Arab Journal of Urology (2013) 11,13–18 Arab Journal of Urology (Ofﬁcial Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY REVIEW Can evidence-based medicine change toilet-training practice? Hsi-Yang Wu Department of Urology, Stanford University School of Medicine, Stanford, CA, USA Received 24 August 2012, Received in revised form 2 November 2012, Accepted 6 November 2012 Available online 8 December 2012 KEYWORDS Abstract Objectives: To assess the evidence showing that a speciﬁc method of toi- let training (TT) is more effective than others, as any method of TT recommended by Toilet training; a physician faces obstacles because parents rarely request advice on TT from physi- Urinary incontinence; cians, and TT practices vary tremendously across cultures and socioeconomic levels. Prevalence Methods: Reports on the natural course of urinary incontinence in children and different methods of TT, published in English between 1946 and 2012, were ABBREVIATION reviewed. Speciﬁcally investigated were historical recommendations on TT, the prev- TT, toilet training alence of urinary incontinence during childhood, the outcome of TT methods, and the effect of culture and socioeconomic status on the choice of TT method and tim- ing. Results: TT now occurs at later ages than it did previously. This progression reﬂects changing ideas about normal childhood physiology and psychology. The prevalence of urinary incontinence in European countries progressively decreased in children aged between 6–7 years and 16–17 years old. TT methods change with increasing socioeconomic levels to ‘child-centred’ techniques applied at older ages, Address: Department of Urology, Stanford University School of Medicine, 300 Pasteur Drive, S-287, Stanford, CA 94305, USA. Tel.: +1 650 724 7608; fax: +1 650 498 5346. E-mail address: firstname.lastname@example.org. Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.11.001 14 Wu but the prevalence of urinary incontinence after ‘parent-centred’ techniques of TT at younger ages has not been studied. There is currently no evidence that a speciﬁc tim- ing or method of TT is more effective or prevents voiding dysfunction. Conclusions: Follow-up studies of urinary continence in children toilet trained at 6–12 months of age might provide evidence for whether a given method or timing of TT is beneﬁcial to prevent voiding dysfunction. The recommendations of physicians might be more readily adopted if they ﬁt culturally accepted ideas of good parenting techniques. ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction population, and these factors might not be evenly matched. The data might be explained by several fac- tors, and it might not be possible to clearly show that The hypothesis that delayed toilet training (TT) in Wes- either the method or the timing of TT was the cause tern countries is responsible for an increased risk of dys- of voiding dysfunction. However, this type of evaluation functional voiding is a provocative idea [1,2]. It suggests would provide the most accurate ‘real-world’ results of that TT needs to be done during an optimal period to TT. The primary outcomes to be evaluated would be: avoid long-lasting effects such as urinary incontinence and UTI. However, the increased prevalence of dysfunc- 1. What is the prevalence of urinary incontinence immediately tional voiding might be due to other factors, such as the after TT? Using a standardised tool would answer the ques- increased recognition of urinary incontinence in children tion of whether an increased risk of dysfunctional voiding in wealthier countries, or it might show that children was due to increased recognition. who are prone to dysfunctional voiding take longer to 2. Was a consistent method of TT applied? If there was a sig- be trained [3,4]. The ability to study this topic is a niﬁcant cross-over from a ‘parent-centred’ to ‘child-centred’ ‘moving target’, as increasing wealth usually leads to approach, that might suggest that some children have difﬁ- the adoption of a ‘child-centred’ TT approach applied culty mastering the physiological steps of TT. at older ages, as diapers become more affordable. While 3. What is the prevalence of urinary incontinence 10 years a prospective trial comparing different methods and tim- after TT? If the long-term outcomes are similar, the short-term outcomes might not be as clinically important. ings of TT would be scientiﬁcally rigorous, success rates One would be more concerned if the data suggested that for TT methods depend on how intensively parents are permanent urinary incontinence could result from using instructed on the method . Parents gather much of an incorrect method or timing for TT. their information on TT from non-medical sources, such as friends and family members with older children or websites, which reﬂect their culture and socioeconomic Methods status . Often, advice from physicians is requested only when TT becomes frustrating for parents. The cheapness of diapers vs. the availability of time for par- Reports published in English between 1946 and 2012 on ents or caregivers to train children might be the key fac- the natural course of urinary incontinence in children tors which inﬂuence families on TT methods. It would and different methods of TT were identiﬁed, combining be difﬁcult to change these social factors with medical the search terms ‘urinary incontinence’, ‘paediatrics’, advice. and ‘toilet training’. Relevant reports were reviewed In the absence of a clinical trial, a prospective multi- for historical recommendations on TT, the prevalence centre case-control study might provide evidence on the of urinary incontinence, outcome of TT methods, and beneﬁts of early ‘parent-directed’ vs. later ‘child-direc- the effect of culture and socioeconomic status on the ted’ methods. To evaluate these data, knowledge of choice of TT method and timing. Papers quoted in the the natural history and prevalence of urinary inconti- Reference sections of these papers were also reviewed, nence in children would be necessary to provide a base- along with papers analysed in previous reviews on pae- line for comparison. The minimum outcomes of this diatric urinary incontinence and methods of TT [7–12]. study would include urinary incontinence (quantiﬁed ‘Parent-centred’ TT is a method where the parent takes by the daily number of episodes), age, gender, family the lead in determining the timing of TT for the child. history, timing and method of TT. Ideally, this cohort This is commonly used in African and Asian countries, would be followed over time to see if the rate of urinary sometimes starting at 3 months of age, more often at incontinence improved at older ages. Other known fac- 6 months, and usually with the goal of having the child tors, such as psychological stress and developmental de- able at 1 year old, to signal to its parents that he or she lay, would be harder to assess in a large survey needs to empty the bladder . There is no initial Can evidence-based medicine change toilet-training practice? 15 expectation that children will be able to clean and dress saves work if your baby doesn’t soil his diapers. But don’t themselves, but as they grow it is expected that they will fool yourself into thinking that a baby under a year old master the additional tasks required to independently can learn to control either his bowels or his bladder. Any- toilet themselves. ‘Child-centred’ TT involves waiting thing that looks like ‘control’ will be because you remem- for the child to show signs of readiness for TT before bered to put him on the toilet...A mother who refuses to embarking on the training process. This is commonly have a battle over toilet training can be pretty sure that used in European and North American countries, usu- once he has caught on, her child will learn without much ally starting at 18–22 months old, and is more popular trouble.’ . The previous emphasis on early TT had when disposable diapers are relatively affordable. Be- been ‘re-packaged’ as the parent becoming trained to cause the child is older, cleaning and dressing after use recognise the infant’s need to void or defecate. The larg- of the toilet is expected . For the purpose of this re- est change to later TT probably occurred in response to view a loose deﬁnition of urinary continence was used, Terry Brazleton’s ‘child-centred’ approach , which i.e. being able to signal to a parent the need to urinate, was popularised in his Touchpoints book series. He used and to stay dry in between, as this will allow a compar- a psychological approach in the paper: ‘Encopresis and ison of the two TT methods. Because nocturnal enuresis urinary incontinence can be traced to adverse or punitive also affects a signiﬁcant population of children and is training practices. Such pathologic symptoms usually re- harder to modify, this review will only discuss daytime ﬂect a fundamental psychological disturbance in the urinary continence. child’s adjustment...There must be a psychologic readi- ness associated with a desire to control the impulses to Results defecate and urinate. These impulses are associated with a kind of primitive pleasure and an immediacy.’ He sug- Historical perspective gested starting with a potty chair at 18 months old. Dur- ing the period of 1951–61, most children in his suburban Early TT was typical in the USA in the mid-1800s. A practice started TT at 24 months old and completed it paediatric textbook from 1847 proposed early TT as a by 30 months. Of 1170 patients 150 (13%) did not com- goal: ‘Children may be so trained to cleanliness, that at plete TT until 3.5 years old, while 12 (1%) remained a very early period of their lives, they will avoid soiling incontinent at age 5 years . themselves. A friend informed us, that the little patient Studies using the stricter deﬁnition of continence of eight months old, for which we were prescribing, had from the 1950s to 1980s showed that it was rare for chil- not worn a diaper since it was a month old; nor had it dren in the USA or Europe to be completely indepen- in a single instance soiled itself, either during the day or dent at toileting until 36–48 months old . A survey the night. When it felt a necessity, it would by signs make of Brazilian children found that 98% of 2-year-old chil- it known in such good time as to prevent accident. This, we dren were dry at 2 years old in 2003, compared to 24% admit, to be a rare instance of discipline, but it is not less of 2-year-olds in 2006 . worthy of imitation.’ . By the early 1900s, failure to Prevalence data and longitudinal follow-up achieve early TT was felt to be a moral failure on the part of the parents. ‘Before the end of the ﬁrst year many intelligent children can be trained to indicate a desire to In European countries, daily urinary incontinence oc- empty the bladder. Many mothers and nurses succeed so curs in 1–9% of children at 7 years old, with girls having well in training children so well that by the tenth or elev- higher rates than boys (2.3–8.9% vs. 1.3–9.2%; mean enth month napkins are dispensed with during the day. On 6% vs. 4%) [4,21,22]. The broad range might be due the other hand it is very common to see children of two or to an increased awareness of urinary incontinence over even two and a half years still wearing napkins due to lack time, as the more recent studies have a higher prevalence of proper training...The annoyance and discomfort from rate . By the time this cohort of children reached 15– the neglect of early training in this particular are very 17 years old, the prevalence decreased to 0.3–5% (girls great.’ ; and ‘In most cases the condition is purely a 3.6–4.7% vs. boys 0.3–1.0%). Interestingly, none of habit, often associated with other habits that indicate an the older children felt that their urinary incontinence was a signiﬁcant issue, and they did not request medical unstable or highly susceptible nervous system’ . treatment [4,23–25]. Both of the longitudinal studies Gradually, the expected age of TT changed towards were carried out in the 1990s. No longitudinal data from later ages, as reﬂected in this ofﬁcial US government Asian or African countries are available, although the publication on children’s care from 1951: ‘When some cross-sectional prevalence of urinary incontinence does neighbour tells you her baby was ‘‘trained’’ at a very early not appear to be signiﬁcantly different from the Euro- age, take it with a grain of salt. You can be sure it was pean studies. English children show a decrease in day- really she who ‘trained’ herself to recognize little signals time urinary incontinence between 4 and 9 years old, that her baby was about to have a movement. Or, her baby from 11% to 2% in girls, and 11% to 3% in boys happened to be one whose bowel movements came at quite . In Australian elementary-school children at a mean regular times earlier than most babies’ do. Of course it 16 Wu age of 7.3 years, 10% reported daily urinary inconti- the process, and did not result in children achieving nence, which was more common in girls than boys early continence . This was supported by another . In South Korean elementary-school children aged study comparing the timing of TT in a predominantly 6–13 years, daytime incontinence occurred in 11%, with white, suburban population in the USA. This study a clear trend towards improvement with age (31% in found that early TT (18–21 months, compared to later) 5-year-olds to 6% in 13-year-olds). UTI and delayed correlated with a longer duration of TT, suggesting that stool control negatively affected dysfunctional voiding there was no beneﬁt to starting TT before 27 months old . Brazilian children aged 6–12 years reported a . By contrast, a study from the UK found that wait- 31% rate of urinary incontinence, although the fre- ing to TT after 24 months was correlated with a higher quency of wetting and trend over time was not speciﬁed risk of daytime urinary incontinence, prolonged TT, . Finnish children have frequent urge incontinence, and relapse to daytime incontinence . The authors at a rate of 4% when 4–7 years old, which decreases to hypothesised that a delay in TT would expose children 0.6% by 8–12 years. It was not reported at all in those to additional stresses, which interfered with TT. A retro- aged 13–26 years, and social problems caused by the spective comparison of Belgian elementary-school chil- incontinence were only reported in 1% of children aged dren found that children with no urinary symptoms 4–12 years . were more likely to start TT before 18 months old than were those with urinary incontinence . A comparison Parent- vs. child-centred TT methods of Taiwanese kindergarten children who had TT at <18, 19–24 and >24 months old found no difference TT methods clearly change with increasing socioeco- in urinary incontinence, uroﬂow patterns or postvoid nomic levels to child-centred techniques applied at older residual volumes. In that study, 28% started TT using ages, probably due to the affordability of disposable dia- a parent-directed method before 18 months old, 30% pers. The prevalence of urinary incontinence after par- at 19–24 months and 42% used a child-directed method ent-centred techniques of TT at younger ages has not after 25 months old . been studied. One Vietnamese paper showed that infants The use of the bedwetting alarm to help train children can be trained by 1 year old, and that the postvoid resid- in day-care settings was shown to be more effective than ual urine volume decreased after infant TT . a control (52% vs. 8%) over the course of 3 weeks . Although the experience of the Digo people of Kenya A survey of Belgian day-care providers showed that is the most referenced paper , the same ‘parent- 82% spent at least an hour each day on TT, 50% used centred’ technique was successfully applied in the readiness signs to determine the proper age to start, Netherlands with 3–7-month-old infants . and 95% used timed toileting to start the process. A No direct comparisons of TT methods have been re- third of providers felt that parents did not participate ported. The Foxx-Azrin method is an intensive parent- sufﬁciently in enforcing TT at home, although 60% of centred technique that requires many steps, including day-care workers also felt pressure from parents to both positive and negative reinforcement by the parents accelerate the process . . The initial publication suggested that 20-month-old Variations by socioeconomic group children could be trained at a mean of 4 h, and would remain dry for 4 months. Follow-up studies showed that the success of the Foxx–Azrin method varied consider- Parents from lower socioeconomic groups had the ably, depending on whether parents were provided with expectation that their children would toilet train at an experienced trainers, vs. those who were only instructed earlier age. African-American children who lived in the to read the book. Parents who did not receive supervi- Milwaukee (WI, USA) area were more likely to train sion were less likely to achieve continence in the child, early than were Caucasian children (50% completing and the children who did become dry in this group TT by 30 vs. 39 months) . A survey of USA parents had a rapid relapse . While the child-centred approach showed that Caucasian parents believed that children suggests looking for several signs as a way of determin- should be trained at a later age than did African- ing when a child is ready to TT, the period during which American parents (25 vs. 18 months). Race was a stron- these signs are apparent varies between 2 and 40 months ger predictor than income for the belief that children old . should be trained at a later age . Turkish children The initial paper from Switzerland comparing early complete TT by 28 months for girls, and 29 months TT (onset between 6 and 9 months, 1954–56) with cur- for boys. Multivariate analysis found that an earlier ini- rent delayed TT (onset between 12 and 24 months, tiation of TT was associated with lower socioeconomic 1974–84) over different periods found that about 90% status, use of a potty chair, and use of punishment. of boys and girls achieved daytime continence at The duration of TT was longer in rural and semi-urban 48 months old in both groups. This paper used a stricter areas than in urban areas . It is unclear whether this deﬁnition of successful TT, including dressing and toilet- is due to a need to minimise expenses for disposable ing. This study suggested that early TT only prolonged diapers, or whether this is associated with a cultural Can evidence-based medicine change toilet-training practice? 17 expectation that children should grow up earlier. British Conclusions mothers who were older and had a longer education were more likely to wait until 24 months to TT, whereas TT practices have varied widely over time, but these young, single mothers with a shorter educational experi- changes were driven less by scientiﬁc data than by pop- ence were more likely to TT at 15 months or earlier . ular ideas of whether permissive or strict parenting was better. Prevalence and incidence data on urinary incon- Readiness signs tinence after ‘child-centred’ TT are available to provide a comparison for children who undergo ‘parent-centred’ Deciding when a child is ready to toilet train depends on TT. Follow-up studies of urinary continence in children the presence of both overall readiness skills and toilet- TT at 6–12 months old might provide evidence on speciﬁc skills. The lesson that can be learned from par- whether ‘parent-centred’ TT is beneﬁcial to avoid void- ent-centred TT is that at a minimum, the child must ing dysfunction. The normal course for urinary inconti- be able to signal to its parent that he or she needs to uri- nence in children is a spontaneous resolution, but nate. This can be present as early as 3 months , but children with signiﬁcant urinary incontinence often do in Western countries, occurs at a median age of not seek medical attention. If TT is used predominantly 28 months for girls and 33 months for boys . Staying by child-care providers in the future, TT methods based dry during an afternoon nap has been suggested as a on scientiﬁc evidence might be easier to implement. good marker for increasing bladder capacity, which oc- curs at a median age of 26 months for girls and Conﬂict of interest 29 months for boys . Unfortunately, the use of absorbent diapers has made it more difﬁcult for parents None. to realise when their children are staying dry, compared to when cloth diapers were used, as the wetting is not Source of funding immediately apparent . Up to 28 separate toilet- readiness signs have been proposed, which occur at None. 2–40 months old [34,44]. This broad range of ages unfortunately provides no guidance to physicians or References parents on when to start TT, although the onset for half  Hellstrom AL. Inﬂuence of potty training habits on dysfunctional of the signs will have occurred at 12–24 months old . bladder in children. Lancet 2000;356:1787. 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Arab Journal of Urology
– Taylor & Francis
Published: Mar 1, 2013
Keywords: Toilet training; Urinary incontinence; Prevalence; TT, toilet training