PEDIATRIC UROLOGY

Relationship between age at initiation of toilet training and duration of training: a prospective study
Blum NJ, Taubman B, Nemeth N
Child Development and Rehabilitation, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania, USA
Pediatrics 2003; 111: 810-4

• Objective: To study the relationship between age at initiation of toilet training, age at completion of toilet training, and the duration of toilet training.
• Methods: A total of 406 children seen at a suburban private pediatric practice were enrolled in a study of toilet training between 17 and 19 months of age, and 378 (93%) were followed by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Information obtained at follow-up interviews included how often parents were asking their child to sit on the toilet or potty and where the child urinated and defecated. Parents were considered to have initiated toilet training when they first took out a potty chair and discussed some aspect of training with the child. Intensive toilet training was defined as asking the child to use the toilet or potty more than 3 times per day.
• Results: Age of initiation of toilet training correlated with age of completion of training (r = 0.275). The correlation between age at initiation of intensive training and age at completion was even stronger (r = 0.459). Younger age at initiation of intensive toilet training was not associated with constipation, stool withholding, or stool toileting refusal. However, age at initiation of intensive toilet training was negatively correlated with duration of toilet training (r = -0.481), indicating that initiation of training at younger ages was associated with a longer duration of training. In addition, the correlation between age at initiation of intensive toilet training and age at completion of training was not significant for those who began intensive training before 27 months of age (r = 0.107).
• Conclusions: Early initiation of intensive toilet training correlates with an earlier age at completion of toilet training but also a longer duration of toilet training. Although earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal, initiation of intensive training before 27 months does not correlate with earlier completion of toilet training, suggesting little benefit in beginning intensive training before 27 months of age in most children.
  
• Editorial Comment
  This study evaluates prospectively the consequences of early toilet training in a suburban private pediatric practice setting. Early toilet training did not correlate with constipation or stool withholding. Earlier toilet training did correlate with prolonged duration of training. The authors conclude that the initiation of intensive toilet training before 27 months of age is rarely indicated.
  This study is important in that there have been concerns that attempts at toilet training started too early might be counterproductive, with more voiding dysfunction and constipation resulting. That did not appear to be the case in this study, although younger children did take longer to train. This study was limited to suburban private practice patients and may not be generalized to other groups. Another problem relates to the fact that the patients were evaluated by regular phone interviews every 2-3 months. Telephone interviews may be unreliable as a method of evaluating voiding dysfunction and constipation. Furthermore, one wonders whether the regular telephone interviews might also have had a therapeutic effect in and of itself. Nonetheless, the study does provide some useful data that suggests that early and aggressive toilet training is not dangerous.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA