Toilet Training

Ninety per cent babies begin to develop voluntary (intentional) control over bladder and bowel between 1 year to 2½ years. In a large proportion, it occurs between 1½ years to 2 years. The baby usually gives a signal in the form of a gesture (say a grunt) or a family word such as su-suor chi-chi. The alert mother finds no difficulty in understanding that the child wants to pass motion or urine.

The whole thing does not happen just overnight. To begin with, he indicates to his mother that he has soiled his nappy. Later, he tells her in his own way as and when he is in the process of soiling it. Still later, he indicates to her that he is just about to wet it. Eventually, he manages to indicate to her that he wishes to do so and gives her time to sort things out. After this stage has arrived – which happens usually by two years of age – he can be relied upon to tell the mother on time about his approaching “movement”. However, before fully depending upon his signal, she should continue reminding him if he wants to pass motion or urine from time to time over quite a few months. This way very many messy situations can be avoided, especially on account of his forgetfulness while being very busy in play or some such thing.

By the age of 2½ years, most babies will pull their pants down as soon as they feel the urge to urinate or defaecate. They are more or less dry at night though accidental “wetting” may occur until the age of five years.

In general, bladder control comes a few months later than bowel control. It is not so difficult for a child to control a movement as to control urine. Most two-year-olds have complete control of movements. However several children of 2½ years of age still wet during day or night.

Then, I have time and again asked, how come some babies have learnt to be clean when they are hardly a few months old. To understand this, imagine a baby being put on the outstretched legs of the mother or on the potty regularly. He is likely to learn the habit to urinate or defaecate at the feel of the legs of the mother or the rim of the potty or perhaps just the special gesture or sound the mother makes. This is not an intentional or a voluntary effort on the part of the child. It is just that he has been conditioned to it. He may do it when put in this position even during sound sleep. I have seen many sophisticated mothers successfully putting three or four-month-old babies on potty.

“When should I begin his potty training?” is an oft-asked question by young mothers. Should it be when the baby is two to three months old? Will the age of around nine months when the baby can sit properly and securely be all right? Or, should she wait until the baby starts communicating to her that he has an urge to pass stool or urine?

I am of the opinion that what indeed matters in toilet training is not the age at which you initiate it but how you accomplish it. Never force him to sit on the potty. Else he will trouble you with behavioural problems later. Also, do not press him to sit on it for too long. On an average a sitting of a few minutes is enough. Whether or not he has passed anything, let him get off if he wishes to. If the child indeed resists sitting on the potty, forget it for the time being. Perhaps you can try again after a gap of a week or so. It is one front on which your fussiness and persistence will only backfire. Take it easy. That is what will eventually pay.

Another important point is – do not feel discouraged because your child has taken longer time to be adequately trained than your neighbour’s child. Do not forget no two children are the same. What works fine for one may not be all right for another. So, have patience. Make enough use of encouragement rather than force and disapproval in training your child.

If you are a believer in early training, I would suggest that you start putting the baby on potty any time between seven and twelve months provided that the baby has movements at the same time of the day. At this age he has developed little voluntary control and can sit comfortably and securely. It will be a good preparation for training if not the real training. But, mind you, it is unwise to try this schedule if the baby’s movement is irregular. You will not know when he is to pass motion. To make him sit on the potty so frequently will mean testing his patience which is most undesirable. You will only be nurturing a rebellion in the mind of the little man.

The most natural age to put the child on the potty seems to be the second half of the second year. This is the age at which he may show more interest in the potty and may, in fact, give a signal of the approaching movement or urination. You must encourage him to give you a signal. Praise him for signalling today. Encourage him to tell you again tomorrow, the day after tomorrow and every day. Do not scold him for an accidental soiling of clothes.

Buy an attractive plastic potty for your baby. Let him play with it, get friendly with it and sit on it. You may suggest that it is meant to have a movement but do not try to force him to use it for this purpose. More often that not, the baby will grow fond of it. This will become his proud possession. Someday he may well begin to pass motion in it.

Difficulties in bowel control

During the bowel training period, see that the child does not get constipated. Unusually hard stools – especially one large piece with a big diameter – may cause pain. At times, such a movement can result in a tear of the anus called anal fissure which is quite painful and takes a long time to heal. Such a child may attempt to hold back his movement lest it causes further pain. What results is still harder stool. A vicious cycle is set up. Look up the doctor for advice. On your part, see that the child receives enough of fluids and juice in his daily diet to safeguard against hard stools. Avoid the use of laxatives or purgatives.

If a trained child becomes irregular, consult the doctor. It is possible he has developed an infection – say diarrhoea. Teething, emotional upset, change of surroundings, and jealousy are some other factors that may cause relapse in a child who has once learnt control. Do not scold or rebuke him. Instead, encourage him in a friendly manner to tide over the situation and return to normalcy again in the course.

Do not lose your temper if your small baby fiddles with his stools and perhaps puts a bit of these into his mouth. Remember, he does not know that these are, as you would like to put it, “nothing but filth”. All that he knows is that these are his very own. He would certainly be interested in exploring these like he explores everything. Soon he will grow out of it.

Then, there are babies who suddenly change their pattern after having used the potty over several months. Such a child starts holding the movement as long as he sits on the potty. No sooner does he get away from the seat, than he moves his bowel in a corner of the room or perhaps in his panties. Do not try to be cross and bossy. That will only aggravate the situation. Psychologists believe that this phenomenon results from the fact that the child has begun to think his stools are a part of his body and he wishes to hold on to his possession more obstinately. Moreover, he wishes to do everything in his own way in the second year of life. Assertive types of boys show it most frequently. They love “fuss” and the entire family revolving round their movements. This is one way they try to demonstrate their importance. You should not evince much interest in his refusal to sit on the potty and should not scold or punish him. A wise change in management, a shift in tactics and lots of patience over weeks and at times months, will most likely bring about a positive response.

Soiling

You should remember that your overenthusiastic attitude towards potty may lead to soiling in infancy. Another cause of soiling, especially if it develops after a period of bowel control, is emotional instability and insecurity. But, experience has shown that if soiling occurs after the age of three or four years, chances are that the child is constipated. The child passes liquid material (around solid, impacted faecal lumps called faecolith) intermittently through the anus, thereby wetting his panties and the like. What I would like to stress again is that you should not let the child’s constipation go on and on. Prevent it but if it occurs willy-nilly, consult your doctor. May be he prescribes half a teaspoonful of Milk of Magnesia or liquid paraffin. Suppositories, purgatives and enemas are rarely, if ever, needed.

A recently-released book, “Guide to Toilet Training”, brought out by the American Academy of Pediatrics, is a recommended reading for parents. This book , having become a runaway hit in the west, outlines readiness skills, stepwise guidelines on what to do, handling of resistance and accidents and tips for managing bed-wetting and toilet training in children with special needs. I have read this excellent book time and again and would strongly recommend the readers to go through it, especially those who see toilet training with concern.

Difficulties in bladder control

Most children learn to be dry during the day at the age of two years; by three years, they are dry by night too.

Some children deliberately ask for the potty every few minutes; others urinate after getting off the potty. Yet another group of children deliberately hold back urine for a considerable time. All these may well be attention-seeking behavioural problems.

I do not think it is necessary for parents to do anything special to correct these. You will be treating these best by just ignoring. But do not forget to seek medical advice if there is a suspicion of a disease. If the child, for instance, starts passing urine excessively, make sure he does not have urinary tract infection. Your doctor will need a urine sample to examine and to tell you if it is an infection or not.

Occasionally, your child may have constant dribbling of urine every minute. Your doctor will certainly like to investigate the child for a malformation which is generally correctable by surgery.

Excessive frequency of urine in association with excessive thirst and voracious appetite could well be a manifestation of diabetes mellitus. There is wisdom in bringing it to the notice of the doctor.

Enuresis (Bed-wetting)

In my experience about 25 per cent children fail to acquire bladder control even after the age of three years. Such a child does not just wet his bed at night; he fails to wait when he gets an urge to pass urine even during daytime. Boys suffer more often than girls. In a considerable proportion of cases, there is a family history of such a problem – in father, in mother or in the siblings. We doctors call the condition enuresis. Since the bed-wetting usually occurs during night, it is also known as nocturnal enuresis.

The cause of enuresis is not always clear – in fact, it is only infrequently precisely defined. Physical factors like threadworm infestation, infection of external genitals or urinary tract and anatomical defects in urinary tract are responsible in some of the cases.

Too late or improper bladder training by the parents is also an important contributing factor.

A general consensus is that enuresis may be a manifestation of family conflict and maladjustment – that is, too strict parents, rejection, jealousy or rivalry among children. An erratic handling of the problem by the parents causes further anxiety to the child. His condition, therefore, gets more aggravated.

Your doctor, when contacted, will interview you as also the child to find the causative – at least accompanying emotional factors. A complete physical check-up as also urine and stool examination, X-ray of lower spine to rule out urinary tract infection, threadworm infestation or anatomical defects may be ordered by him. Treatment of the underlying disease will cure enuresis.

But, as I said earlier, in a large majority of cases no definite cause has been found. Encouragement and not scolding is the most important measure that is going to be of value. You should boost him to have dry nights. In fact he should be offered a special pat and even reward on such occasions when he does not wet the bed. Also, protect the mattress by a waterproof sheet.

Restrict too much of fluids, including tea and coffee, in the evening, especially towards bedtime. Insist on his voiding before retiring to bed.

You should make it a point to wake him up once or twice during the night and make sure that he voids.

If the child is a five-year-old or above, you may make use of a device, an electric buzzer, which is designed in such a way that the child wakes up from noise as soon as the special pad on which he sleeps is wet by a few drops of urine. The device is based on condition reflex response. This technique requires a trial for three months or longer.

Most doctors will prescribe a tablet of imipramine (Depsonil) or amitryptyline (Tryptanol) at bedtime for about six to eight weeks. Some will supplement it with a small dose of diazepam (Calmposeor Valium).

Whatever line of management your doctor suggests for the child, remember that you should never let the child feel guilty. Never put him to shame by scolding him, especially in the presence of guests. A certain mother got into the habit of firing her five-year-old in these words: “You creep, you have been getting on my nerves. You’ll never stop that, I suppose.” Little wonder, the child was too glad to oblige her; his bed-wetting continued until he was ten.

For the child who wets during daytime too what is most important in management is the positive parental attitude. Train him to hold out as long as possible as and when he feels like urinating. This way he will be able to train his bladder to hold more before it empties.

Finally, even at the cost of repetition, I must say that impatience, insecurity, anxiety and too rigid parental attitudes are the solid bottlenecks in the successful management of enuresis. You should review the family situation as also do some heart-searching if your child has had such a problem.