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BACKGROUND. This study reports on toilet training with a focus on the effect of age, methods used, and factors that can affect urinary incontinence in Nigerian children. METHODS. This was a cross-sectional hospital-based study carried out in public and private hospitals in South-Western Nigeria. A questionnaire was used to obtain information about toilet training practices from 350 adults, who toilet trained 474 children. RESULTS. The adults had previously toilet trained children 1-18 years old. In this study, toilet training commenced at
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122 SAJCH OCTOBER 2017 Vol. 11 No. 3
Toilet training is an important aspect of early childhood developmental
milestones, and it may be quite challenging. It involves a complex
integration of neurological, muscular, and behavioural mechanisms.[1,2]
Toilet training is also influenced by physiological, psychological and
sociocultural factors.[3,4] Failure of toilet training may result in significant
physical and psychological consequences like a sense of failure through
partial loss of autonomy.[5]
Different opinions on the optimal time to initiate toilet training cut
across different cultures and beliefs.[2,6] Five to six decades ago, toilet
training in Western countries was initiated at an earlier age compared
with the current initiation age.[2,4] For example, in the USA, the median
age of initiating toilet training ranged from 25 to 27 months in the 80s;
it had increased to n (SD) of 36.8 (6.1) months in 2003.[7] In a report,
toilet training before the age of 18 months had already started ~60 years
ago, while modern parents usually start the training after 18 months.[4]
One of the reasons for the later initiation age of toilet training may be
because of the recommendations by the American Academy of Pediatrics
(AAP). According to the AAP, starting toilet training before the age of
2 years is not recommended because the readiness skills and physical
abilities required only develop between age 18 and 30 months.[8] In
addition to the AAP’s recommendation, the introduction of disposable
diapers, more efficient laundry facilities and both parents working may
contribute to the later age of commencing toilet training.[9] There are
arguments against early and late initiation of toilet training. A delay
in toilet training was considered to be related to increased frequency
of dysfunctional voiding in children.[4,10] For example, in the United
Kingdom, a cohort study showed that when toilet training commenced
after 24 months of age there was an association with diurnal enuresis
and delayed acquisition of bladder control.[11] There were also fears that
toilet training at an earlier age may result in voiding dysfunction.[12]
However, Duong et al.[13] dispelled that fear in a study that investigated
early initiation of toilet training in Vietnamese girls. In that study, it was
noted that toilet training that was initiated at <12 months did not result
in voiding dysfunction.
There are different types of toilet training methods available. In the
Western communities two predominant methods are used; the ‘child-
oriented’ method of Brazelton et al.[14] and the Azrin and Foxx method.[15]
Other methods include variations of operant conditioning, assisted infant
toilet training, and the Spock method.[9] In 1962 Brazelton et al. [14]
described the child-oriented approach. It is based on the principle that the
child must gently but systematically be encouraged to experiment toileting
behaviour. The Azrin and Foxx[15] method, on the other hand, is more
intensive and structured. However, the method has been associated with
reported side-effects of temper tantrums, hitting and avoidance behaviour.
Less known, but applied for many centuries in China, India, Africa, South
and Central America, is assisted infant toilet training. The caregivers play
a key role by observing the child’s evacuation signals and when they occur,
place them in a special position. It is important to note that although
recent guidelines of the AAP[16,17] and the Canadian Pediatric Society[18]
are based on the child-oriented approach[9] and Azrin and Foxx method,[15]
no efficacy studies or randomised controlled trials have been conducted.
Recent studies have identified incorrect toilet training as being predictive
of persistent urinary symptoms, such as urinary incontinence, enuresis,
recurrent urinary tract infection and childhood constipation.[19–21] Urinary
incontinence has an impact on both the child and family. It affects the
self-esteem, interpersonal relationships and school performance of the
children, as described in detail by Mota and Barros[22] in a previous
review. Primary enuresis is related to the presence of nocturnal polyuria,
difficulties waking from sleep and reduced bladder capacity, whereas
secondary enuresis is more related to urinary infections, diabetes
mellitus and emotional disorders.[22-25] Coercive or permissive methods
of toilet training may be associated with the development of enuresis and
encopresis.[14,26,27] In an analysis of the prevalence of enuresis according
to the age of acquisition of daytime urinary continence, Chiozza et
al.[28] observed that, among children who achieved bladder and bowel
control after 36 months, the prevalence of enuresis was 17.1%, whereas
children who achieved control before 25 months and between 25 and 36
months had prevalence rates of 2.7% and 5.8%, respectively. These findings
Background. This study reports on toilet training with a focus on the effect of age, methods used, and factors that can affect urinary incontinence
in Nigerian children.
Methods. This was a cross-sectional hospital-based study carried out in public and private hospitals in South-Western Nigeria. A questionnaire
was used to obtain information about toilet training practices from 350 adults, who toilet trained 474 children.
Results. The adults had previously toilet trained children 1 - 18 years old. In this study, toilet training commenced at ≤12 months, during the
day and night in 40.6% and 33.4% of children, respectively. Of the 350 parents/guardians, 141 (47.7%) commenced toilet training by waking
children from their afternoon nap. The most common method was allowing the child to urinate at fixed time intervals, while the least common
was a reward/punishment system. Furthermore, age was considered as the most common indicator to commence toilet training. For 36.9% of
the children, training lasted 1 - 6 months. Daytime continence was achieved by 33.4% of children at ≤12 months old, and night-time continence
was achieved in 29.7% of children between 12 and 18 months old. By 30 months, 91.1% and 86.9% had attained day- and night-time continence,
respectively, and only 8.6% of the children were incontinent at night.
Conclusion. Assisted infant toilet training is still practised among Nigerian parents despite the influence and the trends in the developed countries.
The age at initiation and completion of toilet training was lower than those reported for developed countries.
S Afr J Child Health 2017;11(3):122-128. DOI:10.7196/SAJCH.2017.v11i3.1287
Toilet training practices in Nigerian children
A U Solarin,1 MPhil, Cert Nephrol (SA) Paed, FWAC Paed, MBBS; O A Olutekunbi,2 FWAC Paed, MBBS;
A D Madise-Wobo,1 FMC Paed, MSc, MBBS; I Senbanjo,1 FWAC Paed, MSc, MB ChB
1 Department of Paediatrics, Lagos State University Teaching Hospital, Lagos, Nigeria
2 Department of Paediatrics, Gbagada General Hospital, Lagos, Nigeria
Corresponding author: A U Solarin (asolar234@gmail.com)
This open-access article is distributed under
Creative Commons licence CC-BY-NC 4.0.
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123 SAJCH OCTOBER 2017 Vol. 11 No. 3
suggest that starting toilet training later may promote enuresis. Certain
interventions to treat enuresis employ techniques of toilet retraining and
provide guidance on regularity of elimination habits.[29,30]
In Africa there is limited literature focusing specifically on the
age aspect of toilet training practices. This study aimed to report on
methods at the time of initiation and the time of completion of toilet
training, as well as any relationships among these factors and enuresis
in our setting.
Method
Study design
This was a cross-sectional hospital-based study designed to answer three
major research questions:
At what age do parents/caregivers commence toilet training on their
children/wards?
What is the age at attainment of day- and night-time urinary
continence?
What is/are the toilet training method/s used by parents/caregivers on
their children?
Study setting
The study was carried out in private and government hospitals in two
states in South-Western Nigeria. The participants from the public hospital
were residents of Lagos State, while those from the private hospital were
residents of Ogun State. Lagos State is a densely populated cosmopolitan
urban setting, while Ogun State is suburban and less densely populated.
The study was conducted between April and July 2016.
Data acquisition
A tested questionnaire was used to obtain information from the
participants. The questionnaire was adapted from a previous questionnaire
which had been validated and used by Bakker and Wyndaele.[4]
Participants
The participants were parents and caregivers who presented to the hospital
for various reasons. The aim of the study was explained to the parents/
caregivers of the children and those who gave verbal consent were included
in the study. The parents were recruited consecutively until the minimum
sample size was achieved. The socioeconomic classes of the participants
were documented using the Oyedeji classification.[31] Those in social
classes 1 and 2 were regarded as upper class, those in class 3 as middle class,
while those in classes 4 and 5 were in a lower socioeconomic class.
The following participants were excluded: parents of children with
neurological problems, e.g. spinal dysraphism, hydrocephalus, and cerebral
palsy, as well as those who had children with urogenital abnormalities.
Variables
The tested questionnaire was used to obtain relevant information
from the participants. The outcome variables were: age at attainment
of day- and night-time urinary continence; toilet training methods
used; duration of toilet training; and factors which affected the age at
attainment of urinary continence.
A potential challenge was failure to understand the questions in
the questionnaire. To avoid this, the questionnaire was pretested in a
different subset of caregivers to avoid ambiguity.
Data measurement
The source of the data was from the questionnaire completed by
the participants. The variables that were normally distributed were
summarised with mean and standard deviation.
For description of the first two outcome variable outcomes, mean and
mode were used to analyse those variables. The χ2 test was used to analyse
the relationship between variables to ascertain which factors affected the
age of attainment of urinary continence. An inter-group comparison was
also done using χ2 test; p<0.05 indicated statistical significance.
Table 1. Sociodemographic characteristics of parents (N=350)
Type of centre
Public (n=250), n (%) Private (n=100), n (%) Total, n (%) p-value
Father’s level of education
None
Primary
Secondary
BSc/HND
Postgraduate
3 (1.2)
9 (3.6)
51 (20.4)
176 (70.4)
11 (4.4)
1 (1.0)
3 (3.0)
24 (24.0)
64 (64.0)
8 (8.0)
4 (1.1)
12 (3.4)
75 (21.4)
240 (68.6)
19 (5.4)
0.616
Mother’s level of education
Primary
Secondary
BSc/HND
Postgraduate
3 (1.2)
67 (26.8)
174 (69.6)
6 (2.4)
2 (2.0)
27 (27.0)
66 (66.0)
5 (5.0)
5 (1.4)
94 (26.9)
240 (68.6)
11 (3.1)
0.574
Father’s occupation
None
Civil servant
Artisan
Businessman
Student
Professional
6 (2.4)
64 (25.6)
41 (16.4)
85 (34.0)
0 (0.0)
54 (21.6)
1 (1.0)
20 (20.0)
11 (1.0)
31 (31.0)
0 (0.0)
37 (37)
7 (2.0)
84 (24.0)
52 (14.9)
116 (33.1)
0 (0.0)
91 (26.0)
0.621
Mother’s occupation
None
Civil servant
Artisan
Businesswoman
Student
Professional
12 (4.8)
81 (32.4)
16 (6.4)
101 (40.4)
9 (3.6)
31 (12.4)
3 (3.0)
18 (18.0)
18 (18.0)
21 (21.0)
2 (2.0)
38 (38.0)
15 (4.3)
99 (28.2)
34 (9.7)
122 (34.9)
11 (3.1)
69 (19.7)
0.432
HND = higher national diploma.
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124 SAJCH OCTOBER 2017 Vol. 11 No. 3
Results
Sociodemographic characteristics of the study
participants
A total of 350 parents/guardians participated in the study. The
sociodemographic characteristics of the caregivers who participated in
the study were defined (Table 1). The mean (SD) ages of the caregivers
were 42 (6.80) and 36.41 (7.15) for the males and females, respectively.
The majority of the parents (284 (81.9%)), were Christian, while 66
(18.1%) practised Islam. Most of the parents had a tertiary level of
education and there was no significant difference in the level of education
of the parents in the different hospitals (p>0.05). The majority of the
parents were either businessmen or businesswomen and professionals,
with no significant difference in the occupations of the parents in the
different hospitals (p>0.05). The social class of the parents in both group
of hospitals was social class 4 (lower social class based on educational
level and occupation of both parents).
All of the study participants had children. Of the 350 parents/
caregivers who participated in the study, information was obtained
for 474 children. A total of 22 (6.3%) participants had grandchildren.
The children were between 1 and 18 years old. The majority of the
participants (67.7%, n=237) had children who were ≤5 years old, 30.6%
(n=107) were between 5 and 10 years old, 19.1% (n=67) were 10 - 15
years old, and 11.7% (n=41) were >15 years old.
Method and age at commencement of toilet training
A total of 309 (88.3%) of the respondents participated in the toilet
training of their own children. The remaining respondents left the
toilet training to either a grandparent, caregiver or family relative
(Fig. 1). A total of 275 (78.6%) participated in toilet training by
giving advice while the others participated in the toilet training of
their grandchildren when the children were in their custody during
the day or during a brief visit. Table 2 shows the method and age
at commencement of toilet training of the children. The parents
considered the age of the child as the most common reason for
commencement of toilet training (Fig. 2).
Toilet training was commenced at ≤12 months in the majority of the
children during the day and night at 40.6% and 35.4%, respectively.
A total of 153 (43.7%) of the respondents commenced toilet training
Fig. 1. Person in charge of toilet training (N=350).
400
300
200
100
0
Number of respondents,
n
Parent Grandparent Nanny Relations
88.3%
4.3% 4.9% 2.6%
Fig. 2. Reasons for initiating toilet training during the day (N=350).
150
100
50
0
On demand
of the
child
His/her
age
School Comment
of others/
family
Season When he/
she was dry
during the
afternoon nap
Saving
diaper
Could not
remember
Reason
Number of respondents, n
Table 2. Method and age of commencement of toilet training
including types of diapers and reasons for commencement
(N=350)
Variab l e n (%)
How grandparent participated in toilet
training
By giving advice
In keeping the children during the day
During a stay
275 (78.6)
39 (11.1)
36 (10.2)
Age of commencement of day-time toilet
training (months)
≤12
13 - 18
19 - 24
25 - 30
≥31
Yet to start
Do not remember
142 (40.6)
80 (22.9)
74 (21.1)
31 (9.0)
12 (3.4)
0
11 (3.1)
Age of commencement of toilet training at
night (months)
≤12
13 - 18
19 - 24
25 - 30
≥31
Do not remember
Yet to start
124 (35.4)
79 (22.6)
86 (24.6)
30 (8.6)
21 (6.0)
7 (2.0)
3 (0.9)
Dryness during aernoon nap
Yes
No
Do not remember
153 (43.7)
119 (34.1)
78 (22.3)
Type of diaper used
Cotton
Flannel
Disposable
Plastic pants
25 (6.6)
3 (0.9)
317 (83.7)
4 (1.1)
Method used
Urinate at xed time
Remove the diaper
On demand of the child
Reward
Punish
Imitation of parent or older sibling
Do not remember
163 (46.6)
105 (30.0)
47 (13.4)
8 (2.2)
8 (2.3)
9 (2.6)
10 (2.9)
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125 SAJCH OCTOBER 2017 Vol. 11 No. 3
during an afternoon nap. Disposable diapers were the most commonly
used diapers. The most common method of toilet training was allowing
the child to urinate at fixed time intervals (46.6%) and the least common
method was by either reward or punishment.
Attainment of continence
The duration of toilet training was 1 - 6 months for 36.9% (n=129) of the
children; the shortest duration of training was <1 month. Training took
place at home in 88.6% (n=310) of the children, with 7.1% (n=25) at the
crèche. Continence was described for day- and night-time. The modal
age at attainment of daytime continence in the wards of the participants
was <12 months of age, closely followed by children age 19 - 24 months
(33.4 and 29.7%, respectively). By 30 months of age 91.1% (n=319) of
the children had attained daytime continence. Contrary to the daytime
continence, 29.7% (n=104) attained night-time continence between 12
and 18 months of age. Similar to the finding of the daytime continence,
by 30 months of age the majority of the children, 86.9% (n=304) had
attained night-time continence. A total of 4.6% (n=16) achieved night
time continence after 5 years of age while 30 (8.6%) had not achieved
continence at the time of this study. Among the 30 children who were still
incontinent at night, the age at commencement of their toilet training
was 18 - 24 months (13.3%), >30 months (13.3%), <1 year (16.7%),
12 - 18 months (23.3%) and 24 - 30 months (33.3%) Table 3.
Comparison between private and public hospitals
The age at attainment of night-time continence, place of training and
who was in charge of the training were compared for private and public
hospitals. There were no significant differences in results between
private and public hospitals (p>0.61). However, there was a significant
difference in the age of attainment of night-time continence (p<0.05) in
both study centres. While most of the children from the public hospital
achieved continence between 12 and 18 months, most of the children
at the private hospital attained continence at a more advanced age of
18 - 30 months. Also, the age at which toilet training was commenced
in the public hospital was mainly ≤12 months. The children from
the private hospital commenced training at either ≤12 months or
19 - 24 months (Table 4).
Test of associations
The test of association was computed for variables such as who was in
charge of toilet training, age at which the child commenced training,
method used and duration of toilet training for continence against age at
Table 3. Age of attainment of continence, location and
duration of training (N=350)
Variable n (%)
Duration of toilet training for continence (months)
≤1
1 - 6
7 - 12
≥12
Still wet
55 (15.7)
129 (36.9)
84 (24.0)
75 (21.4)
7 (2.0)
Where the training mainly took place
At home
With grandparent
In reception class
In crèche
310 (88.6)
8 (2.3)
7 (2.0)
25 (7.1)
Age of attainment of night-time continence
(months)
<12
12 - 18
19 - 30
31 - 60
>61
Still wet
70 (20.0)
104 (29.7)
84 (24.0)
46 (13.1)
16 (4.6)
30 (8.6)
Age of attainment of day-time continence (months)
<12
12 - 18
19 - 24
25 - 30
≥31
Do not remember
Yet to start
117 (33.4)
68 (19.4)
104 (29.7)
30 (8.6)
21 (6.0)
7 (2.0)
3 (0.9)
Table 4. Comparison between public and private hospitals in
relation to toilet training
Types of tertiary centres
p-value
Public
(n=250),
n (%)
Private
(n=100),
n (%) Total,
n (%)
Who was in
charge of toilet
training?
0.427
Parent 217 (88.8) 92 (92.0) 309 (88.3)
Grandparent 11 (4.4) 4 (4.0) 15 (4.3)
Caregiver 15 (6.0) 2 (2.0) 17 (4.9)
Relations 7 (2.8) 2 (2.0) 9 (2.6)
Age at attainment
of night-time
continence
(months)
0.002*
≤12 57 (22.8) 13 (13.0) 70 (20.0)
13 - 18 82 (32.8) 22 (22.0) 104 (29.7)
19 - 24 47 (18.8) 37 (37.0) 84 (24.0)
25 - 30 31 (12.4) 15 (15.0) 46 (13.1)
≥31 14 (5.6) 2 (2.0) 16 (4.6)
Still wet 19 (7.6) 11 (11.0) 30 (8.6)
Place of toilet
training
0.613
At home 219 (87.6) 91 (91.0) 310 (88.6)
With
grandparent
7 (2.8) 1 (1.0) 8 (2.7)
In reception 6 (2.4) 1 (1.0) 7 (2.0)
At crèche 18 (7.2) 7 (7.0) 25 (7.1)
Age when
toilet training
commenced
(months)
0.414
≤12 92 (36.8) 32 (32.0) 124 (35.4)
13 - 18 59 (23.6) 20 (20.0) 79 (22.6)
19 - 24 55 (22.0) 31 (31.0) 86 (24.6)
25 - 30 20 (8.0) 10 (10.0) 30 (8.6)
≥31 17 (6.8) 4 (4.0) 21 (6.0)
Still wet 4 (1.6) 3 (3.0) 7 (2.0)
Do not
remember
3 (1.2) 0 3 (0.9)
*Statistically signicant.
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126 SAJCH OCTOBER 2017 Vol. 11 No. 3
attainment of both day- and night-time continence. It was observed that
there was significant association among all those variables tested against
age at attainment of day- and night-time continence (p≤0.05). Mothers
and grandparents were in charge of toilet training in the majority of
children who were dry during the night before 12 months of age. Toilet
training was commenced in children within 18 months of birth in the
majority of children who were continent before 30 months. The most
common method used in children who were continent before 18 months,
was urinating at fixed time points. A toilet training period of 1 - 6 months
was noticed most among children who became continent at night before
18 months (Table 5).
Discussion
There are limited reports on toilet training in children in Africa. This
study was conducted to describe the toilet training practices and factors,
if any, which influenced the age of continence in Nigerian children.
In this study, toilet training was initiated at ≤12 months in most of the
subjects. The findings in this regard contradict reports from previous
studies where toilet training started at a later age of 18 - 24 months.[4,7]
The reason for this difference was not obvious. Possible explanations may
be the difference in race, culture and beliefs among the subjects. This is
because the present study included an African population group, while
previous studies had been conducted in developed countries. It has been
shown in a previous report that, among other factors, race affects the age
at which toilet training is initiated.[2,32] To our knowledge, there are no
reports on the association, if any, between race and the age at initiation of
toilet training. Different methods have been used to toilet train children.
In the present study, children were asked to urinate at a fixed time. This
involved removing the diapers and allowing for urination at fixed times.
This bears semblance with the assisted infant toilet training method – a
parent-oriented training method.[33] This method existed centuries before
the Western methods were described. It is popular among populations in
China, India, South and Central America and less popular in North
America and European countries. De Vries et al.[6] studied this method
among the Digo tribe in East Africa and noted that it was effective and
resulted in early achievement of continence. The implication of this
finding is that the advent of westernisation has not affected the age-old
traditional method of toilet training in Nigeria.
Table 5. Test of association among dierent variables and age of attainment of day-time continence
Age of attainment of day time continence (months)
<12 12 - 18 19 - 30 31 - 60 >61 Still wet Yet to
start
Age of commencement of day-time
toilet training (months)
≤12 114 (97.4) 26 (38.2) 1 (1.0) 1 (3.3) 0 0 0
χ2=781.377;
p=0.000
13 - 18 0 42 (61.8) 29 (27.9) 2 (6.7) 0 7 (100) 0
19 - 24 0 0 66 (63.5) 3 (10.0) 5 (23.8) 0 0
25 - 30 0 0 6 (5.8) 23 (76.7) 2 (9.5) 0 0
≥31 0 0 0 0 9 (42.9) 0 3 (100)
Do not remember 3 (2.6) 0 2 (1.9) 1 (3.3) 5 (23.8) 0 0
Duration of toilet training for
continence (months)
<1 36 (30.8) 12 (17.6) 1 (1.0) 0 4 (19.0) 0 2 (66.7)
χ2=467.232;
p=0.000
1 - 6 81 (69.2) 34 (50.0) 2 (1.9) 0 7 (33.3) 4 (57.1) 1 (33.3)
7 - 12 0 9 (13.2) 15 (14.4) 28 (93.3) 10 (47.6) 0 0
>12 0 13 (19.1) 82 (78.8) 2 (6.7) 0 0 0
Still wet 0 0 4 (3.8) 0 0 3 (42.9) 0
Who was in charge of training
Parents 107 (91.5) 63 (92.6) 90 (86.5) 19 (63.3) 21 (100) 6 (85.7) 3 (100)
χ2=88.611;
p=0.000
Grandparents 6 (5.1) 1 (1.5) 7 (6.7) 0 0 1 (14.3) 0
Caregiver 4 (3.4) 3 (4.4) 7 (6.7) 3 (10.0) 0 0 0
Relatives 0 1 (1.5) 0 (0.0) 8 (26.7) 0 0 0
Method of toilet training
Urinate at xed intervals 75 (64.1) 21 (30.9) 54 (51.9) 2 (6.7) 8 (38.1) 2 (28.6) 1 (33.3)
χ2=248.912;
p=0.000
Remove diaper 19 (16.2) 35 (51.5) 41 (39.4) 2 (6.7) 5 (23.8) 3 (42.9) 0
On demand of the child 23 (19.7) 4 (5.9) 2 (1.9) 8 (26.7) 8 (38.1) 2 (28.6) 0
Reward 0 0 0 7 (23.3) 0 0 1 (33.3)
Punishment 0 4 (5.9) 4 (3.8) 0 0 0 0
Imitation of parent/older sibling 0 4 (5.9) 0 5 (16.7) 0 0 0
Do not remember 0 0 (0.0) 3 (2.9) 6 (20.0) 0 0 1 (33.3)
continued...
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127 SAJCH OCTOBER 2017 Vol. 11 No. 3
The duration of toilet training in most of the respondents in the present
study was 1 - 6 months. The finding in this regard is incongruent with
report from previous studies.[2,4,34] The general trend noted from previous
reports was that training is completed within 1 year of commencement.
It was therefore not surprising that 70% of the children were continent
within 1 year of commencement of training in the present study.
In the present study, the age at attainment of day- and night-time
continence was <12 and 12 - 18 months, respectively. This finding
was contrary to reports from previous studies. Daytime continence
was achieved at 32.5 and 35 months in boys and girls, respectively, in
the report by Schum et al.[35] Also, a recent report has shown that only
40 - 60% of children completed training by 36 months. The general trend
noted from previous reports was that complete continence was attained at
30 - 40 months – much later than the age reported in the present study.
A possible reason may be because of the earlier timing of initiation of
toilet training and the method used, as noted earlier. It has been observed
that age at attainment of day- or night-time continence is dependent on
factors such as timing of initiation and method used. Even if the age at
attainment of continence in the present study is earlier than in previous
reports, the finding in this regard is not far-fetched. This is because bladder
development and maturation occur at about 18 months of age, which was
the time reported by the majority of the respondents in the present study.
Attempts have been made to document factors which affect toilet
training from previous studies. In the current study, factors which
affected the time of attainment of continence were the individuals
responsible for toilet training, time of initiation of toilet training
and the method of toilet training. Most of the children who achieved
continence within 1 year of commencement were trained by their
mothers. This is not surprising because the mothers are more patient
or tolerant compared with the fathers or any other relatives/persons.
Children who commenced toilet training within 1 year of life also
achieved continence earlier. It has been shown that the duration of
toilet training is related to the age at initiation of training.[36] Children
who commenced training earlier achieved continence earlier.[4,36]
But this is not always the case, because some children may develop
problems along the line of training and if this not handled properly by
Table 5. (continued) Test of association among dierent variables and age of attainment of night-time continence
Age of attainment of night-time continence (months)
<12 12 - 18 19 - 30 31 - 60 >61 Still wet
Age of commencement of toilet training
at night (months)
≤12 64 (91.4) 58 (55.8) 1 (1.2) 1 (2.2) 0 0
χ2=533.445;
p=0.000
13 - 18 0 46 (44.2) 19 (22.6) 7 (15.2) 0 7 (23.3)
19 - 24 0 0 63 (75.0) 11 (23.9) 10 (62.5) 2 (6.7)
25 - 30 0 0 0 16 (34.8) 6 (37.5) 8 (26.7)
≥31 0 0 0 11 (23.9) 0 10 (33.3)
Do not remember 6 (8.6) 0 1 (1.2) 0 0 0
Yet to start 0 0 0 0 0 3 (10.3)
Duration of toilet training for continence
<1 month 24 (34.3) 23 (22.1) 1 (1.2) 2 (4.3) 5 (31.2) 0
χ2=273.882;
p=0.000
1 - 6 months 46 (65.7) 33 (31.7) 29 (34.5) 0 7 (43.8) 14 (46.7)
7 - 12 months 0 48 (46.2) 22 (26.2) 4 (8.7) 4 (25.0) 6 (20.0)
>12 months 0 0 28 (33.3) 40 (87.0) 0 7 (23.3)
Still wet 0 0 4 (4.8) 0 0 3 (10.0)
Who was in charge of training?
Parents 58 (82.9) 93 (89.4) 77 (91.7) 35 (76.1) 16 (100) 30 (100)
χ2=70.181;
p=0.000
Grandparents 8 (11.4) 7 (6.7) 0 0 0 0
Caregiver 4 (5.7) 3 (2.9) 7 (8.3) 3 (6.5) 0 0
Relatives 0 1 (1.0) 0 8 (17.4) 0 0
Method of toilet training
Urinate at xed intervals 28 (40.0) 51 (49.0) 53 (63.1) 9 (19.6) 8 (50.0) 14 (46.7)
χ2=185.931;
p=0.000
Remove diaper 19 (27.1) 41 (39.4) 23 (27.4) 8 (17.4) 0 (0.0) 14 (46.7)
On demand of the child 23 (32.9) 4 (3.8) 0 (0.0) 10 (21.7) 850.(0) 2 (6.7)
Reward 0 0 0 8 (17.4) 0 0
Punishment 0 4 (3.8) 4 (4.8) 0 0 0
Imitation of parent or older sibling 0 4 (3.8) 0 5 (10.99) 0 0
Do not remember 0 0 4 (4.8) 6 (13.0) 0 0
RESEARCH
128 SAJCH OCTOBER 2017 Vol. 11 No. 3
the guardian/parent, it may hamper training and prolong the duration
of training and time to achieve continence. Children who were trained
by urinating at fixed intervals achieved continence earlier. There are no
randomised studies on the assisted infant training method, but studies
that have been done with the other training methods have shown that
those methods affected the time of continence.[33] There are, however,
conflicting reports in this regard.
The present study compared findings from caregivers who attended
private and public tertiary hospitals. The sociodemographic characteristics
were similar between the respondents of both hospitals. It was therefore
not surprising that there were similar findings in both children.
Conclusion
Nigerian children are being toilet trained at an earlier age compared with
children in developed countries. Also, the age-old traditional method
of toilet training is still practised in Nigeria despite the influence of the
Western world on our way of life. The age of attaining continence is also
lower than for developed countries.
Acknowledgements. Sincere appreciation to the parents of the children.
Author contributions. AUS developed the concept, literature review,
data collection and analysis and discussion. OAO did data collection and
analysis. ADM helped with the literature review, analysis and discussion.
IS contributed to the concept and review of manuscript.
Funding. None.
Conflicts of interest. None.
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... Ocup., 6(1), 771-793, 2022. asiáticos e africanos, como China (Huang et al., 2020;Li et al., 2020;Wang et al., 2019e Xing et al., 2020, Vietnã (Duong, Jansson, & Hellström, 2013), Tailândia (Benjasuwantep & Ruangdaraganon, 2011), Irã (Hooman, Safaii, Valavi, & Amini-Alavijeh, 2013), Quênia (deVries & deVries, 1977) e Nigéria (Solarin, Olutekunbi, Madise-Wobo, & Senbanjo, 2017). Rugolotto et al. (2008) definem a comunicação de eliminação como uma prática adotada por cuidadores nos primeiros meses de vida do bebê, em que se observa sinais e/ou padrões que antecedem a eliminação de fezes ou urina, para auxiliar o bebê, posicionando-o de "cócoras" -membros inferiores fletidos. ...
... Os resultados mostraram descrições semelhantes para este método, o que aponta padronização da comunicação da eliminação, sendo a mais significativa referente à descrição dos sinais de eliminação (Benjasuwantep & Ruangdaraganon, 2011;Duong et al., 2013;Jordan et al., 2020;Rugolotto et al., 2008;Smeets et al., 1985e Sun & Rugolotto, 2004 Uma análise aprofundada dos momentos específicos revela que, em sua maioria, eles foram diretamente ligados à micção, incluindo o auxílio do som de "assobio" (deVries & deVries, 1977;Duong et al., 2013;Solarin et al., 2017;Yang et al., 2011e Xing et al., 2020. Jordan et al. (2020) relacionaram o momento específico "após mamar" à defecação, devido à atuação do reflexo gastrocólico. ...
... O próprio vaso sanitário se apresenta como uma barreira para a criança conseguir usá-lo, pois é necessário o uso de adaptações, como redutor de assento e apoio para os pés, para possibilitar o uso independente pela criança (SBP & SBU, 2019). Porém, mesmo com a existência das barreiras em contexto ocidental, a comunicação de eliminação foi apontada como facilitadora na conquista da independência no uso do vaso sanitário (Bender & She, 2017;Rugolotto et al., 2008;Smeets et al., 1985e Sun & Rugolotto, 2004 (Bender & She, 2017;deVries & deVries, 1977;Duong et al., 2013;Hooman et al., 2013;Largo & Stutzle, 1977;Rugolotto et al., 2008;Solarin et al., 2017;Sun & Rugolotto, 2004;Wang et al., 2019e Yang et al., 2011. ...
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Introdução: O método de treinamento no uso de toaletes, conhecido como “comunicação de eliminação”, é comum em comunidades orientais e africanas e vem sendo incorporado ao cotidiano de famílias brasileiras. Porém, erros no treinamento podem interferir negativamente no desenvolvimento infantil, sendo recomendada orientação profissional. Objetivos: Apresentar o estado da arte sobre a comunicação de eliminação nas publicações acadêmicas, identificar sua definição e discutir a possibilidade de configurar prática do terapeuta ocupacional. Método: Revisão Integrativa da literatura, realizada nas bases de dados SciELO e Medline/PubMed, utilizando os descritores “treinamento no uso de toaletes”, “terapia ocupacional”, “toilet training” e “occupational therapy”, considerando os critérios de inclusão: artigos que abordem o treinamento iniciado entre zero e 18 meses, na língua portuguesa, inglesa ou espanhola, e que tenham resumo disponível. Resultados: Foram encontrados 17 artigos. O método consiste em auxiliar o bebê, desde primeiros meses, a eliminar fezes ou urina, o que facilitou o desfralde a longo prazo e preveniu a ocorrência de transtornos da eliminação. Discussão: O método proporciona melhora da qualidade de vida do bebê por diminuir episódios de choro, otimizar a consciência corporal e facilitar o desfralde. Porém, se malconduzido, acarreta desfralde precoce, o que pode ser evitado com a orientação do terapeuta ocupacional para o treinamento correto da atividade. Conclusão: Existe carência de estudos científicos sobre a comunicação de eliminação em contexto brasileiro, sendo necessário adaptação cultural e recomendada para seu uso a supervisão de um profissional que trabalhe com desenvolvimento infantil, como o terapeuta ocupacional. Palavras-chave: Terapia Ocupacional. Treinamento no uso de toaletes. Atividades cotidianas. 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The method consists helping baby, since first months, to eliminate feces or urine, a conduct that facilitated long-term toilet training, and prevented the occurrence of disorders of elimination. Discussion: The method improves the baby's quality of life by decreasing crying episodes, optimizing body awareness and facilitating toilet training. However, if it is misconducted, it leads to wrong toilet training, which can be avoided with the guidance of the occupational therapist for the correct training of activity. Conclusion: There is a lack of scientific studies on elimination communication in the Brazilian context, requiring cultural adaptation and recommended for its use the supervision of a professional who works with child development, such as the occupational therapist.Keywords: Occupational therapy. Toilet training. 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To describe longitudinally the development of micturition patterns in children who are potty trained early. Healthy children in Vietnam from newborn up to 1 year were investigated every 3 months. This included mapping of the micturition pattern through the 4-h micturition observation method. Forty-seven children participated in all five investigations. At the ages of newborn, 3, 6, 9 and 12 months, 70%, 82%, 91%, 99% and 100% of the mothers, respectively, were potty training their children. Mean lowest bladder volume (voided volume + residual urine) triggering a micturition was 18 ml at the age of 2 weeks compared to 33 ml at 12 months. Post-void residual urine decreased according to age, and already at 9 months was less than 7 ml (mean 0.7 ml). The dyscoordination between the sphincter and detrusor muscle seems to have already disappeared at the age of 9 months in infants who are potty trained very early. These findings suggest that potty training can be beneficial in small children with urinary tract infections or renal scars.
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This study investigates the association between age at initiation of toilet training and development of daytime bladder control. The main aim is to examine whether initiation of toilet training after 24 months is associated with increased odds of daytime wetting in school-age children. The study is based on more than 8000 children, aged 4.5 to 9 years, from a UK birth cohort--The Avon Longitudinal Study of Parents and Children. Using multinomial logistic regression, the analysis examined the association between age at initiation of toilet training and 4 previously established trajectory groups representing different patterns of development of daytime bladder control (described as "normative development," "delayed acquisition," "persistent daytime wetting," and "relapse"). Compared with children whose toilet training was initiated between 15 and 24 months, initiation of toilet training after 24 months was associated with higher odds of membership to the trajectory groups representing persistent daytime wetting (1.52 [1.23-1.88], p < .001), delayed acquisition of daytime bladder control (1.47 [1.29-1.66], p < .001), or relapse in daytime wetting (1.52 [1.28-1.80], p < .001). Adjustment for confounding variables, including sex, developmental delay, difficult temperament, and the mother's self-reported depression, did not alter the main conclusions. There is evidence that initiating toilet training after 24 months is associated with problems attaining and maintaining bladder control. It is possible that delaying the onset of toilet training until after 2 years prolongs the exposure time to potential stressors that could interfere with the acquisition of bladder control, resulting in delays in achieving continence and susceptibility to relapses in daytime wetting.
Article
Acquisition of bladder and bowel control is influenced by physiological, psychological and sociocultural factors. The objective of this study was to evaluate the prevalence of children out of diapers by 24 months of age and the factors associated with this finding. A total of 3,281 children born in Pelotas, RS, Brazil in 2004 were enrolled on a longitudinal study. At 24 months their mothers were visited at home and replied to a questionnaire containing questions about sociodemographic data and the characteristics of their children's urinary and intestinal evacuation habits, with special attention to toilet training. Multivariate analyses were carried out using Poisson regression. From the total, 24.3% were out of diapers during the day, with the female sex predominating (27.8 vs. 21.1%, p < 0.001) and 8.6% were out of diapers at night, also with the female sex predominating (10.6 vs. 6.8%, p < 0.001). The abilities needed to start toilet training were present in 85.5% of the children. Guidance was received from a pediatrician in 10% of cases, and more frequently among richer mothers than among poorer mothers (22.9 vs. 4.8%). Mothers who spent more years in education (13.2%) and were from higher social classes (14%) took their children out of diapers later; a greater number of children living at home (relative risk = 1.32) and being able to communicate the need to go to the toilet (relative risk = 11.74) both increased the probability of being out of diapers; previous unsuccessful attempts delayed removal of diapers (relative risk = 0.59). Although the abilities needed for acquisition of bladder and bowel control were already present at 24 months, indicating that toilet training could be started, the majority of children had not yet started this training. Better-informed mothers delayed training the most.
Article
Enuresis was investigated in the context of different styles of training for bladder control among three Israeli ethnic groups (Jews of Moroccan, Kurdish or Eastern European descent). Semistructured interviews were conducted in ethnically homogeneous agricultural villages with 46 mothers of 248 children between the ages of 3 and 18 years. In contrast to previous British and American studies, no sex differences were found, but there were higher rates of primary enuresis and lower rates of secondary (regressive) enuresis. Enuresis was correlated among siblings in the Kurdish group only and with disorderly sleeping arrangements in the Moroccan group. The Moroccan and Kurdish groups had higher rates of enuresis than the Ashkenazi group. The higher rates appear to be related to differences in the age of onset of training and a lack of age-appropriate changes in the parent-child interaction, which led to chronic enuresis and the inability to seek effective assistance. These results are discussed in terms of a proposed typology for training: an early symbiotic style, a strict toddler style, and a communicative partnership.