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Toilet training and toileting refusal for stool only: a prospective study
1University of Pennsylvania School of Medicine, Department of Pediatrics, Philadelphia, USA.
Insights
Stool toileting refusal affects 22% of children during toilet training. Pediatricians should monitor for constipation and delayed training, offering support for families facing challenges.
Area of Science:
- Pediatrics
- Child Development
- Gastroenterology
Background:
- Toilet training is a developmental milestone.
- Stool toileting refusal is a common challenge during this process.
- Child-oriented approaches are increasingly used.
Purpose of the Study:
- To determine the incidence of stool toileting refusal in children undergoing toilet training.
- To investigate the outcomes and associated factors of this behavior.
- To provide guidance for pediatricians and parents.
Main Methods:
- Prospective study of 482 healthy children aged 18-30 months.
- Parents completed questionnaires on toilet training.
- Families were followed via office visits or phone calls.
Main Results:
- 22% of children experienced at least one month of stool toileting refusal.
- Younger siblings and parental limit-setting issues were associated with refusal.
- Stool withholding occurred in 61 children, with 80% being refusers.
- Interrupting training and returning to diapers resolved refusal in 24/27 children.
Conclusions:
- Stool toileting refusal impacts approximately one in five children.
- Pediatric intervention may be needed for stool withholding/constipation and delayed training (by 42 months).
- Late-stage untrained children can cause family stress, requiring professional support.
Objective:
To determine the incidence of toileting refusal for bowel movements and its outcome when toilet training children using a child-oriented approach.
Design:
Prospective study.
Setting:
Private suburban pediatric setting consisting of middle and upper middle class families.
Methods:
Healthy children between 18 and 30 months with no signs of developmental delay were enrolled in the study. Parents were given questions regarding their child's toilet training and behavior. Families were followed every 6 months during an office visit or by phone call until the child was successfully day time toilet trained.
Results:
A total of 482 children (255 males) completed the study. There were 106 children (54 males) (22%) who experienced at least 1 month of stool toileting refusal. There was an association between the presence of younger siblings (P = .023) and parental inability to set limits for the child (P = .017) and stool toileting refusal. Stool toileting refusers trained at a later age than the rest of the group (P < .0001). Fifty percent (22/44) of the children who trained between 42 and 48 months and 73% (8/11) of the children who trained after 48 months experienced stool toileting refusal. Sixty-one of the study children developed stool withholding during toilet training. Forty-nine (80%) of these children were stool toileting refusers (P < .00001). In 77 (73%) of the children no intervention was undertaken. Of these, the behavior lasted more than 6 months in 20. Intervention was undertaken with 29 children, either because of severe stool withholding (23) or the age of the child (6). Interupting toilet training and having the child return to diapers resulted in the child spontaneously using the toilet for bowel movements within 3 months in 24 of 27 children.
Conclusion:
Stool toileting refusal occurred in one in five children in this study population. Two behaviors associated with stool toileting refusal may require the intervention of the pediatrician. The first is stool withholding causing constipation which can result in rectal impaction and primary encopresis. The second is lack of successful toilet training by 42 months of age. A child who is still untrained at this late age can be a source of family conflict and stress requiring the advice and support of the pediatrician.