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Toilet Training

A guide to toilet training

The most important part of toilet training is establishing a calm attitude and routine. Once your child has settled into the routine of sitting on the potty, he/she will soon develop the skills to use it. As a parent you will need to show patience, persistence, relaxed encouragement and a total lack of concern.

At first, emptying of the bowel and bladder is a reflex action. A baby cannot be properly taught to use the potty until he is old enough to control his bowels and bladder voluntarily, just like an adult.

Think of yourself as being there to help a natural development, and be persistent not insistent.

Children develop at different rates, and you should begin potty training only when your child is ready. Most are ready for potty training at some time between 18 months and two and a half years of age, with girls often being ready before boys.

By the age of three, nearly all children are able to control their bladder and bowels during the day. Becoming dry at night may come at the same time, but commonly a child may reach the age of six before being completely dry every night.

It is important not to rush your child into potty training merely because of their age, because friends' children are trained or because the nursery or nanny says the child should be trained by now – these pressures will only lead to problems later.

Control of the bowels is attained before bladder control. The sequence is generally as follows, but may vary:

1. First, bowel control at night
2. Next, bowel control during the day
3. Then, bladder control during the day
4. Finally, bladder control at night

Bowel movements are more predictable than urination, so try to note the time of the day and encourage use of the potty at this time.

Your child may feel uncomfortable using the potty to begin with and may hold on until a nappy is put on.

Look for signs of needing a bowel movement, such as reddening of the face, hiding, standing still, crying, pointing.

Aiming for dryness during the day

Ensure that the potty you buy is sturdy and won't tip up. Include your child when buying it. A splash guard is a good idea for little boys.

Explain to your child what the potty is for and encourage him to sit on, but not play with, it.

Encourage awareness of other members of the family using the toilet.

Talk to your child about 'wees' and 'poos' when changing nappies.

When your child wees without a nappy, talk about it; this will help build and reinforce the link between the feeling of needing to pass urine and then doing it.

First stage

1. Begin potty training at a calm time – preferably during the summer.
2. Avoid times of change e.g. the arrival of a new baby, moving house, starting nursery, illness in your child or other members of the family.
3. Look for signs that your child is ready:
4. Nappy stays dry for a reasonable length of time
5. Your child indicates that s/he has done a wee or poo in the nappy
6. Trying to find somewhere private when filling a nappy
7. Fussing to be changed straight after filling a nappy
8. Place the potty in a warm, accessible room, preferably where your child spends a lot of time so it can be reached quickly.
9. Develop a routine that fits in with family life and stick to it. Sit your child on the potty at regular intervals. At first, this may be every 60 minutes. If your child is dry after 60 minutes, gradually increase the time until it is 2-3 hours.
10. Use appropriate clothing that is easily removed, such as elasticated trousers and pants. It may be easier to leave your child undressed from the waist down at first.
11. Encourage your child to choose their own underpants or knickers, as s/he may be less willing to spoil them.
12. Give lots of praise and encouragement when your child sits on the potty.
13. There are several books for children about potty training that you can read together.
14. Use nappies when going out or during a daytime sleep.
15. Do not restrict drinks as this will make your child thirsty and fretful.
16. Accidents will happen, so clean up the mess calmly.
17. Be aware that your child might have lots of fears and ideas about the toilet and their own body.

Second Stage

1. When your child sits on the potty regularly and happily try to encourage him/her to ask for it and introduce pants.
2. Try venturing out to shops without a nappy.
3. Ask your child regularly if s/he needs a wee, and continue to praise and encourage.
4. An open disposable nappy on the car seat can help to make accidents less of a problem.
5. Do not expect your child to be dry at night for up to 12 months after he is dry in the day. When s/he begins to stop wetting the night time nappy try without it and cover the bed with a plastic sheet.
6. Dryness at night can be related to bladder size and the depth of your child's sleep. The pattern of night dryness can also be genetic.
7. When your child is confident about using his own potty and toilet, encourage the use of different potties and toilets to prevent problems when visiting friends or on holiday.

Dealing with difficulties in toilet training

One of the main causes of difficulties is trying to train a child too early. If some of the signs are there but you are having no success at all then it is probably best to stop using the potty for a month or two. Explain to your toddler what is happening and help them maintain a positive association with the potty.

There may be times, even after a successful period of using the potty, when your child may require a nappy. Although this may be frustrating for you and them, it is important that you keep praising and encouraging their efforts and help them to understand that success normally follows practice.

Pressurising your child or reprimanding for accidents or lack of success, will lead him/her to develop an unhappy association with the potty, which can take a great deal of time and effort to reverse.

It is quite common for a child to become uncooperative or turn using the potty into a battle of wills. This becomes more likely if your child senses that you are anxious or frustrated about it. If you find yourself in this situation, you need to relax heightened tensions between you before you try again. This will take a great deal of effort on your part and it may seem like your child is getting his or her own way. However, your toddler will become increasingly uncomfortable with soiling their nappies and is likely to seek a way to return to the potty in their own time and way.

If your child stubbornly refuses to cooperate, seeing other children their age who are using the potty throughout the day may provide the incentive they need to succeed.

You might try a short delay in changing your child's soiled nappy and getting them to stand up when you change them. Both of these actions will be less comfortable for your child and can help them to see the unpleasantness of remaining in nappies.

Patience, understanding and a lot of positive reinforcement can deal with most difficulties with potty training. However, if your child is over the age of three and has been trying to use the potty for more than six months without much success, you should see your doctor with your child to exclude possible medical causes and to get further advice.

You should also see your doctor if your child refuses to open the bowels and develops chronic constipation. In this situation, your doctor will examine your child to rule out medical causes and may then recommend a regular 'bowel programme' to get the bowel moving again.

Bed wetting

There can be several causes of a lack of night time bladder control. It tends to run in families.

Children who wet the bed do not do it on purpose and are not naughty or lazy.
And it is not your fault. Some children take longer to gain full control of their bladder at night. All children are individuals and develop at their own pace.

Bed wetting is common. One in every six children starting school wet the bed.

Most children can be helped by giving them support and encouragement. We have a team of School Nurses who specialise in bed wetting problems and will be happy to help and advise you and your child.

If you would like further information or help, please contact one of these clinics:

Northbrook Health Centre
93 Northbrook Road
Shirley
B90 3LX
Telephone: 0121 745 8366

Kingshurst Clinic
Marston Drive
Kingshurst
B37 6BD
Telephone: 0121 770 3446

Craig Croft Clinic
Craig Croft
Chelmsley Wood
B37 7TR
Telephone: 0121 770 3228

Helpful Hints

1. Your child should drink plenty of fluids during the day. Milk or water is recommended.
2. After 4pm avoid:

Tea
Coffee
Chocolate flavoured drinks
Squash and fizzy pop should be avoided at all times.

3. Don't let your child wear pants in bed.
4. Encourage your child to use the toilet before bed and again before going to sleep.
5. Praise your child for any dry nights, and ignore wet nights.
6. If your child has any discomfort on passing urine, contact your family doctor.
7. If your school-age child wets the bed regularly, don't be afraid to discuss this with your School Nurse.

Soiling

When a stool enters the rectum causing it to stretch, nerves are stimulated and those send messages to the brain telling us that we need to go to the toilet.

However, when a child withholds (for whatever reason) the rectum fills with faeces and slowly enlarges over weeks and months. The faeces become harder because water is reabsorbed by the bowel. Eventually it becomes so large that the child no longer feels the need to go. The constipation becomes so severe that it leads to a partial blockage of the bowel, some of the motions become liquid and leak around the impacted area, soiling the child's underwear.

Children with the condition are unaware of the constipation and are unable to prevent the leakage.

Programme for bowel retraining following soiling

1. Keep a record or diary sheet of:
any medication
going to the toilet and results
2. Give your child a hot drink with each meal
3. Ensure your child is eating enough fibre.
4. Because the most likely time to be successful is after eating, your child should go to the toilet about 20 minutes after each meal.
5. Your child should sit on the toilet for at least 10 minutes. Provide some comics for amusement but also tell your child to try pushing every so often by pretending to blow up a balloon.
6. A box to rest feet on will help with the pushing.
7. Even if a small stool is passed your child should go on trying to pass another one.
8. You could try using a star chart to encourage your child with rewards.
a happy face for the chart for trying (and staying the full 10 minutes)
a further two happy face stickers for producing a poo
9. Your family can help by looking at the charts and offering encouragement (never criticism) and praise for trying.
10. Make an appointment with your health visitor to review.

Soiling is a common problem. Three in every 100 five year olds will be soiling.

Between the ages of seven and eight years about two out of every 100 children are soiling.

At 12 years about one in every 100 boys (and some girls) are still soiling.

Because of the shame felt about this problem and the attempt by many families to keep the soiling secret, these figures may be underestimated. Many parents are likely to think that their child has a unique problem because most parents have never heard of another child who is soiling.

Children of all levels of ability and from all walks of life have this problem.

Constipation or hard bowel movements cause pain, irritability and a decreased appetite.

A child's emotional state (due to stress or trauma) can affect the functioning of the bowel so soiling may result from distressing events.

Some children have never established bowel control. The medical term for this is primary encopresis. When bowel control has been established for at least six months before soiling begins, it is referred to as secondary
encopresis.

Diarrhoea in children

Diarrhoea is frequent, watery bowel movements. The most common cause is infection by virus or bacteria which alter the lining of the gut. Diarrhoea is the body's way of getting rid of harmful substances produced by the infection.

Prevention

Keep your child well nourished, warm and clean. Hand washing is important after changing nappies or using the toilet and before handling food or making up feeds. Take care to sterilise baby equipment as this will help prevent the spread of diarrhoea.

Can diarrhoea be dangerous?

Diarrhoea usually improves within a few days and if mild can be treated at home with extra clear fluids (water) along with a normal diet. However, if diarrhoea is severe and persistent or becomes accompanied by vomiting this can cause dehydration, which is the major risk factor for children. Babies and toddlers are at highest risk as they dehydrate more quickly.

When to consult your doctor

If diarrhoea seems more severe and persistent
If there are signs of dehydration – sunken eyes, weakness or lethargy or the skin when gently pinched on the thigh takes time to return to normal
If the child/baby has a persistent fever and seems ill
If stools are bloody or slimy
If your child is listless, unusually sleepy or unusually irritable

The doctor may need to prescribe an oral rehydration solution to prevent or treat dehydration.

What you can do to help

Give extra water drinks as well as normal feeds while waiting for diarrhoea to settle. This will maintain hydration and hasten recovery.

If breast feeding, continue and offer the breast more often.

If bottle feeding, give usual feeds and extra if tolerated.

Foods containing a lot of sugar, such as ice-cream, juices and fizzy drinks may worsen diarrhoea. Starchy foods such as bread, rice and potatoes can help.

Do not give medicines to prevent diarrhoea – these are not recommended for infants and young children.

Occasionally children have persistent loose stools after an episode of diarrhoea. This is generally not severe and will disappear within a few days. However, if it continues longer than this you should consult your GP.