This blog was written by Davina Richardson, Children’s Specialist Nurse at Bladder & Bowel UK.

1. FABLE: Your child will tell you when they are ready to toilet train

FACT: Some children will become increasingly aware of when they are doing a wee or a poo. At some point between the ages of two or three, these children will start to let their families know that they need their nappy changed, or even ask to wear washable pants. However, this happens much less often than it used to in the days when all children wore cloth nappies. In the 1960s and 70s most children were toilet trained by the time they reached their second birthday. Now most children are toilet trained at around the age of three years.

Disposable nappies are excellent at what they do: keeping a child’s bottom feeling dry and comfortable when they wee or poo. This allows the child to ignore the sensation of needing the toilet and carry on with what they are doing. They know that they will be changed when their full nappy is noticed.

The signs that many families are told to look for to know their child is ‘ready’ to toilet train do not work with disposable nappies. Things that are often relied on as signs, such as the child indicating they have done a wee or a poo, are not backed-up by research. There is not even agreement from professionals and experts about which of the ‘readiness signs’ are most important, or how many of them should be present.

Looking at it another way, why would a child instinctively want to change something that has worked for them since birth? This is even more true for children with additional needs, who may not understand the social expectation to use a toilet.

The nurses at Bladder & Bowel UK recommend starting to work on the skills for toilet training as your child approaches their second birthday and even earlier than this for children with known additional needs. These skills include learning words for wee and poo, learning to sit on the potty or toilet, recognising the bladder and bowel sensations and eventually getting wee and poo in the right place.

There is lots of information about how to approach toilet training at https://www.bbuk.org.uk/children-young-people/children-resources/

2. FABLE: Toilet training gets easier as your child gets older, particularly if they have additional needs

FACT: Learning how to use the toilet may take children with additional needs longer than their typically developing peers. However, leaving it later does not make the process quicker or more successful. Leaving toilet training until your child gets older may make it even more difficult. This is because your child has had more time learning that the place where they wee and poo is their nappy. It is harder to change habits that have been in place for longer.

There is evidence that early potty training helps the bladder mature. This can prevent problems with the bladder later in childhood. Also, there is a cost saving to families once children are toilet trained: there is no need to buy nappies. It is also better for the environment as nappies are made from oil-based products and end up in landfill.

At Bladder & Bowel UK, we recommend that all children should be supported to start learning the skills for toilet training before they reach their second birthday and by about eighteen months of age for children with additional needs. In this way the toilet training process becomes a normal part of their day.  For children with additional needs the step-by-step approach to toilet training works particularly well. There is information about this in the Bladder & Bowel UK leaflet ‘Toilet training children with special needs’ at: https://www.bbuk.org.uk/wp-content/uploads/2018/03/Information-sheet-re-Toilet-training-children-with-additional-needs.pdf

Bladder & Bowel UK have joined forces with Positive About Down Syndrome to create two closed Facebook pages to support families of children with Down syndrome in the UK to toilet train their children. These are: ‘DSUK Going POTTY?! Toilet training advice & tips 4 children with Down syndrome’ and ‘DSUK Toileting issues 4 children & young people with Down syndrome aged 5+’

3. FABLE: If your child is having problems with wetting it is because they are drinking too much

FACT: The human body is mainly water, so needs us to drink well every day to stay healthy. If children do not drink enough water-based fluids, they are more likely to become constipated. This is because the bowel will take extra water out of our poos, so the poos become hard. Having hard poos stuck in the lower bowel, gives the bladder less space. This can upset the bladder and make it twitchy, which results in wetting.

When humans do not drink enough water their wee becomes stronger (darker yellow). This can upset the lining of the bladder and may also cause bladder twitching which results in wetting.

A good fluid intake keeps poos soft and prevents constipation. It also helps the kidneys to make a greater quantity of wee that is more dilute (pale yellow). Therefore, the bladder is not irritated and gets more exercise, so learns to work better. Regular drinks (about every two hours until an hour before bedtime), followed by regular toilet visits after each drink, can prevent wetting.

Wetting is not caused by drinking too much. However, it can be caused by not drinking enough water-based fluids. Wetting can also be made worse by drinking the wrong things. Fizzy drinks and drinks that contain caffeine (tea, coffee, hot chocolate, cola and many energy drinks) can all make wetting worse. How much children should drink varies according to age.

Suggested intake of water-based drinks per 24 hours by age and sex

(Adapted from CG 111 Nocturnal Enuresis NICE 2010 and American dietary requirements, cited in CG 99 Constipation in Children and Young People, NICE 2010)

For more information on daytime wetting see the Bladder & Bowel UK leaflet ‘Talk About Daytime Bladder Problems’ at https://www.bbuk.org.uk/wp-content/uploads/2018/12/Talk-about-Day-Time-Bladder-Problems.pdf

4. FABLE: Children who get wee or poo in their pants are lazy and/or naughty

FACT: Children are not naturally lazy. They are energetic and love to learn about things that interest them. Children are also not deliberately naughty. They may do things adults do not like, because they have different priorities, or do not understand how things should be done, or are trying to solve a problem the only way they know how.

Children who get wee or poo in their pants nearly always have a bladder or bowel condition. Constipation, which is not always easy to diagnose in children, is nearly always the cause of poo accidents and can be the cause of wetting as well. Bladder twitching can cause children to do the ‘wee dance’, hold their groin, or crouch with their heel against their bottom. Others will appear to run to the toilet at the last minute, or even too late. This is an automatic response to the bladder twitching suddenly and unexpectedly and is not the child being lazy or naughty. Children who wet the bed when they are asleep may only do so on some nights. Again, this is not their fault but is as the result of a bladder and/or bowel problem.

Wetting and soiling (pooing in the pants) are very common in childhood but are not often spoken about. For this reason, many families feel alone. If you are concerned, speak to your child’s health visitor, school nurse or contact the Bladder & Bowel UK helpline at email bbuk@disabledliving/co.uk or telephone 0161 214 4591.

5. FABLE: Bedwetting is caused by children sleeping too deeply

FACT: Bedwetting is caused by children either making more wee during the night than their bladder can hold, or their bladder not working as well as it should while they are asleep. Children who wet the bed are unable to wake fully to the bladder signals, which is why their bladder lets go.

Children who wet the bed often sleep less well than their peers. This is because the bladder signalling that it needs to empty during the night disturbs their sleep, it just does not fully wake the child. This may leave children who have bedwetting more tired the next day and therefore even less able to wake the following night.

An assessment and treatment should be offered to children who have ongoing bedwetting after their fifth birthday. Your child’s health visitor, school nurse or GP should be able to offer some initial suggestions and if these do not help, they should be able to offer treatment or refer your child to a specialist clinic.

There is more information about bedwetting available in the Bladder & Bowel UK leaflet ‘Talk About Bedwetting’ at https://www.bbuk.org.uk/wp-content/uploads/2018/09/Talk-about-bedwetting.pdf

6. FABLE: Laxatives make the bowel lazy

FACT: Constipation can affect up to one-third of children at any time. For about one in three of these, the constipation will continue and become chronic, that is it will last for more than a month.

If constipation continues, it often gets worse as larger amounts of poo get stuck in the child’s lower bowel. The large poos stretch the muscles that line the bowel, so that they become less able to do their job of moving poo towards the bottom.

Laxatives (medicines to help treat constipation) help to clear out any poo that has become stuck inside the bowel. However, if they are stopped too soon the stretched bowel muscles will not have had a chance to recover. Because they are still over-stretched, they are not good at pushing the poo to the bottom, so the poo starts to build up again. This may make it seem as if the laxatives have made the bowel lazy when it is actually that they have not been given for long enough.

It is important to treat constipation with laxatives as soon as you notice a problem with your child. The laxatives should be continued for as long as necessary and only stopped gradually.

There is more information about constipation in the Bladder & Bowel UK leaflet ‘Understanding Childhood Constipation’ at https://www.bbuk.org.uk/wp-content/uploads/2017/11/Understanding-childhood-constipation-leaflet-advice-for-parents-and-carers.pdf

To see the full range of Bladder & Bowel UK’s information leaflets for children and families visit https://www.bbuk.org.uk/children-young-people/children-resources/

For more information and advice speak to your healthcare professional and always follow their advice. You may also contact the Bladder & Bowel UK confidential helpline at email bbuk@disabledliving.co.uk or telephone 0161 214 4591.