholding as soon as possible is important. Withholding behavior often can be improved by decreasing milk intake and increasing fiber intake. Daily fiber (in grams) should equal the child's age (in years) plus five [2]. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation" and "Constipation in infants and children: Evaluation" and "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
RESOURCES — Caregivers and children may find the following books helpful in the toilet-training process.
●Books 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 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 for Girls" (Hannah & Henry Series) by Alyssa Satin Capucilli and Dorothy Stott
•"The Potty Book for Boys" (Hannah & Henry Series) by Alyssa Satin Capucilli and Dorothy Stott
•"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:
•"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 JA 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
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they 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. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topics (see "Patient education: Constipation in children (The Basics)" and "Patient education: Bedwetting in children (The Basics)" and "Patient education: Daytime wetting in children (The Basics)" and "Patient education: Fecal incontinence in children (The Basics)")
●Beyond the Basics topics (see "Patient education: Toilet training (Beyond the Basics)" and "Patient education: Constipation in infants and children (Beyond the Basics)" and "Patient education: Bedwetting in children (Beyond the Basics)")
SUMMARY
●Readiness – Toilet training should begin when the child is developmentally ready or shows signs of readiness. Pediatric health care providers must be able to recognize and understand the importance of readiness for both the caregiver and the child. They should discuss toilet training with caregivers at each health supervision visit beginning at age 12 months (table 1). (See 'Readiness' above.)
•Child readiness – The child's readiness is based upon the attainment of certain physiologic (eg, sphincter control), developmental (eg, ability to walk, remove clothing, sit on toilet), and behavioral milestones (eg, desire to please), rather than chronologic age. (See 'Child readiness' above.)
•Caregiver readiness – Caregivers must be prepared for the toilet-training process before they begin. They should know how to tell when their child is ready to begin training and should have realistic expectations about the duration of training, accidents, and setbacks. Caregivers should plan toilet training when at least one caregiver is able to devote the time and emotional energy necessary to be consistent on a daily basis for a minimum of three months. (See 'Caregiver readiness' above.)
●Guidelines – Toilet training involves many steps: communicating the need to go, undressing, eliminating, wiping, dressing, flushing, and hand washing. Going through these steps consistently reinforces proper toileting skills. (See 'Guidelines for toilet training' above.)
●Problems and setbacks – Toilet training is a challenging process that is frequently accompanied by problems and setbacks. Temporary setbacks are a normal part of the process and do not constitute failure; they are expected in times of acute illness, a family move, new child care arrangements, or a family crisis. Nocturnal enuresis and toileting refusal are the most common problems in healthy children. (See 'Problems and setbacks' above.)
