More approaches to toilet training/Did this infant receive proper care?
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I take issue with Dr. Barton Schmitt's advice to limit pull-ups and put children in underpants after five to 10 successful attempts at using the toilet ("Toilet training: Getting it right the first time," March 2004). His concern that the child will like or accept diapers and have "no reason to change" does not match the reality I find in practice.
A child has two powerful incentives to use a toilet: First, he (or she) wants to copy whatever his parents (and older siblings) do. By simply giving him relaxed, positive reinforcement, he will move toward the desired behavior naturally. The best positive reinforcement is simple parental approval and encouragement. Forget stickers! Second, it is uncomfortable to sit around in one's stool and urine; as soon as a child realizes that, he will use the toilet on his own initiative.
The most common problem I see, which Dr. Schmitt mentions in his second article ("Toilet training problems: Underachievers, refusers, and stool holders," April 2004), is the child who has become chronically constipated because he was placed in pants before he was ready for them. He then faces the dilemma of not wanting to stool in his pants but also not wanting to use the toilet. The result? He simply chooses to not stool at all and gets large, painful stools that frighten him and make him even more reluctant to stool. And then we've created a child who is chronically constipated.
The wonderful thing about pull-ups is that the child can pull them down and use the toilet whenever he wants to and, when he doesn't want to, he can stool in the pull-up. Once the child uses the toilet comfortably for both urine and stool and uses his pull-ups as though they were pants, it's time to give him pants. Even then, advise the parents to have a transition time when he can choose whether it is a "pants day" or a "pull-up day."
All normal children ultimately use the toilet. Consider how many cases of constipation you have treated in the past year compared to how many of your first grade patients are still in pull-ups. I advise parents not to create a problem by rushing, pushing, putting the child into pants before he is ready, and, in general, creating an artificial timetable for something that will happen naturally.
It is impossible for one human being to physically compel another to eat, sleep, and go to the bathroom. Any time that parents (and pediatricians) try to do so, our children prove that to us.
I commend Dr. Schmitt for a superb review of a "teaching based" toilet training program. I have been struck by the observation that children learnon their own without being taughteverything but going potty. Never a day goes by in my office that I don't witness a 12-month-old holding a phone close to his ears, imitating talking, pushing buttons, going through Mom's purse, putting fingers in the outlets. Parents delight in telling me how their little one is acquiring skills that were never taught.
My own upbringing in India, during a time when there were no diapers, provided me with insight into the field of toilet training. Being the eldest of seven siblings, I witnessed how my mother put a weeks-old baby brother in a flexed fetal squatting position, with both glutei resting on her inverted feet while sitting on the floor and making a "sha-sha-sha" noise known as sissana at short intervals. I am not sure what that noise did, other than to condition (as in Pavlov's experiments), but the position itself raised intra-abdominal pressure in the baby while stretching the anal sphincter, leading to evacuation most of the time. The opportunity was all around to watch grown-ups defecating, and a growing child got his or her cues about the whole process.
I have developed a simple approach to the complex problem of toilet training. At around the time a child starts crawling and cruising around the furniture, I recommend taking him or her to the bathroom with every member of the family when they use the toilet. I ask parents to have a potty chair there for exploration and imitation purposes. The diaper must come off during these times. No active effort is encouraged on the part of adults to direct the child in any way. I remind the parents that no one taught the child how to use the telephone or remote, but that the child learned these things on his own simply by watching, and I assure them that he is going to learn potty the same way. Parents who have followed that recommendation confirm what I witnessed in my native land: The child becomes trained at 12 to 18 months, plus or minus three to six months depending on individual developmental status.
Toilet training while wearing a diaper is an oxymoron. The longer the diaper stays on, the more it is accepted as the defecating place by the child, sometimes leading to insistence on having a diaper in which to defecate. Just as there is no physiologic difference between a bottle and a sippy-cup, there is no difference between a diaper and a pull-up. Divorcing from the diaper is a prerequisite to the toilet-learning process.
Most of the learning at an early age is need-based and role model-based. There is a window of opportunity between 9 months and 15 months during which a child blindly copies the visual impressions of caretakers. What makes us think that our children can learn everything by watching us but the pot? How many of us remember teaching use of the telephone the same way that we teach potty to our children? Should we write off the observations made in underdeveloped nations as invalid in this matter? Or should we learn from them? It's our choice.
Author reply: Dr. O'Connell and I agree that preventing stool holding and chronic constipation should be a high priority for all pediatricians. We agree that children who hold back bowel movements should never be denied access to a diaper or a pull-up. However, even these children can wear underwear all day but continue to have access to diapers when they need to defecate. As for the etiology of stool holders, I see more power struggles; Dr. O'Connell sees more placing children in underpants too soon. We both see pain avoidance.
Where we disagree is when to stop pull-ups and diapers in normal kids. After a child has used the toilet spontaneously five or 10 times, I like to continue the momentum. Most children see underwear as a privilege and badge of success. Being in underwear motivates them to complete toilet training. It locks in bladder control and urine continence. For those children who don't want underwear, I agree with continuing pull-ups for a while.
In my view, keeping a child in pull-ups or diapers full time is de-motivating. Most bladder trained children who have a bowel problem experience bladder regression if they are put back in diapers or pull-ups. It is just too convenient to release urine into them instead of traveling to the toilet.
As for the two powerful incentives that Dr. O'Connell mentions, they are helpful with normal toilet training. With each passing year, however, many children are less willing to imitate their parents. And as for sitting in one's stool or urine all day, some kids don't seem to care. Both of the behaviors I describe are frequently present in children with toilet training resistance.
Toilet training problems come in many flavors. Dr. O'Connell and I may be talking about different age groups or patients. From my perspective, any child who is old enough to deliberate whether or not to use the toilet and who can "use pull-ups just like underpants" is more than old enough to be wearing underwear and reaching closure on toilet training. Aren't you weary of seeing 4- and 5-year-olds still hooked on pull-ups and pacifiers?
Dr. Dave gives us a new paradigm: the "just by watching" approach for normal toilet training. He recommends teaching by modeling, not by words. It makes sense. Most of us over-instruct our children, telling them much more than they ever wanted to hear. Too many pep talks can easily transition into nagging, leaving us with a resistant child.
I agree with his point, "don't have your child wear a diaper if he is in the bathroom." But a complete "divorce from the diaper" is harder for me to reconcile, because it requires a parent who is willing to provide almost constant supervision. Most children can be trained on a part-time basis (being "bare bottom" in teaching fragments).
As for the onset of toilet training, Dr. Dave says 9 to 12 months. And here I thought my suggestion to begin readiness training at 18 months was early! He reports his patients have finished toilet training between 12 and 18 months. That of course perks my interest, and I hope Dr. Dave or one of his colleagues will report on this intriguing approach with more detail.
In conclusion, the jury is still out on the best way to toilet train a child in America.
"Fussy, febrile, and 5 months old: Can you take him at face value?" (Pediatric Puzzler, February 2004) was an excellent case. However, I was left with many questions, not necessarily related to the final diagnosis.
In this case, the febrile infant was seen in an emergency room less than 24 hours before his re-evaluation. At best, this child received bad care; at worst, it was malpractice, and the initial evaluating physician is lucky this child didn't progress to meningitis. There were no fewer than three mistakes. First: I have a hard time believing that this child's tympanic membranes were adequately assessed during the first exam. Second: With a WBC count greater than 15,000, and a bandemia in the presence of a fever, this child should have received ceftriaxone (Rocephin) at the first visit. And third: This child had received only one PCV7 vaccination, putting him at high risk of streptococcal pneumonia bacteremia. Again, another reason for ceftriaxone.
I hope that a case like this would be discussed with the original physician, as a means of educating someone who is not following standard guidelines for pediatric care. Discussions like this can usually be done with an informative and non-threatening approach. Such cases should also serve as a red flag for the level of care provided by a given physician, and some monitoring (and mentoring) would be in order.
Author reply: I agree with Dr. Thome's assessment of this patient's initial evaluation. This infant's tympanic membranes were not adequately assessed at presentation to the emergency room, and a bilateral otitis media with evolving early mastoiditis was missed. As has been noted in some recent studies, there is no formal mandated training in the evaluation for otitis media for pediatric residents in the United States and, as a result, the skill of many pediatric residents has been noted to be less than adequate for proper diagnosis.1,2
Second, to discharge a 5-month-old with fever, fussiness, an elevated white blood cell count, and a bandemia without further evaluation and treatment with parenteral antibiotics is also not standard of care.
This patient was, as Dr. Thome notes, behind on his vaccinations, and though he did not have streptococcal bacteremia/otitis media, was at higher risk of having such infections and should have been covered with appropriate antibiotics and vaccinated.
I believe this case illustrates the challenges physicians face when re-evaluating patients who have been seen and treated by other clinicians. It is always important to reassess the data presented and question treatment offered and diagnoses made with thorough review of the patient's history, physical exam findings, and studies done. I strongly agree with Dr. Thome on the need to discuss patient management and outcomes with individual residents and practicing physicians, and also in morbidity and mortality conferences to educate a wider audience.
1. Steinbach WJ, Sectish TC, Benjamin DK Jr, et al: Pediatric residents' clinical diagnostic accuracy of otitis media. Pediatrics 2002;109:993
2. Steinbach WJ, Sectish TC: Pediatric resident training in the diagnosis and treatment of acute otitis media. Pediatrics 2002;109:404
Readers' Forum. Contemporary Pediatrics August 2004;21:82.