Toilet Training: Common Questions and Answers

 

Toilet training is a significant developmental milestone in early childhood. Most U.S. children achieve the physiologic, cognitive, and emotional development necessary for toilet training by 18 to 30 months of age. Markers of readiness for toilet training include being able to walk, put on and remove clothing, and follow parental instruction; expressive language; awareness of a full bladder or rectum; and demonstrated dissatisfaction with a soiled diaper. Other readiness cues include imitating toileting behavior, expressing desire to toilet, and demonstrating bladder or bowel control (staying dry through a nap or through the night). Physicians should provide anticipatory guidance to parents beginning at about 18 to 24 months of age, noting the signs of toilet training readiness, and setting realistic expectations for parents. Parents should be counseled that no training method is superior to another. Parents should choose a method that is best suited to them and their child, and the method should use positive reinforcement. Complications of toilet training include stool toileting refusal, stool withholding, encopresis, hiding to defecate, and enuresis. These problems typically resolve with time, although some may require further investigation and treatment. Medical comorbidities such as Down syndrome, autism spectrum disorder, and cerebral palsy reduce the likelihood of successfully attaining full toilet training and often require early consultation with occupational therapists, developmental pediatricians, or other subspecialists to aid in toilet training.

Toilet training is a significant developmental milestone in early childhood as a child gains mastery over a previously involuntary bodily function. It can bring a sense of accomplishment or frustration for the family, depending on the approach, its timing, the child's readiness for training, and the caregiver's and child's responses to the approach. This article answers commonly asked questions regarding toilet training to help the family physician best address parental expectations and concerns.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Anticipatory guidance and parental counseling about toilet training should begin at 18 to 24 months of age, just before most children demonstrate developmental signs of readiness.1,11,12

C

Expert opinion and consensus guidelines in the absence of clinical trials

The American Academy of Pediatrics and the Canadian Paediatric Society recommend a child-oriented approach to toilet training.1,10,11

C

Expert opinion and consensus guidelines in the absence of clinical trials

Consultation with an occupational therapist, developmental pediatrician, or other subspecialist is recommended to aid in toilet training of children with developmental or physical disorders (e.g., Down syndrome, autism, cerebral palsy).3337

C

Expert opinion and consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Anticipatory guidance and parental counseling about toilet training should begin at 18 to 24 months of age, just before most children demonstrate developmental signs of readiness.1,11,12

C

Expert opinion and consensus guidelines in the absence of clinical trials

The American Academy of Pediatrics and the Canadian Paediatric Society recommend a child-oriented approach to toilet training.1,10,11

C

Expert opinion and consensus guidelines in the absence of clinical trials

Consultation with an occupational therapist, developmental pediatrician, or other subspecialist is recommended to aid in toilet training of children with developmental or physical disorders (e.g., Down syndrome, autism, cerebral palsy).3337

C

Expert opinion and consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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DREW C. BAIRD, MD, FAAFP, is the director of the Family Medicine Residency Program at Carl R. Darnall Army Medical Center, Fort Hood, Tex., and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

MICHAEL BYBEL, DO, is the research director of the Family Medicine Residency Program at Carl R. Darnall Army Medical Center and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences.

ADAM W. KOWALSKI, MD, is a family physician at Winn Army Community Hospital, Fort Stewart, Ga.

Address correspondence to Drew C. Baird, MD, FAAFP, Carl R. Darnall Army Medical Center, 113 Drovers Run, Belton, TX 76513 (email: drew.c.baird.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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