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Potty training debate continues

While there may be a lack of medical studies on potty training, there is certainly no shortage of opinions on this issue. Overall, it's an incredibly complex issue that touches on many things, including parenting styles.

Some parents may be more laid back while others are more anxious to have the child trained. There is also a great deal of difference between childrens' physical development. And there are cultural differences as well. As one example, during Grand Rounds at Yale not long ago, a colleague described how in Africa children demonstrate the ability to pee on demand at six months of age. So it's no wonder why there are so many opinions.

For this study, the researchers tried very hard to include children at normal developmental milestones. They excluded children who had to be hospitalized or were developmentally delayed. One major study flaw was that the children were 88 percent Caucasian. It would have been interesting to see results from children of other races or ethnic groups. We know that non-Caucasian children potty train at a younger age.

In our practice, we are very proactive about toilet training and hand out guidelines at well-child visits. It's a continuation of discussions we've had with parents since birth. There's a lot of talk about children showing signs and signals that they are ready to start training about 18 to 24 months, but in practice, I've found that success comes a lot later than that, especially for boys.

Around two, children can be very defiant and a lot of kids just don't want to relinquish control over anything, including the use of their diapers. Many times, it can be easier to wait until 30 months.

Establishing a routine for potty training can make the process much easier for most children. Usually we recommend parents have their child first sit on the potty while still wearing their diaper. Then they can try it when not wearing clothes, like after a bath.

If you find that the child develops a fear of the potty, it can really sabotage your efforts. Again, I would recommend waiting a bit until the fear eases. Use lots of positive reinforcement.

Avoid "pull up" disposables
In warmer months, it's a good idea to have a child wear regular underwear (while outside). Parents remind the child to use the potty to see if that motivates him or her. If not, you might want to wait a couple of weeks and try again.

Our practice does not recommend the use of “pull-up” disposable diapers. They can stand in the way of making that final step to routinely using the potty since a bulky wet diaper can be a potty training motivating force.

Once in a while, a mom will ask if she should bring her daughter into the bathroom with her. That's usually not a good idea since an adult and a child are so anatomically different. Witnessing a parent using the toilet can be frightening or confusing for a child. Regarding the sequence of events leading up to potty training that the researchers described, I would recommend that parents remember each child is different. Your own child may not follow steps in a particular order and that's perfectly okay.

By age four, the child should be on his or her way. If a four-year-old still poops in a diaper, I would gently have the child be a part of the process of cleaning up. Have the child go get a clean diaper prior to pooping, help empty the diaper into the toilet afterward and flush the toilet. Make pooping in a diaper as inconvenient for the child as possible.

A child who is physically and psychologically ready will have the easiest time training. Before parents start potty training their child, I suggest they look for the following physical cues:

• Introduce the topic after the child has been walking at least two to three months.
• Notice if the child has a pattern of elimination, particularly after a meal or first thing in the morning. Take advantage of timing.
• Watch to see if the child indicates in some way—either verbally or physically—that he is going to go.
  

A child is psychologically ready when he or she:

• Has some interest in pleasing parents (such as when parents clap for a particular behavior).
• Has a desire to be "grown up."
• Is uncomfortable in a soiled diaper.

Dr. Germain is an attending pediatrician and an associate clinical professor of pediatrics at Yale-New Haven Children's Hospital and in private practice in New Haven and Cheshire.