This article outlines what is considered normal bladder and bowel function in children, and gives advice on when and how to start toilet training with children.
What is considered normal bladder and bowel control in children?
• Children should be able to control their bowel by the age of 4
• Children should have control of their bladder during the day by age 5 and at night by age 6
Research and most healthcare professionals recommend commencing toilet training between 18 months and 3 years of age. Determining the right time for your child is important. Avoid times of big changes or when you’re busy at home.
How do I know when my child is ready for toilet training?
Signs that a child could be ready for toilet training include when they:
• Show interest in the toilet and/or ask to use the toilet themselves
• Are staying dry for two or more hours or waking up dry after their afternoon nap
• Can follow simple instructions
• Can sit still for short periods of time
• Can walk and pull their pants up and down
• Tell you that they need to or have done a wee or poo with words or gestures
• Ask for a nappy change or get upset if they have wet or soiled themselves
• Do not want to wear nappies anymore
Steps for toilet training success:
1. Get the right equipment
You will need:
a. A potty or toilet insert– let your child help to choose which they prefer
b. A foot stool or stepladder – To assist your child to safely get on and off the toilet.
c. Plenty of clean underpants and clothes
d. A mop & bucket – to clean up any accidents
e. Books or youtube clips on toilet training – making learning fun
f. Books or toys – make toileting fun, helping them to sit for longer, aiming for up to 2 minutes.
2. Encourage your child to sit on the toilet every 1 ½ hrs to 2hrs for 2-3 mins (“it’s time to sit on the toilet please”).
The best times to sit your child on the potty or toilet are:
- As soon as they get up in the morning
- 20-30 minutes after eating
- After their afternoon nap
- Before bathtime
- At nappy change times
- or at the time your child seems to regularly poo
3. Teach them a good toileting routine:
- Pull pants down
- Sit on toilet
- Do a wee or a poo
- Wipe their bottom (always front to back)
- Flush the toilet
- Wash their hands
- Do not make them sit for longer than 2 minutes
4. Extra tips:
- Stay at home for the first few days to help your child establish a routine. Then they will need to get familiar with using the toilet when you are out. Sometimes public toilets are dirty so always take wipes with you so you can clean the toilet.
- Dress your child in clothing that can be easily pulled down and back up again.
- Tell your child no more nappies during the day. Put your child in underwear as it may make them more aware if they have an accident.
- Be prepared, there will be accidents. Clean up any leaks and change their clothes calmly and without fuss.
- Praise your child for any wanted behaviour and ignore behaviour you do not want.
- Reward the action of sitting on the toilet not just the outcome of a wee or a poo. You can give small rewards such as stickers, cuddles or high fives. Rewards should be given straight away and may help your child continue to build confidence with toilet training.
5. Once your child’s toileting routine is well established:
- Change your language to “What is it time for?’’. As your child becomes more reliably dry and independent, begin to ask your child “Do you need to go to the toilet?” Eventually this will lead to them telling you when they are going to the toilet or just taking themselves independently.
- Continue to reward their behaviour not just the outcome.
- Younger children will continue to need help wiping their bottoms.
- There may be times when toilet training may not go to plan, for example,if there is new sibling in the house, if your child is sick, or if they are not quite ready. If this happens, take a break from toilet training and then start again when things have settled.
- Signs that a child could be ready for toilet training include when they
- Show interest in the toilet and/or ask to use the toilet themselves
- Are staying dry for two or more hours or waking up dry after their afternoon nap
- Can follow simple instructions
- Can sit still for short periods of time
- Can walk and pull their pants up and down
- Tell you that they need to or have done a wee or poo with words or gestures
- Ask for a nappy change or get upset if they have wet or soiled themselves
- Do not want to wear nappies anymore
Common causes of daytime wetting:
- An overactive bladder (the bladder involuntary contracts at low bladder volumes)
- The bladder over flowing from withholding to wee or the bladder being underactive.
- The bladder not emptying properly
Constipation
Common causes of enuresis:
- An overactive bladder (the bladder involuntary contracts at low bladder volumes)
- Increase urine production of a night
- Low arousal levels
- Constipation
- (More information on nocturnal enuresis can be found in this article)
Bowel dysfunction
Soiling can affect up to 3% of children and is more common in boys. The amount of soiling can vary from skid marks in your child’s undies to a formed stool. Soiling often occurs because your child is constipated and is not emptying their bowel properly. Constipation can affect up to 25% of children and if not treated early can lead to bladder and bowel dysfunction. Children who experience soiling may be unaware that it’s happened.
Reasons your child may become constipated:
• Your child may not feel the urge to go or ignore the urge if busy doing something else.
• It may hurt when they poo, so they start to avoid pooing.
• They do not want to use the toilet at school or kindy due to issues with cleanliness or privacy.
Bladder and bowel dysfunction is not your child’s fault. It is usually the result of their bladder or bowel not functioning as it should. It is not because your child is being naughty. Structural or neurological problems are rare but your child should be medically screened to rule these things out. Your child should not be blamed or shamed for what is happening. Bladder and bowel dysfunction can lead to poor self-esteem and negatively impact your child’s quality of life.
Things you can do to instil good bladder and bowel habits in your children include:
• Educate your child on how their bladder and bowel works
• Encourage regular toileting and for your child to go to the toilet as soon they get the urge/ when their bladder and bowel tells them to go, and not to hold on until they are busting.
• Encourage your child not to rush or strain and to take their time whilst weeing and pooing.
• They should sit in a well-supported position on the toilet to help their muscles relax so they can completely empty their bladder and their bowel
• They should drink at least 30ml/kg of their body weight in fluids per day, evenly spaced out throughout the day. Always offer water first. Fizzy drinks and drinks that contain artificial sweetener or caffeine can irritate the bladder.
• Encourage your child to consume a high fibre diet including fresh fruit and vegetables every day.
• Always wipe their bottom from front to back
• Speak to your child’s school about joining the toilet tactics program to promote healthy bladder and bowel habits in school. This is a free program run by the Continence foundation of Australia.
Children should be encouraged to tell an adult if:
- It hurts when they wee or poo
- If it’s hard for them to get their wee or poo out or they don’t feel empty after toileting
- If they see wee or poo in their undies when they older than 4-5 years
- If their tummy hurts
- Parents/carers: If your child is experiencing the above seek professional help as there is more that can be done.
Here at Sydney Pelvic Clinic, we will take a thorough history and perform a physical examination that likely includes you completing a bladder or bowel diary to determine what your child’s bladder or bowel is doing.
Management may include:
- Educating your child on normal bladder and bowel function
- A toileting program
- Education on how to correctly sit on the toilet
- Fluid advice
- Education on how to activate or relax their pelvic floor muscles.
- Treating the underlying constipation that may be causing the wetting or soiling
