Written by Dr Nické Theron, Pediatrician.

I am sure that you also dream about the day that your little one is potty trained every time you try to change your running/jumping/kicking/rolling toddler’s diaper. You long for the day that diapers will no longer be a part of your shopping list. But just like most other childhood-topics there are so many different products, “fail-proof methods” and expectations that are all “the best and only way” that it can feel like potty training is a mountain that you have to climb! I do not have the perfect recipe for potty training, but I can give you a few tips based on anatomy, physiology and research to help your child develop healthy toilet habits. Be warned: there will be a lot of “dirty” talk in the next few paragraphs! 😉 

For proper bladder development and healthy bowels, young children need to pee and poop uninhibited. The sphincter muscles of the bladder and bowels are initially controlled by primitive local reflexes only (if their urine enters the bladder, a reflex allows the sphincter to open and the bladder to contract). This is why a baby has a wet and dirty nappy after every feed. As the brain develops, the frontal lobes suppress these primitive reflexes so that the child can now “take control” of his sphincter actions. As with any other milestone, each child reaches this control at their own pace (within an expected range) and you should only start potty training when your child is ready.  

To be potty trained, your child does not need to learn to “hold” their pee and poop, they need to learn how it feels to have a full bladder/bowel, and they need to be willing to make the choice to interrupt play to go and do something about it. Toddlers are not known for their great decision-making skills. If you start potty-training too early, they can learn withholding behaviours which can lead to problems such as bedwetting, constipation or recurrent urinary tract infections (UTI’s).

There are some research that suggests that it is better to potty train early (from 18months) and that leaving it to later than 32months can cause more episodes of wetting, but these studies did not take into account why the training was left to an older age. A study done by Schum et al noted that most children have not yet mastered the needed skills by 18 – 24months of age, and that the starting age should rather be 22 – 30months. 

In a study in Sweden it was shown that only 31% of 2 year olds have good bladder sensation. By the age of 3 years 79% of children had good bladder sensation.

So, how will you know when your child is ready? Look for the following skills:

Physical: 

• toddler can walk and climb on the potty/toilet unaided
• can pull his own pants down and up 
• he is aware of when he is peeing or pooping and can verbalise these concepts
• nappy is dry for more than 2 hours

Emotional:

• toddler shows interest in your toilet-habits, in potties/the toilet
• he is willing to go to the potty regularly
• there are no signs of anxiety of using the potty or toilet

It is OK to start and then go back to using diapers if your child refuses, struggles or you get frustrated.

“You’ll never love diapers more than the day you begin potty training. ”

Busy Toddler.com

Preparing for potty training

Prepare your child

• read books about potty training, talk about how pets also need to poo and pee
• Lead by example: let your child see how you and other family members use the toilet
• Buy underwear that will motivate and excite them

Prepare yourself

• Choose a time to start when you are relaxed and can be at home with your child
• Be realistic: accidents are common and normal. Even when you have “completed” potty training there will still be some episodes of pee or poo in the underwear. Expect this and do not make too much of a fuss over it
• Be patient

Prepare your house

• Remove any special carpets or bedding that might be damaged or make the clean-up process more difficult
• Make sure your toddler feels safe and stable when sitting on a toilet seat or potty. If their feet dangle, it influences the way they can activate their muscles to empty their bladder and bowel.  If you use a toilet seat, get a low bench or step for their feet

Constipation and potty training

The bladder and bowels work together closely, and a problem in one area often leads to problems in the other. Chronic constipation is VERY common in toddlers, and potty training is often a cause for constipation as they withhold their poo for many practical and emotional reasons. Constipation is often also the cause of problems with potty training. If your child refuses to do number 2 on the potty, suddenly starts to poo in their pants, struggles with bedwetting or shows any signs of withholding behaviour (running away, hiding, crossing their legs), he is probably constipated. I have written a previous blog post about constipation if you want to find out more: https://pediatricsandplaydough.com/2018/11/11/to-poo-or-not-to-poo/

Ready, steady, potty!

Some more tips:

• Make it fun, use a reward system or star chart for every successful potty-visit
• Schedule routine potty-visits during the day to become a part of their normal routine, for example when waking up and before meals. Let them practise to sit on the potty for a few minutes, first with all their clothes on, then bare-bum
• Boys should also sit on the potty initially. Once the other concepts of potty training are mastered, you can transition to standing
• Never punish a child for accidents
• Never force a child to sit. If he refuses to sit on the toilet or potty, rather back off and try again in a few weeks
• Prevent Urinary Tract Infections (UTI) by regular toilet visits, preventing constipation and avoiding bubble baths
• If your child does not want to use public restrooms, try to use a portable toilet seat at home that you can then also use in public restrooms

“…being strengthened with all power according to His glorious might so that you may have great endurance and patience.”

Colossians 1:11

Whether you choose to do the three-day boot camp or a more gradual approach, if you follow these basic guidelines, potty training should be a positive experience for both you and your toddler! I will discuss enuresis (bedwetting) in the next article. Please share your potty-training wins and bloopers with us!

Resources

1. Schum TR, et al. Factors Associated with Toilet Training in the 1990s. Ambulatory Pediatrics. 2001;2:79-86.
2. Jansson UB, Hanson M, Sillén U, Hellström AL. 2005. Voiding pattern and acquisition of bladder control from birth to age 6 years–a longitudinal study. J Urol. 2005 Jul;174(1):289-93.
3. Tips from Steve Hodges MD (Pediatric urologist)
4. https://www.parentingscience.com/potty-training-problems-prevention.html