Who am I?
Hi, I'm Esther. I'm a mother of two young children and a pelvic health physiotherapist specializing in helping kids with pee and poop problems.
I've toilet trained both of my children without tears and with minimal effort. In fact, with my second child, I didn't have to train her at all—she potty-trained herself! One day, I happened to see her from the corner of my eye as she walked over to the potty chair, removed her shorts, expertly positioned herself over the chair, sat down, and successfully used the potty.
My goal is to share honest parenting tips for toileting from the lens of a healthcare professional that make toilet or potty training a breeze. This includes evidence-based information, practical tips and strategies for creating a positive experience for children and their families.
When is the best time to start potty training your child?
According to Pediatric Urologist Dr. Steve Hodges from Wake Forest University, the timing of potty training matters in preventing toileting issues. Children who initiate potty training before the age of 2 are three times more likely to experience constipation and pee accidents. This is because children at that age have a limited ability to recognize the urge to use the toilet and thus have a tendency to establish a persistent pattern of retaining urine and stool.
On the other hand, Dr. Hodges' same research also shows that children who are trained after age 3 experience the same issues as children trained before age 2.
This means that the ideal timeframe for potty training falls within the ages of 2 and 3. Dr. Hodges believes that children should only be introduced to the concepts of potty training closer to 3 years old. That being said, this isn’t a hard and fast rule because every child and family is unique.
It's important to note that while Dr. Hodges' research provides valuable guidelines, every child and family is different and individual circumstances should be considered. For instance I carefully weighed the pros and cons and decided to start potty training my child a few months before his second birthday, despite the risk of him becoming a 'holder.' This choice was driven by my child's chronic eczema and frequent diaper rash, which severely affected his behavior and sleep.
When it comes to potty training, creating a positive and supportive environment can make all the difference in your child's journey. Allow your child to arrive at this milestone on their own by creating a supportive home that encourages their natural progression towards this goal. Here's how to establish a poop and pee positive environment:
Steer clear of unrealistic expectations – Beware of social media content, books and articles that popularize the idea of training a child in 1 to 3 days. This places an unnatural deadline that isn’t always the best fit for your child and family.
Get into your child’s mind – Tap into your child's interests and preferences to make the experience enjoyable for them. Create a customized potty space with their favorite theme or color. Incorcoprate fun elements like a car-themed potty.
Model the behavior – Let them observe you use the toilet too. By modelling the behavior, you normalize the experience and show them that using the potty is natural and normal. You could even take this opportunity to teach them proper anatomical terms by naming the penis and the vulva so that children know proper ways of labelling their bodies without shame.
Celebrate success – Once your goose has laid its golden egg in the potty, get really excited about it, announce it to the whole family, give high-fives and hype them up. Positive reinforcement solidifies their progress.
No shaming! – Accidents are a normal when acquiring a new skill. Instead of shaming or punishing your child for accidents, gently remind them that pee and poop belongs in the potty. Reassure them that accidents happen and try again next time.
Observe for urgency – Pay attention to your child's verbal or non-verbal cues to toilet. Children signal the urge to pee or poop by bringing their legs together, holding their genital area, looking uncomfortable or even complaining of a tummy ache. If you notice these signs, offer them the opportunity to use the potty, but respect their decision if they decline, even if it means for them to have an accident.
Embrace naked time – Allow your child to have some naked time to help them recognize that they've had an accident or feel wetness. If they don’t like to be bottomless, you can introduce cotton undies or pants so that they can still feel the wetness or accident. Children learn through trial and error, so it is important to allow them to make mistakes. You don't need pull-ups for day time training but it is ok to use them if you child requests for them.
Daytime dryness preceed nighttime dryness – On average, it takes about 10 months for children to attain nighttime dryness after they are daytime potty trained (Jansson, 2006). As children continue to progress, its normal and common for them to use pull-ups or diapers during the night even if they're dry during the day.
Toilet sits – Keep it brief. Get your child to sit on the potty or toilet for not more than 5-10 minutes. This allows children to connect the urge to go with the behavior of sitting on the toilet. Whilst they're sitting on the toilet, remember to encouarge proper posture and breathing. See below for further information about potty ergonomics and technique.
One essential item for potty training
When it comes to potty training, having the right equipment can make a big difference. A small potty chair or a potty training seat with steps is often the only item you will need. Personally, I opted for a small potty chair because I believed that it provided a safer environment for my little ones to safely and independently get on and off the potty with minimal supervision. However, the biggest downside to using a potty chair is the "ick" factor of throwing out pee and poop, and children might get too comfortable using the potty chair that they resist transitioning to sitting on the actual toilet. Once they are slightly older, I taught them how to use the ladder toilet seat that is positioned directly over the toilet.
Monitor for signs of constipation
It’s incredibly important to monitor your child for signs of constipation. Constipation can lead to various issues, including bladder and bowel-related accidents. When stool become backed up, the end of the colon or rectum gets stretched out by all the stool inside. The enlarged recturm that is filled with hard poop puts pressure on the bladder, causing pee accidents. In addition, soft, more liquid poop from the top leaks around the hard stool resulting poop accidents, fecal seepage or accidents, a condition known as encopresis.
Check out this old but gold video on constipation and encoporesis:
Signs of constipation
- Are there pee or poop accidents?
- Extra-large poops
- Pellet or log poops
- Tummy ache
- Urgent or frequent need to pee
- Itchy bottom
- Skid marks on underwear
- Straining or crying when they poop
Checking before you flush: Bristol Stool Scale for Children
Before flushing, check your child's stool by using the Bristol Stool Scale for Children. This is a visual representation of different stool types and an indication of their gut health. Ideally you want daily soft, type 4 stool.
Posture matters: Key to effortless peeing and pooping
- Maintaining a neutral spine and lean forward with elbows on knees for pooping, and with hands on knees for peeing.
- Boys should first master sitting to urinate before progressing to standing.
- Inhale through the nose and exhale with pursed lips, as if blowing out birthday candles to empty their bladder or bowels.
- If their feet are dangling, support their feet with a stool so that their knees are slightly higher than their hips.
Unlocking your child's sensory awareness: Interoception and potty training
Interoception refers to the ability to sense and interpret internal bodily sensations and feelings. Children may not have a fully matured interoceptive ‘sense’ or in the case of potty training, correctly interpret the urge to toilet. An example of interoception is the awarness of feeling of nervous, as famously described by Eminem’s rap bar ‘His palms are sweaty, knees weak arms are heavy.’ In this description, he expresses his ability to tune into his body’s reaction to performance anxiety.
Children are still developing their ability to notice the dialogue between their mind and body. As parents you should expect them to have accidents and hiccups even if they are completely day and night trained.
Gently help them connect the dots by encouraging them to use the toilet whenever you observe outward signs of urgency.
Who to seek help if you run into bowel and bladder problems?
It's important to that remember being toilet trained is a developmental milestone that most children eventually accomplish on their own between the ages of 2-3 or later, similar to sleeping through the night. It's essential to support your child and provide encouragement and guidance.
If your child continues to struggle with incontinence beyond the expected age range, which is generally around 5 years old for daytime incontinence, and 4 years old for bowel symptoms, it may be beneficial to seek evaluation from a healthcare professional (Austin et al, 2014). Consulting with your General Practitioner, Pediatrician or Pediatric Urologist can help identify any underlying issues and provide appropriate assistance.
How can a pediatric pelvic health physiotherapist help?
If you suspect that your child has bowel and bladder issues beyond a certain age mentioned earlier, seeking support from a pediatric pelvic health physiotherapist is a step towards holistic care.
During a typical evaluation, a pediatric pelvic health physiotherapist will assess your child's core muscle control, check for the presence of retained primitive reflexes, and examine pelvic floor muscle performance and coordination. These underlying factors play a crucial role in healthy toileting and provide valuable insight into the root causes of the challenges your child might be facing.
One example of a reflex associated with poor bladder control and bedwetting is a retained Spinal Galant reflex (Blythe, 2002). This reflex can cause involuntary muscle movements, particularly in the lower back, when stimulated. In some cases, the residual Spinal Galant reflex has been associated with issues such as poor bladder control and bedwetting in children.
If deemed appropriate, a pelvic health physiotherapist will provide biofeedback training to the pelvic floor to ensure that children relax their pelvic floor muscles when they use the toilet (de Jong, 2007). In general, pediatric pelvic health physiotherapists work with the child and caregiver to provide specialized and individualized treatment strategies to address the child and family's specific needs. They can provide guidance on urotherapy, behavioral training techniques, targeted exercises to improve bowel and bladder function, and support your child's overall well-being.
Final Thoughts – Every child is has their own timeline, and there is no one-size-fits-all approach to potty training. Patience and understanding are key as you navigate this milestone with your child.
Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, Rittig S, Vande Walle J, von Gontard A, Wright A, Yang SS, Nevéus T. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children's Continence Society. J Urol. 2014 Jun;191(6):1863-1865.e13. doi: 10.1016/j.juro.2014.01.110. Epub 2014 Feb 4. PMID: 24508614.
Blythe, S. G. (2002). Reflexes, movement, learning & behaviour: Analysing and unblocking neuro-motor immaturity. HAWTHORN PRESS.
de Jong, T. P., Klijn, A. J., Vijverberg, M. A., de Kort, L. M., van Empelen, R., & Schoenmakers, M. A. (2007). Effect of biofeedback training on paradoxical pelvic floor movement in children with dysfunctional voiding. Urology, 70(4), 790–793. https://doi.org/10.1016/j.urology.2007.05.005
Hodges SJ, Richards KA, Gorbachinsky I, Krane LS. The association of age of toilet training and dysfunctional voiding. Res Rep Urol. 2014 Oct 3;6:127-30. doi: 10.2147/RRU.S66839. PMID: 25328866; PMCID: PMC4199658.
Jansson UB, Hanson M, Sillén U, Hellström AL. Voiding pattern and acquisition of bladder control from birth to age 6 years--a longitudinal study. J Urol. 2005 Jul;174(1):289-93. doi: 10.1097/01.ju.0000161216.45653.e3. PMID: 15947669.
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