0021-7557/08/84-01/9

Jornal de Pediatria
Copyright 2008 by Sociedade Brasileira de Pediatria
REVIEW ARTICLE

Toilet training: methods, parental expectations and

associated dysfunctions
Denise M. Mota,1 Aluisio J. D. Barros2

Abstract
Objective: To review both the scientific literature and lay literature on toilet training, covering parents expectations,
the methods available for achieving bladder and bowel control and associated morbidities.

Sources: Articles published between 1960 and 2007, identified via the MEDLINE, Cochrane Collaboration, ERIC,
Web of Science, LILACS and SciELO databases plus queries on the Google search engine; a search of related articles,
references of articles, by author and of pediatrics societies. A total of 473 articles were examined and 85 of these were
selected for this review.

Summary of the findings: Parents have unrealistic expectations about the age at which diapers can be withdrawn,
not taking child development into account. Toilet training strategies have not changed over recent decades, and in the
majority of countries the age at which children are trained has been postponed. Training methods are rarely used.
Starting toilet training prematurely and stressful events during this period can extend the training process. Children
who have not been trained correctly present with enuresis, urinary infection, voiding dysfunction, constipation,
encopresis and refusal to go to the toilet more frequently. Literature intended for lay parents is both abundant and
adequate, available in book form and on the Internet, but it is not widely available to the Brazilian population. Just three
international pediatrics societies have published guidelines on toilet training.

Conclusions: Toilet training is occurring later in the majority of countries. The training methods that exist are the
same from decades ago and are rarely used by mothers and valued little by pediatricians; incorrect training can be a
causative factor for bladder and bowel disorders, which in turn cause problems for children and their families.

J Pediatr (Rio J). 2008;84(1):9-17: Toilet training, enuresis, child, urinary tract infection, elimination disorders.

Introduction for parents and for children. The majority of parents, even

Toilet training is a developmental milestone and is a chal- those who are better informed, have inappropriate expecta-
lenge to parents and children. It is one of the first steps that tions with relation to the age at which toilet training should be
children take to become self-sufficient. All children will man- completed.3,4
age to acquire the necessary control eventually, but the diffi-
culty involved is a major concern for parents and causes A child can be considered toilet trained when no longer
conflicts within the family.1 requires help or supervision to use the toilet (or potty). He or
Toilet training is influenced by physiological, psychologi- she can take responsibility for independent toilet use and has
cal and sociocultural factors. The childs first point of refer- the ability to keep him/herself clean and dry, i.e., not wetting
ence is the family, followed by enrollment at school or in or soiling their pants.5 A child is completely trained when able
daycare. There are few issues in the area of child develop- to be conscious of his or her own need to eliminate urine and
ment that involve greater concern than subjects related to toi- stools and can initiate the act without being reminded or pre-
let training and its disorders.2 Successful toilet training is good pared by parents.5

1. Mestre. Mdica nefrologista peditrica, Programa de Ps-Graduao em Epidemiologia, Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil.
2. Doutor. Professor associado, Programa de Ps-Graduao em Epidemiologia, UFPel, Pelotas, RS, Brazil.
No conflicts of interest declared concerning the publication of this article.

Manuscript received Oct 16 2007, accepted for publication Nov 21 2007.

Suggested citation: Mota DM, Barros AJ. Toilet training: methods, parental expectations and associated dysfunctions. J Pediatr (Rio J). 2008;84(1):9-17.
doi:10.2223/JPED.1752

9
10 Jornal de Pediatria - Vol. 84, No. 1, 2008 Toilet training - Mota DM & Barros AJ

Toilet training itself is complex and is accomplished in abstracts. The chosen outcomes were bladder and bowel con-
steps. Acquisition of the independence necessary to use the trol, training methods and associated morbidity. The searches
toilet includes: walking to the toilet or potty, sitting on it, uri- used combinations of the following keywords: toilet training,
nating or evacuating, pulling pants down and back up, flush- potty training, development and toilet training, toilet training
ing, washing hands and returning to the original location. and enuresis, toilet training and dysfunction elimination syn-
Being ready for this stage is important to make it more drome, toilet training and constipation, toilet training and
enjoyable and of shorter duration. Acquiring autonomy to use encopresis, toilet training and urinary tract infection, toilet
the toilet requires that the child has mastered not just lan- learning, toilet conditioning, toilet teaching, toilet educating
guage, but also motor, sensory, neurological and social skills. and toilet behaviors, resulting in the identification of a total of
Climate, culture and access to disposable diapers are impor- 735 articles.
tant factors in starting toilet training.6-8 The temperament of
each child also has an influence on this training.9 After limiting searches to articles in French, English or
Spanish, and on normal children from zero (neonates) to 19
Different cultures have different methods of toilet train-
years of age, 484 articles remained. Of these, 150 articles on
ing and distinct expectations about when bladder and bowel
the treatment and diagnosis of constipation, encopresis or
control should be achieved. The strategies employed to
enuresis were excluded, plus 64 articles on toilet training chil-
achieve this control have changed over the last 60 years:
dren with special needs; 49 articles on malformations of the
training now starts later, regular times for urination have been
urinary and intestinal tracts; 100 articles unrelated to the sub-
abandoned and the regular toilet seat without adapter and
ject and 37 articles with no abstract and unrelated titles. The
step stool to support the feet is being used instead of a
remaining 85 articles were read in full and included in this
potty.1,10
review article.
Recent studies have identified incorrect toilet training as
being predictive of persistent urinary symptoms, such as uri- Many articles were repeated, with different keywords.
nary incontinence, enuresis, recurrent urinary tract infection Some publications were about the same groups of children,
and childhood constipation.11-14 The term dysfunctional elimi- but discussed different outcomes. Duplicate articles were
nation syndrome was introduced by Koff & Jayanathi to excluded together with articles with no abstract and titles
described the association between voiding and intestinal dys- unrelated to the subject under review. The criteria employed
function. Although well-known, its precise mechanisms to assess the articles methodology were those described by
remain unexplained. 15 Downs & Black.16 The review covered the period from 1960
to August of 2007.
This article reviews the scientific literature on the theme,
covering parents expectations, methods available and meth- Searches were also run to locate Internet resources aimed
ods actually used to achieve urinary and intestinal conti- at parents, primarily using Google, and many sites were
nence (toilet training) and also associated morbidities. The identified.
section on literature for parents is based on a review of sites
on the Internet, best-selling books on the subject and parent Parents expectations
associations.
We should point out that parents opinions and concerns
Literature review relating to their children have an influence on the rhythm of
the childs development and on behavior; beliefs also have an
The search strategy for the literature review included the
important influence on parent-child interaction and, conse-
following databases: MEDLINE/PubMed, Cochrane Central
quently, on child development. Realistic and appropriate
Register of Controlled Trials, ERIC (Educational Resources
expectations are associated with positive interaction between
Information Center), Web of Science, LILACS, SciELO and
parents and child and facilitate child development. In con-
Google. Additionally, searches were run for related articles,
trast, unrealistic expectations can have adverse conse-
article references and by relevant authors. The Internet sites
quences (frustration, punishment, negligence, abuse and lack
of international pediatrics societies in several countries were
of stimulation).3 Many children are forced to try to learn when
also browsed in a search for guidelines on the subject. This
they do not yet have the necessary biological conditions, caus-
last search identified just three sets of guidelines: published
ing frustration for parents and grandparents and disappoint-
by the American Academy of Pediatrics (http://
ment for school teachers with rigid, inflexible demands with
www.aap.org/), the Canadian Paediatric Society (http://
relation to childrens mictional and intestinal habits.
www.cps.ca/) and the American Academy of Family Physicians
(http://www.aafp.org/).
Chronological age is considered a magic moment for
Prospective and retrospective cohort studies, cross- starting to remove diapers, and the preference is to start
sectional studies, case-control studies and clinical trials were before 24 months, especially before 18 months.17 A recent
included. Articles were selected on the basis of their titles and study based on the 12-month home visits paid to the Pelotas
Toilet training - Mota DM & Barros AJ Jornal de Pediatria - Vol. 84, No. 1, 2008 11

2004 Birth Cohort, demonstrated that the majority of par- time.24 In 1971, Azrin & Foxx25 developed a rapid training sys-
ents exhibit unrealistic expectations of the age for toilet train- tem for children with disabilities and difficulties with toilet
ing and dont take into consideration the stage of development training. This method was later used with normal children. The
or readiness skills needed for this training. Around 70% of method is based on the principles of conditioning and imita-
mothers expected their children to be trained by 18 months; tion,26 with a more intensive and structured approach.
5.6% cited some type of ability acquired by the child as a
parameter to indicate that toilet training should be initiated A third, little-known method is early elimination training
and 53% of mothers decided to take their children out of dia- (assisted training). This method starts during the first weeks
pers based on the childs age.18 Despite these expectations, of life, employing a strategy of observation of the signs of
when the same cohort was visited at 24 months, just 25% of elimination emanating from the baby. Once these signals have
children were out of diapers during the day and 9.5% at night been recognized by the mother (or carer), the baby is placed
(unpublished observation). It is important to bring this sub- on the potty to eliminate, while held by the mother/carer. This
ject up with families, since the correct guidance can help pre- system is currently used by some communities in China, India,
vent family conflicts between parents and child. 4,19 Africa, South and Central America and parts of Europe.27

Other factors that should be considered are the differ- Another method mentioned is that of Spock, which
ences between the opinions and the expectations of parents, appeared before Brazeltons, being similar in that the child is
daycare staff and doctors. Many daycare centers that accept not forced. There are no scientific reports of the application of
children still in diapers train them intensively during their edu- these last two methods.28
cational activities, contrasting with the attitudes of parents
at home. This difference in opinions and instructions con- There are no studies that compare toilet training methods
fuses the children, since they receive conflicting messages and with each other, just some clinical trials comparing the same
do not know whose instructions to follow.17 method with different approaches.29,30 Because of this, it is
difficult to assess which is the best method to use. When we
There are few articles on parents expectations of toilet
evaluate toilet training it is important to define what one
training and the theme is generally dealt with as part of an
defines as trained, i.e. whether the child is merely able to
overall assessment of child development topics. The majority
remain dry or whether, in addition to this, they are also able
of articles employ samples of convenience, in which parents
to use the bathroom with autonomy. The majority of articles
are interviewed while seeking care at clinics. This being the
do not go on to define autonomy.
case, generalizations can not be applied to populations of chil-
dren from specific areas.
Epidemiology of toilet training
The evolution of training strategies
In the great majority of countries the age at which toilet
At the start of the twentieth century, the predominant atti- training takes place is increasing.31 In the United States a ten-
tude with relation to toilet training was permissiveness, dency has been observed for the age at which bladder and
changing to strictness during the 1930s.20 Parents were bowel control are achieved to increase: in 1947,20 60% of chil-
advised to train their children as early as possible, in order to dren were trained at 18 months and 95% at 33 months; in
free them from the obligation of changing diapers.5 As clini- 1962,22 26% at 24 months and 98% at 36 months; in 1974,20
cal evidence evolved, reports emerged suggesting that devel- 59% at 33 months and; in 1977, 78% at 36 months. In 1980,
opment of bladder and bowel control is a process of maturation the mean toilet trained age varied from 25 to 27 months and,
that should not be accelerated, but should be left until the child in 2003, it had increased to 36.8 (standard deviation = 6.1
manifests interest in being trained. In 1950, parents were not months).32 Parents expect to start training later: more than
interfering with training and childrens toilet behavior was 95% before 24 months in 1970, 73% before 29 months in
observed, without the punishments of previous years.21 In 1985 and 65% before 30 months in 1996.1,4,33
1962, Brazelton observed a very high prevalence of enuresis
and proposed a training strategy to attempt to change this In Brazil the same tendency to delay training is being
prevalence, following the guidelines laid down by Spock, still observed. Based on a cross-sectional study carried out in 2003
followed today, with minor adaptations and changes to the with children born between 1994 and 2000, the mean age at
age at which training is started.22,23 This strategy is based on which daytime bladder and bowel control was achieved was
passive guidance in which, in addition to the childs physi- 22.6 months, while, at 24 months, 97.6% of the children had
ological maturity, training should be delayed until the child daytime control and 89.9% nighttime control.34 In 2006, the
demonstrates interest and the psychosocial ability to start data from the children in the Pelotas 2004 cohort indicated
training. It was designed to minimize conflict and anxiety and that, at 24 months, just 24.1% of the children had daytime
emphasize the importance of flexibility. Training should be car- control and 8.5% nighttime control, a prevalence of control
ried out in a relatively gentle manner and with confidence that that is four times lower during the day and 10 times lower dur-
the child will learn to go to the bathroom alone, at the right ing the night (unpublished observations).
12 Jornal de Pediatria - Vol. 84, No. 1, 2008 Toilet training - Mota DM & Barros AJ

In Sweden, Hallgren observed that 92% of children had context also emerges when we see that African American chil-
daytime urinary control at 4 years. Almost 50 years later, Jan- dren initiate and complete training, on average, earlier (a
sson reported that 50% of the children had daytime control mean of 21 and 30 months for starting and completing,
at 3.5 years which also suggests an increase in the age at respectively) when compared with white children in the United
which control is achieved. The same author observed that, States (30 and 39 months). These parents expectations are
since the introduction of disposable diapers and the accep- different with relation to the age of this control.3 Mothers in
tance that children will decide when they are ready to become less developed countries also expect their children to be
continent, the age of initiating training has been increasing, trained at earlier ages, when compared with developed
and bladder and bowel control has come to be seen as a stage countries.
of maturation.35,36
Training is considered premature when initiated before the
In 2002, Wong carried out a validation study on a test of necessary skills are present (generally around 18 months) and
development to be used with Chinese children and detected late when these abilities are already present, but training has
that these children exhibited a median independent control not been initiated (generally around 36 months). Early toilet
age of 54 months, with this control being defined as bladder training can have a negative influence on acquisition of blad-
and bowel control, with trips to the bathroom as needed and der and bowel control, particularly when prior training has
without reminders from parents.37 been attempted without success, frustrating parents and
child.26,44,45 On the other hand, late training may result in an
Factors that can affect training
increased risk of infectious diseases (diarrhea) among chil-
Learning bladder and bowel control is based on two dren in daycare,46 and also an increase in the prevalence of
processes: training by parents, who teach the child where and symptoms of voiding dysfunction,47 constipation and refusal
how to urinate and pass stools and learning by the child, not to go to the toilet.
just the appropriate behavior, but also to recognize their
Stressful situations and events in the lives of children can
bodys signals how to control release and retention by sphinc-
38 make them regress to earlier stages of development. Chil-
ters. It should be stressed that each child exhibits an indi-
dren who have already acquired control may go back to uri-
vidual rhythm of development.
nating and passing stools in inappropriate places and children
In turn, certain factors can affect acquisition of bladder still being trained may take longer to acquire control. A child's
and bowel control, such as sex, race, cultural factors, age at temperament is also a factor in this training. Children who
start of training, prior failed attempts, stressful events in the have problems following orders, whose interactions with their
childrens lives (birth of siblings, separation of parents, mov- parents are problematic, or who are stubborn and prone to
ing house) and the childs temperament.39,40 tantrums may not wish to collaborate with the stages of this
training.
Girls generally mature earlier than boys, particularly in
terms of skills related to socialization (speaking, dressing and On the other hand, hyperactive children may not be able
undressing, following orders) and start and complete toilet to remain seated long enough to wait for elimination.
training earlier.1,6,8,41 The fact that boys are taught to use the
toilet in two different ways in order to urinate and to pass Problems related with training
stools (standing and sitting) may be one of the factors that
Normal lower urinary tract function is the result of inte-
make their learning slower.8 Similarly, cultural factors limit
gration of neurological pathways at the peripheral and cen-
acceptance of the guidance that boys should first be taught to
tral levels. Although the cerebral circuits involved in controlling
urinate sitting, which would eliminate this duality in their toi-
lower urinary tract function are automatic, control of the blad-
let training.6
der under low pressure and emptying of the bladder are under
The social context and aspects of the culture in which the voluntary control, which may or may not be adequately con-
child lives contribute to the way they are cared for, both by trolled by the child, depending on how toilet training has been
family members and daycare staff and by health profession- carried out.
als.10,42 Poorer mothers who have spent less time in educa-
tion start training earlier,43 as do younger mothers,18 basing Voiding dysfunction
the decision purely on the age of the child, without giving
It has been observed that the prevalence rates of symp-
importance to their development. Knowledge on the subject
toms of voiding dysfunction have been increasing,10,48 but the
is greater among mothers in more favorable economic
causes of bladder instability are as yet unknown. Symptoms
situations.
of voiding dysfunction are very often ignored by parents, since
Based on a radically different concept, mothers in some they believe that they are part of their children's habits (wait-
African tribes start to train their children from 2 to 3 weeks of ing until the last minute before urinating, wetting pants,
life and expect them to be trained by 5 months. The cultural resisting the urge to urinate while involved in other activities).
Toilet training - Mota DM & Barros AJ Jornal de Pediatria - Vol. 84, No. 1, 2008 13

Control of the pelvic floor is voluntary and, together with In common with voiding dysfunction, constant contrac-
the urethral sphincter, it has an important role in mictional tion of the pelvic floor results in contraction of the anal sphinc-
dysfunctions of childhood.12 Repeated contraction of the pel- ter, resulting in incomplete emptying of the bowel,
vic floor in order to avoid urinary incontinence also leads to constipation and soiling. Incomplete evacuation leads to
contraction of the urethral sphincter. As the immature blad- stools becoming dry and voluminous, causing pain when they
der (neonatal) undergoes transition to mictional control, there are passed. This pain triggers an inhibition against relaxing
is a risk that symptoms of voiding dysfunction may emerge. the sphincter, increasing stool retention. A vicious cycle is
This risk increases if the transitional period is prolonged, thereby established, the initiating factor of which, in truth,
started late or if urinary habits and positions are incorrect.49,50 remains unclear.38,65,66

Positions that are inappropriate for bladder emptying For a long time it was believed that premature toilet train-
occur when a potty that is too low is used, resulting in a "squat- ing could result in refusal to go to the toilet. Taubman45,64 pub-
ting" position, which creates pressure during micturition.51,52 lished a conflicting result, reporting that children who were
On the other hand, a standard adult toilet, with no adapter late to start toilet training were more likely to refuse. Consti-
seat (potty seat), motivates the child to contract their thigh pated children do not initiate toilet training earlier than chil-
muscles and not to relax the perineal musculature, making dren who are not constipated, but they do exhibit more
bladder emptying more difficult. This being the case, the ideal problems with toilet training, and take longer to complete it.58
solution is to use a potty seat and a support for the feet (step In the same study, Borowitz, reported that pain while passing
stool)53,54 or a potty chair that is the correct size for the child. stools was the cause of constipation most often cited by par-
ents among under-2-year-olds, followed by transition from a
Constant contraction of the pelvic floor and the sphincter
liquid to a solid diet and from breastmilk to bottle feeding.
does not allow the floor to relax sufficiently during micturi-
After 2 years of age, pain while passing stools continues to be
tion, leading to residual urine remaining. When this situation
the cause most often cited by parents, followed by toilet
is repetitive, the result is reflux of bacteria from the urethra
training.
to the bladder, causing recurrent urinary infections. Several
different studies have confirmed that girls with voiding dys- The negative connotations of feces in our culture may lead
function have an increased risk of recurrent urinary infec- children to become ashamed of their feces, hiding them-
tions 11,55,56 and of chronic constipation with or without selves from adults when they pass stools.64,67,68
53
soiling.
There is evidence that difficulty relaxing the external anal
Constipation, refusal to go to the toilet and sphincter while evacuating is one of the principal factors in
encopresis constipation, but this can be treated by reconditioning bowel
habits - applying control techniques. For example, going to
Elimination of stools is a complex process which involves the bathroom 5 to 15 minutes after each meal benefits the
the abdominal and pelvic musculature and the anal sphincter. gastrocolic reflex and re-conditions the intestine to a new pat-
It is activated when the rectum is distended by the presence tern of functioning.69
of feces. After continence has been acquired, eliminations can
be inhibited voluntarily by contracting the anal sphincter, in Enuresis
accordance with the child's will.57
Bedwetting has an impact on both child and family, affect-
The prevalence of childhood constipation varies depend- ing self-esteem, interpersonal relationships and perfor-
ing on age, with prevalence rates having an inverse relation- mance at school. Primary enuresis is related to the presence
ship with age, and varying from 0.3 to 28%.58 In addition to of nocturnal polyuria, difficulties waking from sleep and
the factors that are known to be involved in the etiology of reduced bladder capacity,70-72 whereas secondary enuresis
constipation (transition in diet, genetic predisposition, pain is more related to urinary infections, diabetes mellitus and
or difficulty when passing stools), according to some authors emotional disorders.
incorrect toilet training (premature training, difficulties with
The capacity of the bladder increases throughout the first
training, traumatic experiences in the bathroom) may also be
8 years of life70,73 and can be influenced by toilet training
related with the emergence of constipation,59-61 but no evi-
methods.71,74-76 Coercive or permissive methods of toilet
dence of this association is available.
training may be associated with the development of enure-
One in every five children will go through a period during sis22,77 and encopresis.65 Analyzing the prevalence of enure-
their toilet training when they refuse to go to the bathroom. sis according to age of acquisition of daytime urinary
This behavior is associated with negative consequences, such continence, Chiozza observed that, among children who
as later acquisition of bladder and bowel control, maneuvers achieved bladder and bowel control after 36 months, the
to retain feces and an increased risk of primary encopresis, prevalence of enuresis was 17.1%, whereas children who
and, very often, requires medical intervention.62-64 achieved control before 25 months and between 25 and 36
14 Jornal de Pediatria - Vol. 84, No. 1, 2008 Toilet training - Mota DM & Barros AJ

months had prevalence rates of 2.7 and 5.8%, respec- all topics are covered82 and neither are parents asked which
78
tively, suggesting that starting toilet training later may favor topics they would like to discuss.83
the occurrence of enuresis.
In 1998 the American Academy of Pediatrics published the
Certain interventions to treat enuresis employ tech- first guidelines on training methods and, in 2003, a guide to
niques of toilet retraining and provide guidance on regularity toilet training written by pediatricians which deals with meth-
of elimination habits.53,79 ods of training, the most common doubts and difficulties, and
also includes topics on enuresis.84,85 The objective of these
What the parent-oriented literature says
publications was to complement information coming from
Information available in books, journals and magazines pediatricians and not to substitute it. The Canadian Paediat-
contains valuable information for the understanding of this ric Society and the American Academy of Family Physicians
topic, because it represents the opinions, not just of special- published their guidelines in 2005, following the same method
ists, but of other social actors as well, offering a more com- described by the American Academy of Pediatrics. The Brazil-
plete view of the concepts and beliefs disseminated through ian Society of Pediatrics (Sociedade Brasileira de Pediatria)
society. has not published guidelines on toilet training to date.

The international literature, for parents who are inter-

Conclusions
ested, have better social economic status and are able to read
English, is rich in information. Parent-oriented books and vid- Although toilet training is strongly influenced by cultural
eos on children of all ages are available in the bookshops of variations, it is universally seen as a milestone in child devel-
many countries, especially in the United States. For those with opment, being one of the first challenges a child faces in
access to a computer, there are many websites containing acquiring independence. An increase in the age at which toi-
information on how to proceed during this phase of develop- let training is initiated has been observed over recent decades
ment, run by entities as diverse as non-governmental chil- and we do not know the true reason. Paradoxically, parents
dren's organizations, University-based institutions from and carers report expectations of a very early age for the start
subject areas related to education, psychology, anthropol- of toilet training.
ogy and medicine and even by the manufacturers of diapers,
Correct bladder and bowel voiding habits are important
toys and accessories for toilet training.
for a healthy life and good self-esteem. Urination and evacu-
Analyzing the references identified, similarities can be ation problems cause discomfort for children and their fami-
observed between the recommendations, following the lies, and are motives for conflicts, distress and painful
method described by Brazelton in 1962.22 The guidelines are experiences for families and children and also during social-
practical, appropriate and many of them stimulate the pur- ization at schools, when playing with friends and performing
chase of accessories for training. In the recommendations leisure activities.
reviewed here, no inappropriate guidance was observed, but
An increase has been observed in the prevalence of elimi-
the literature is extremely rich and it was not possible to review
nation dysfunctions (of both urine and stools), and attempts
all of the websites available. In Brazil however, these sites are
have been made to link this phenomenon to a lack of correct
not numerous.
toilet training.
What pediatric societies and pediatricians The introduction of behavioral methods for the treatment
recommend of elimination dysfunction, such as the introduction of retrain-
A universal schedule for toilet training cannot be defined, ing of urination and evacuation habits, has brought good
because each method has its own definition of the training results, suggesting that well conducted toilet training may
process23 and each culture exhibits characteristics specific to prevent future problems. Despite the importance of this pro-
it. cess, the two principal methods of toilet training described are
from the middle of the last century. They have never been
The general guidelines that do exist are very important
tested or compared with each other by means of randomized
for supervising child health, but, very often, these guidelines
clinical trials. Even so, they are used as the basis for the rec-
are not followed. They consist of medical information for fami-
ommendations of pediatric societies' guidelines and parent-
lies about what to expect of child development, what parents
oriented literature.
can do to promote this development and the benefits of
healthy habits.80 They may be provided in a variety of ways, As a result of this lack of assessment and a lack of interest
such as group discussions, media (videos, posters) or in writ- on the part of pediatricians in the subject, these training meth-
ten form (books, folders).81 They are different from the coun- ods are not often used and mothers tend to follow guidance
seling and guidance provided for specific problems. Despite provided by people with influence over them, such as rela-
their importance, these guidelines are little used by physi- tives and friends or just follow their own experience in the sub-
cians during routine consultations and, when employed, not ject, acquired during life.
Toilet training - Mota DM & Barros AJ Jornal de Pediatria - Vol. 84, No. 1, 2008 15

We believe that it is important that the methods that have 17. Ritblatt S, Obegi A, Hammons B, Ganger T, Ganger B.Parents'
already been proposed be reviewed, brought up to date and and child care professionals' toilet training attitudes and
practices: a comparative analisys. J Res Child Educ. 2003;
tested, so that we have a strategy that can be legitimately 17:133-46.
suggested to parents as the correct manner of approaching
18. Mota DM, Barros AJ. Treinamento esfincteriano precoce:
toilet training. prevalncia, caractersticas materna, da criana e fatores
associados numa coorte de nascimentos.Rev Bras Saude Mater
Infant. 2007;no prelo.

19. Macias MM, Roberts KM, Saylor CF, Fussell JJ. Toileting
concerns, parenting stress, and behavior problems in children
References with special health care needs. Clin Pediatr (Phila). 2006;45:415-
1. Schum TR, McAuliffe TL, Simms MD, Walter JA, Lewis M, 22.
Pupp R. Factors associated with toilet training in the 1990s. 20. Martin JA, King DR, Maccoby EE, Jacklin CN. Secular trends and
Ambul Pediatr. 2001;1:79-86. individual differences in toilet-training progress. J Pediatr
2. Howe AC, Walker CE. Behavioral management of toilet training, Psychol. 1984;9:457-67.
enuresis, and encopresis. Pediatr Clin North Am. 1992;39:413- 21. Spock B, Bergen M. Parents' fear of conflict in toilet training.
32. Pediatrics. 1964;34:112-6.
3. Pachter LM, Dworkin PH. Maternal expectations about normal 22. Brazelton TB. A child-oriented approach to toilet training.
child development in 4 cultural groups. Arch Pediatr Adolesc Med. Pediatrics. 1962;29:121-8.
1997;151:1144-50.
23. Brazelton TB, Christophersen ER, Frauman AC, Gorski PA,
4. Stehbens JA, Silber DL. Parental expectations in toilet training. Poole JM, Stadtler AC. Instruction, timeliness, and medical
Pediatrics. 1971;48:451-4. influences affecting toilet training. Pediatrics. 1999;103:1353-8.
5. Doleys DM, Dolce JJ. Toilet training and enuresis. Pediatr Clin 24. Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods,
North Am. 1982;29:297-313. clinical interventions, and recommendations. American Academy
6. Blum NJ, Taubman B, Nemeth N. Relationship between age at of Pediatrics.Pediatrics. 1999;103:1359-68.
initiation of toilet training and duration of training: a prospective 25. Azrin NH, Foxx RM. A rapid method of toilet training the
study. Pediatrics. 2003;111:810-4. institutionalized retarded. J Appl Behav Anal. 1971;4:89-99.
7. deVries MW, deVries MR. Cultural relativity of toilet training 26. Foxx RM, Azrin NH. Dry pants: a rapid method of toilet training
readiness: a perspective from East Africa. Pediatrics. 1977; children. Behav Res Ther. 1973;11:435-42.
60:170-7.
27. Rugolotto S, Sun M, Ball T, Boucke L, de Vries M. A surging new
8. Schum TR, Kolb TM, McAuliffe TL, Simms MD, Underhill RL, Lewis interest on toilet training started during the first months of age
M. Sequential acquisition of toilet-training skills: a descriptive in Western countries. Tech Coloproctol. 2007;11:162-3.
study of gender and age differences in normal children.
28. Klassen TP, Kiddoo D, Lang ME, Friesen C, Russell K, Spooner C.
Pediatrics. 2002;109:E48.
The effectiveness of different methods of toilet training for bowel
9. Schonwald A, Rappaport L. Consultation with the specialist: and bladder control. Evid Rep Technol Assess (Full Rep). 2006:1-
encopresis: assessment and management. Pediatr Rev. 2004; 57.
25:278-83.
29. Candelora K.An evaluation of two approaches to toilet training
10. Bakker E, Wyndaele JJ. Changes in the toilet training of children normal children. Diss Abstr Int. 1977;38(5-B).
during the last 60 years: the cause of an increase in lower urinary
30. Matson JL, Ollendick TH. Issues in toilet training normal children.
tract dysfunction? BJU Int. 2000;86:248-52.
Behav Ther. 1977;8:549-53.
11. De Paepe H, Hoebeke P, Renson C, Van Laecke E, Raes A, Van
31. Michel RS. Toilet training. Pediatr Rev. 1999;20:240-5.
Hoecke E. Pelvic-floor therapy in girls with recurrent urinary tract
infections and dysfunctional voiding. Br J Urol. 1998;81 Suppl 32. Blum NJ, Taubman B, Nemeth N. Why is toilet training occurring
3:109-13. at older ages? A study of factors associated with later training. J
Pediatr. 2004;145:107-11.
12. De Paepe H, Renson C, Hoebeke P, Raes A, Van Laecke E, Vande
Walle J. The role of pelvic-floor therapy in the treatment of lower 33. Seim HC. Toilet training in first children. J Fam Pract. 1989;
urinary tract dysfunctions in children. Scand J Urol Nephrol. 29:633-6.
2002;36:260-7.
34. Mota DM, Victora CG, Hallal PC. Investigao de disfuno
13. Polaha J, Warzak WJ, Dittmer-Mcmahon K. Toilet training in miccional em uma amostra populacional de crianas de 3 a 9
primary care: current practice and recommendations from anos. J Pediatr (Rio J). 2005;81:225-32.
behavioral pediatrics. J Dev Behav Pediatr. 2002;23:424-9.
35. Hallgren B. Enuresis. I. A study with reference to the morbidity
14. Schmitt BD. Toilet training: Getting it right the first time. risk and symptomatology. Acta Psychiatr Neurol Scand. 1956;
Contemp Pediatr. 2004;21:105-22. 31:379-403.

15. Koff SA. Evaluation and management of voiding disorders in 36. Jansson UB, Hanson M, Sillen U, Hellstrom AL. Voiding pattern
children. Urol Clin North Am. 1988;15:769-75. and acquisition of bladder control from birth to age 6 years - a
longitudinal study. J Urol. 2005;174:289-93.
16. Downs SH, Black N. The feasibility of creating a checklist for the
assessment of the methodological quality both of randomised 37. Wong SS, Wong VC. Functional Independence Measure for
and non-randomised studies of health care interventions. J Children: a comparison of Chinese and Japanese children.
Epidemiol Community Health. 1998;52:377-84. Neurorehabil Neural Repair. 2007;21:91-6.
16 Jornal de Pediatria - Vol. 84, No. 1, 2008 Toilet training - Mota DM & Barros AJ

38. Fleisher DR. Understanding toilet training difficulties. Pediatrics. 59. Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector
2004;113:1809-10. W, et al. Constipation in infants and children: evaluation and
treatment. A medical position statement of the North American
39. Jansson UB, Sillen U, Hellstrom AL. Life events and their impact
Society for Pediatric Gastroenterology and Nutrition.J Pediatr
on bladder control in children. J Pediatr Urol. 2006;3:171-7.
Gastroenterol Nutr. 1999;29:612-26.
40. Schonwald A, Sherritt L, Stadtler A, Bridgemohan C. Factors
60. Fischer P. Early toilet training. J Fam Pract. 1990;30:262, 360.
associated with difficult toilet training. Pediatrics. 2004;
113:1753-7. 61. Polanco I, Prieto G.Functional constipation. Semin Pediatr
Gastroenterol Nutr. 1992;3:8-10.
41. Largo RH, Molinari L, von Siebenthal K, Wolfensberger U.
Development of bladder and bowel control: significance of 62. Blum NJ, Taubman B, Osborne ML. Behavioral characteristics of
prematurity, perinatal risk factors, psychomotor development children with stool toileting refusal. Pediatrics. 1997;99:50-3.
and gender. Eur J Pediatr. 1999;158:115-22.
63. Chase JW, Homsy Y, Siggaard C, Sit F, Bower WF. Functional
42. Finney JW, Weist MD. Behavioral assessment of children and constipation in children. J Urol. 2004;171:2641-3.
adolescents. Pediatr Clin North Am. 1992;39:369-78. 64. Taubman B, Blum NJ, Nemeth N. Stool toileting refusal: a
43. Horn IB, Brenner R, Rao M, Cheng TL. Beliefs about the prospective intervention targeting parental behavior. Arch
appropriate age for initiating toilet training: are there racial and Pediatr Adolesc Med. 2003;157:1193-6.
socioeconomic differences? J Pediatr. 2006;149:165-8. 65. Fishman L, Rappaport L, Cousineau D, Nurko S. Early
constipation and toilet training in children with encopresis. J
44. Luxem M, Christophersen E. Behavioral toilet training in early
Pediatr Gastroenterol Nutr. 2002;34:385-8.
childhood: research, practice, and implications. J Dev Behav
Pediatr. 1994;15:370-8. 66. Griffin GC, Roberts SD, Graham G. How to resolve stool retention
in a child. Underwear soiling is not a behavior problem. Postgrad
45. Taubman B. Toilet training and toileting refusal for stool only: a
Med. 1999;105:159-61, 65-6, 72-3.
prospective study. Pediatrics. 1997;99:54-8.
67. Shaikh N. Time to get on the potty: Are constipation and stool
46. Pickering LK, Bartlett AV, Woodward WE. Acute infectious toileting refusal causing delayed toilet training? J Pediatr. 2004;
diarrhea among children in day care: epidemiology and control. 145:12-3.
Rev Infect Dis. 1986:539-47.
68. Taubman B, Blum NJ, Nemeth N. Children who hide while
47. Bakker E, van Gool J, Wyndaele JJ. Results of a questionnaire defecating before they have completed toilet training: a
evaluating different aspects of personal and familial situation, prospective study. Arch Pediatr Adolesc Med. 2003;157:1190-2.
and the methods of potty-training in two groups of children with
69. van der Plas RN, Benninga MA, Taminiau JA, Buller HA.
a different outcome of bladder control. Scand J Urol Nephrol.
Treatment of defaecation problems in children: the role of
2001;35:370-6.
education, demystification and toilet training. Eur J Pediatr. 1997;
48. Hellstrom AL. Influence of potty training habits on dysfunctional 156:689-92.
bladder in children. Lancet. 2000;356:1787.
70. Caldwell P, Edgar D, Hodson E, Craig J. Bedwetting and toileting
49. Newborg J, Stock J, Wnek L, Guidabaldi J. Battelle Developmental problems in children. MJA Practice Essentials-Paediatrics. 2005;
Inventory. Itasca: Riverside Publishing; 1988. 182:190-5.

50. Wiener JS, Scales MT, Hampton J, King LR, Surwit R, 71. Hjalmas K. [Still much ignorance about the fact that children with
Edwards CL. Long-term efficacy of simple behavioral therapy for enuresis need treatment]. Lakartidningen. 2004;101:276-80.
daytime wetting in children. J Urol. 2000;164:786-90.
72. Yeung CK. Nocturnal enuresis (bedwetting). Curr Opin Urol.
51. Christophersen ER. Toileting problems in children. Pediatr Ann. 2003;13:337-43.
1991;20:240-4.
73. Jansson UB, Hanson M, Hanson E, Hellstrom AL, Sillen U.
52. Vernon S, Lundblad B, Hellstrom AL. Children's experiences of Voiding pattern in healthy children 0 to 3 years old: a longitudinal
school toilets present a risk to their physical and psychological study. J Urol. 2000;164:2050-4.
health. Child Care Health Dev. 2003;29:47-53.
74. Fergusson DM, Horwood LJ, Shannon FT. Factors related to the
53. De Paepe H, Renson C, Van Laecke E, Raes A, Vande Walle J, age of attainment of nocturnal bladder control: an 8-year
Hoebeke P. Pelvic-floor therapy and toilet training in young longitudinal study. Pediatrics. 1986;78:884-90.
children with dysfunctional voiding and obstipation. BJU Int.
75. Hjalmas K, Arnold T, Bower W, Caione P, Chiozza LM, von Gontard
2000;85:889-93.
A, et al. Nocturnal enuresis: an international evidence based
54. Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, management strategy. J Urol. 2004;171:2545-61.
Gomes S, et al. Voiding dysfunction in children. Pelvic-floor
76. Sillen U, Hjalmas K. Bladder function in preterm and full-term
exercises or biofeedback therapy: a randomized study. Pediatr
infants - free voidings during four-hour voiding observation.
Nephrol. 2006;21:1858-64.
Scand J Urol Nephrol Suppl. 2004;215:63-8.
55. Hellstrom AL. Micturition habits and incontinence in 7-year-old
77. Abramovitch IB, Abramovitch HH. Enuresis in cross-cultural
Swedish school entrans. Eur J Pediatr. 1990;149:434-7.
perspective: a comparison of training for elimination control in
56. Wan J, Kaplinsky R, Greenfield S. Toilet habits of children three Israeli ethnic groups. J Soc Psychol. 1989;129:47-56.
evaluated for urinary tract infection. J Urol. 1995;154:797-9.
78. Chiozza ML, Bernardinelli L, Caione P, Del Gado R, Ferrara P,
57. Catto-Smith AG. 5. Constipation and toileting issues in children. Giorgi PL, et al. An Italian epidemiological multicentre study of
Med J Aust. 2005;182:242-6. nocturnal enuresis. Br J Urol. 1998;81 Suppl 3:86-9.

58. Borowitz SM, Cox DJ, Tam A, Ritterband LM, Sutphen JL, 79. Hellstrom AL, Hjalmas K, Jodal U. Rehabilitation of the
Penberthy JK. Precipitants of constipation during early childhood. dysfunctional bladder in children: method and 3-year followup.
J Am Board Fam Pract. 2003;16:213-8. J Urol. 1987;138:847-9.
Toilet training - Mota DM & Barros AJ Jornal de Pediatria - Vol. 84, No. 1, 2008 17

80. Green M, Palfrey J, Clark E, Anastasi J, Arlington V, editors.Bright 84. American Academy of Pediatrics A. Toilet training. Guidelines for
Futures: guidelines for health supervision of infants, children, parents. Elk Grove Village: AAP; 1998.
and adolescents. Arlinton, VA: National Center for Education in
Maternal and Child Health; 2002. 85. Wolraich ML.Guide to toilet training. New York: Bantam Dell;
2003.
81. Nelson CS, Wissow LS, Cheng TL. Effectiveness of anticipatory
guidance: recent developments. Curr Opin Pediatr. 2003;
15:630-5.

82. Galuska DA, Fulton JE, Powell KE, Burgeson CR, Pratt M, Elster
A, et al. Pediatrician counseling about preventive health topics:
results from the Physicians' Practices Survey, 1998-1999.
Correspondence:
Pediatrics. 2002;109:E83-3. Denise Marques Mota
General Osrio, 956
83. Schuster MA, Duan N, Regalado M, Klein DJ. Anticipatory CEP 96020-000 Pelotas, RS Brazil
guidance: what information do parents receive? What Tel.: +55 (53) 3222.4356
information do they want? Arch Pediatr Adolesc Med. 2000; Fax: +55 (53) 3227.2257
154:1191-8. E-mail: [email protected]