The Dangers of Potty Training Too Early
A doctor's case for training later in childhood
By Steve Hodges, M.D. with Suzanne Schlosberg   |   March 23, 2012
You've probably heard the arguments in favor of early toilet training. They train early in Europe! Toddlers are more compliant than three-year-olds! Diapers are bad for the environment! Perhaps you've even read scientific studies concluding that children who train later are more likely to end up having accidents.
As a pediatric urologist who specializes in toileting problems, I'll tell you this: Children under age 3 should not manage their own toileting habits any more than they should manage their college funds. Preschools that require 3-year-olds to be potty trained - like the one in Virginia that suspended 3 ½-year-old Zoe Rosso for excessive potty accidents - are harming kids. And infant toilet training, promoted in Mayim Bialik's new book Beyond the Sling , is just plain nuts - unless, like Bialik, you monitor your child 24/7, feed your child a high-fiber vegan diet, and home-school your child. Babies need to experience uninhibited voiding , or elimination, without the expectation of using the toilet at such an early age.
It's not that young kids can't be potty trained. Sure they can. But knowing how to poop on the potty is not the same as responding to your body's urges in a judicious manner.
Let's fast-forward two or three years. That's when potty prodigies show up at my clinic - one of a handful specializing in dysfunctional voiding - with the sudden onset of pee and poop accidents, urinary tract infections (UTIs), urinary frequency, and/or bedwetting.
"I don't get it," a mom will tell me. "I didn't push her - she basically trained herself."
I believe these parents, but unfortunately it's typically the kids who trained earliest and most easily who develop the most serious problems. I see about 100 kids a week at my clinic, and about half are dysfunctional voiders; most of them trained before 3.
To understand the risks of early training, it's important to know that virtually all toileting problems - pee and poop accidents, bedwetting, urinary frequency, and urinary tract infections - are related to chronically holding pee or poop or both.
Signs your kid is ready:
• She/he can tell you she is peeing and pooping
• She/he asks to use the toilet
• She/he can dress and undress herself
• Your child's poops are mushy (like sweet potatoes or hummus)
Though some toddlers with older siblings insist that they want to use the potty, they don't understand what that means. Three years is generally a good age to begin.
Children - and I mean all children - don't like to interrupt their lives to use the bathroom. Once kids learn to put off peeing and pooping, essentially the definition of toilet training, they tend to do so often and for as long as they can. This is a dicey habit. Each time you squeeze your sphincter to prevent the release of pee, you create resistance in your bladder. What happens when muscles go up against resistance? Exactly what happens when you train your hamstrings at the gym: They get thicker and stronger. But unlike muscular hamstrings, a thicker bladder is a bad thing. It has a smaller capacity and its sensation mechanism goes awry. When a child habitually delays peeing, over months and years, his bladder wall becomes more muscular and eventually the bladder can get so strong and irritable that it empties without any input from the child.
Chronically holding poop, a problem exacerbated by our kids' low-fiber diets, compounds the damage. A mass of poop forms in the rectum, right behind the bladder, and can stretch the rectum from about 2 centimeters in diameter to 10 centimeters or more. There's only so much room in the pelvis, so the bladder gets squeezed out of the way and can't hold as much urine. What's more, the nerves controlling the bladder, which run between the bladder and the intestines, can get irritated when the intestines are enlarged, causing unexpected and unwanted bladder contractions - in other words, mad dashes to the toilet and accidents.
Chronically holding pee and poop also causes urinary tract infections. The less often a child pees, the more opportunity for infection-causing bacteria to creep up to her bladder. And if this kid is also hauling around a hefty load of poop, she's harboring about a gazillion (to be precise) more times the bacteria than when her rectum has been emptied. Since the bladder is only a couple of inches from the rectum, the offending bacteria have a short trip to make, crawling through the perineal skin and into the vagina and the area around the urethra.
Though the data is robust, I believe these numbers are actually underestimates. Since parents tend to believe potty problems are normal, many don't bother bringing their kids to the doctor.
Even when they do see a physician, the cause of their children's toileting troubles often go unnoticed. That's because most parents, and even many pediatricians, equate constipation with infrequent pooping. In reality, many constipated kids poop regularly, even multiple times a day. Large poop masses in children typically go unnoticed because looser poop oozes by and finds a way out more easily than the hard stuff, giving the impression that the child has fully eliminated. This is what happened with Zoe Rosso, the girl who was suspended from preschool and who is now my patient. As it turned out, Zoe had a poop mass the size of a miniature Nerf football stuck in her rectum, which both her pediatrician and pediatric urology clinic missed because they failed to X-ray her.
Plenty of published research, including our clinic's 2012 study published in Urology , demonstrates that when you clear up clogged kids and prevent them from holding, the accidents, UTIs, and bedwetting episodes cease. Our study simply confirmed results from a remarkable series of Canadian studies published in the 1980s . These showed convincingly that children with wetting problems were severely constipated, despite showing few or no outward signs, and that treating constipation resolved the wetting and UTIs dramatically. (Remember that by constipation we mean a rectum clogged with stool - not failing to poop regularly.)
The reason kids who train at age 2 have more of these problems than children who train later, in my opinion, is that they have spent more months or years deciding for themselves when they should pee or poop - before they're mature enough to understand the importance of eliminating as soon as they feel the urge. What's more, the bladder needs about three or four years to grow and develop, and uninhibited voiding (read: diapers) facilitates maximum growth.
Parents often tell me their child has accidents because she has a "small bladder," as if an undersized bladder is something the child was born with. The child's bladder may be small, but that's because its capacity has been compromised by holding.
Do you know how often I see children who are still in diapers and have recurrent UTIs? Never. Do you know how often I treat newly potty-trained children for recurrent UTIs? Every day. These kids fill a quarter of my clinic. This is not a coincidence and demonstrates quite clearly that toilet training in very young children is harmful. There is no way that healthy, developmentally normal, un-constipated children who learn to use the potty at 3 ½ have a higher rate of chronic pee or poop accidents than children who train at 2 ½. Kids in diapers don't hold; many toilet-trained children do. Every year of constipation-free, uninhibited voiding - in other words, wearing diapers - leads to bladder growth; every year of holding shrinks the bladder and makes it more overactive.
And consider this: Typical therapy for accidents involves giving kids laxatives and putting them on a pee schedule, taking the decision of when to eliminate out of their hands.
Well, there's a major flaw in this research: The authors didn't check, via X-ray, to see if these kids were constipated at the time they started training. The records we keep at my clinic suggest that among late trainers, it's not the age of training, but rather unrecognized constipation that correlates with problems. We have found that children who trained after age 3 and have toileting troubles either trained late because they were constipated (their parents had tried earlier but failed) or trained late and are constipated.
So, if you are training your 2-year-old because the preschool you've chosen requires children to be potty trained by 3, I suggest you find another school. Sending an early-trained child to preschool only increases the risk of potty problems, particularly if these schools don't allow the safety net of a Pull-Up. Think about it: You're placing a 3-year-old in an unfamiliar environment where, for possibly the first time in her life, she has no family members around for half the day, and you're expecting her to interrupt her teacher during the story circle and announce that she needs to use the toilet or to climb out of the fort she's just built with her friends and make her way over to the potty. Whoever thought that was a good idea has surely never set foot in a pediatric urology clinic.
Making matters worse, these kids are ill-equipped to deal with the sub-par restrooms and restrictive bathroom policies that may await them in elementary school and beyond. I have countless patients who have developed the capacity to hold their pee and poop from 7:30 a.m. to 4:30 p.m. - and have developed serious bladder problems and recurring urinary tract infections because of it.
Children who are newly potty trained need a lot of follow-up, no matter how well they are able to stay dry, and the earlier you train a child, the longer it's your responsibility to monitor the child's peeing and pooping habits closely. Children need reminders to use the toilet about every two hours. (And caretakers should never ask a child if he needs to go potty, because most kids will say no. It's your job to instruct the child when to go.)
It's also important to glance at your child's poops whenever you have a chance (luckily, kids often forget to flush!). Look for poop that's thin and/or mushy, like mashed potatoes or hummus (it's the watery, diarrhea-like poops that signal a problem). Extra-large poops and thick, formed poops are signs of constipation.
You can also teach your child to check on his own poop and report its appearance to you. (Yeah, all this sounds gross, but these conversations are important for families to have, and lots of kids think talking about poop is fun stuff.) Finally, try to keep track of the last time your child pooped.
I know most parents dream of the day when they can be completely removed from their children's goings-on in the bathroom. Heck, I look forward to that day myself. But don't get too fixated on your own potty liberation. You need to pay attention to your kids' pooping habits until you're absolutely positive they have it down.
FORCING potty training early is bad. but there is absolutely no evidence that people in the rest of the world have issues and no one else "waits until the child shows signs of readiness between 2 & 3" like we do :P
Wow! Complimentary posts, I'm not sure how to respond! For Kate - you hit upon an important topic that we covered recently in a post on Slate.com, you can find it if you google "Slate" and "bedwetting" over te last month. For Mary - if you are aware of these problems you are way ahead of the game, as long as you maintain soft stools and don't promote holding you should be fine. There are lots of theories of how these problems all develop, I am a believer in the work of Dr. O'Regan and think the retention and accumulation of rectal stool is the initiating event in these kids, one of the reasons I promote late training is that otherwise you're training them around the same time the constipation issues arise, compounding things. Anyway, thanks for the comments.
This article worries me that I am harming my baby. I am doing a modified form of EC (essentially, I do what is described in the book "Diaper Free Before 3" where my baby is in diapers full time but I offer her the potty fairly frequently, and whenever she indicates to me that she has to go). I started at 5 months; she is 9 months old now. I believe she prefers to poop in the potty, though perhaps that is because I have told her "good job" for going in the potty. There is no penalty for going in the diaper; I simply clean her up and change her. Is this a "safe" way to attempt early training? If not, how would you recommend that I backtrack now? Thank you in advance for your help!
Thank you for this article. My daughter trained around 3, and I worried so much as many other moms I knew insisted on training earlier and I felt like I was doing something wrong not being able to get it done earlier. We had a recent onslaught of pee accidents at age 4, and I was stumped, I responded by just putting her on a schedule and it worked well (although she still insists, "I don't have to go!" and then does.) . I think it was triggered by a stressful two weeks in an unfamiliar environment, lots of family stress, away from home and having to leave her with unfamiliar babysitters where she didn't feel comfortable asking to go, so she held it for too long. Now after three or four weeks things are back on track. I just really appreciate your perspective, other parents can be so self-satisfied and sanctimonious about how it is some kind of badge of honor if their kids trains early. My question is: my daughter still requires pull ups at night. I am refusing to worry about this for now and will get rid of the pull ups only when they are dry in the morning. Any other tips for night-time training or is it just when they are ready?
Dr. Hodges - First I'd like to say thank you for your thought provoking article, and second I'd like to say thanks for sticking around and reading and answering the comments. And thanks to all the commenters who presented their reactions, corrections, and criticisms in a respectful and thoughtful way. This has truly been the most productive Internet commenting exchange I've ever seen, and it's been really helpful for me personally. I''m an expecting mom with no horse in the race yet. I heard a podcast on ec and it really spoke to me and all the experiences I've had/heard with all my many young cousins. The main thing that rung true for me was the assertion that really we train babies to go in diapers - that initially babies resist going in them and then learn that it's okay, and that that is why newborns tend to pee and poop all over you as soon as you take the diaper off but then quickly stop doing that. They argued that most babies take well to diapers but that some are always sensitive to sitting in their own waste and resist going - and I wondered if that was what was going on with my cousin who tended to resist going in his diaper and ended up badly constipated. The rest of ec, as I understood it was that you were learning as a parent to be Ina tune with your baby and knowing more often than not when they needed to go and then helping them do that away from their bodies. The upside being that you don't have to train twice - first to go in diapers and then not to go in diapers - instead you're just helping the baby stay aware of when they need to go and helping them find somewhere comfortable to go when they do. That said, many of the things stated in this article made sense to me - the idea that it is damaging to your body to hold it when you have to go and that active kids might ignore tht urge made sense. That said, the ec book I read - Diaper Free Baby - seemed to indicte that what would happen when the kid was too busy to alert you was that the kid would just go in the diaper/on the floor and then alert you that they needed to be changed. Anyway, I haven't practiced any of these things yet - but I just wanted to say thank you for engaging with the commenters after the article. The article itself made me feel confused and unsure about ec, but as I read your comments and reactions it seems clear that you might have misunderstood what ec was all about. At the same time, your article provided a very clear roadmap for what would be the pitfalls and things I need to look out for if I'm going to try ec. I promise to make sure my child isn't trying to hold it - to the best of my ability! Also, the study sounds like a great idea. I would think it would be prudent to track all children in all groups from birth, if possible - identifying, treating, and recording cases of constipation as they come up - that way it might yield information about which method, if any, is correlated with higher rates of constipation in the first place. It seems to me, based on what you said in your article, the diagnosing severe constipation is difficult for many practitioners without an x-ray, so finding ways to prevent it, if possible, would be a boon. Thanks again for sticking around to thoughtfully engage with the comments. Sorry some people were being inappropriate jerks about diaper companies.
But doesn't the author only see children with problems? What about the children who are potty trained early and don't have problems? Obviously, he wouldn't see them as they would have no reason to go to his clinic in the first place. Perhaps the better conclusion might be that children who are prone to bladder problems or constipation should stay in diapers longer as they may have a higher need to ensure that everything runs smoothly down there.
This is literally the story of my life. Recurring utis from age 5 to 12. Constant bed wetting, drs visits, medicines. Surgeries!!! I was catheterized at 12 and my bladder filled until I couldn't hold it. I was crying the whole time cuz tgey wanted me to stop holding it and just go but to me, peeing the bed was bad. I dnt wish this on anybody. One day it just stopped. They never figured out wat it was or y it happened. I've always wanted to know.
My child became constipated because of dehydration from a virus, had one very painful movement and decided no more. Fear of pain caused herr to start withholding which snowballed and so took a long time to undo. In her case extra fiber made stools bulkier and so even more problematic. It had nothing to do with the timing of her potty training. It is important to figure out the source of the problem before making generalizations about cause or remedy,
Great points below. I see almost universally in the kids in my clinic the unwillingness to poop in strange environments. As we mention in the book, very few kids poop at school, and the most common place accidents occur is on the way home from school (after holding all day). Training late does not make you immune to holding once you are trained but does allow maximal bladder growth so that it is less of an issue. In other words, the earlier you start holding the worse it is. It is important to make sure all kids pee and poop regularly, an that the stool is soft and thin, and most people take a "train and forget about it" attitude that leads to issues. One of the many reasons I wrote the book was to inform parents and preschool as well as grade/middle/high school instructors of these pitfalls. Hopefully discussions like this will at least increase awareness which is unfortunately very low.
Great points below. I see almost universally in the kids in my clinic the unwillingness to poop in strange environments. As we mention in the book, very few kids poop at school, and the most common place accidents occur is on the way home from school (after holding all day). Training late does not make you immune to holding once you are trained but does allow maximal bladder growth so that it is less of an issue. In other words, the earlier you start holding the worse it is. It is important to make sure all kids pee and poop regularly, an that the stool is soft and thin, and most people take a "train and forget about it" attitude that leads to issues. One of the many reasons I wrote the book was to inform preschool and grade/middle/h
Steve and A: You've got me thinking. Steve: From the number of five and six year olds I see 'dancing' in the park on a sunny day, I very much doubt that they are 'mature enough to understand the importance of eliminating as soon as they feel the urge'. However, from my own ec adventures I know that all sorts of things change the pooping schedule of a toddler - teething being the most obvious to me. As children grow older they seem to become more regular in their bowel habits. So perhaps the older children don't need to stop playing to go to the toilet because they already have a regular bowel movement in the morning or evening or both? This is fresh in my mind because I recently read this 'how to set up good bowel habits' manual from 1929. http://studymore.org.uk/baby1929.htm#TheForceofHabit (scroll down to the heading Regular Bladder and Bowel Action). No constipation there and the kids are in woollen drawers from 7-8 months... (OK, so most of the rest of the page is bonkers, but it's still interesting ;) )
Jenn & Steve - Following on your point Jenn. My daughter now goes to nursery, I was surprised one day when she said she didnt want to 'poo' at nursery only at home. We have never impressed on her not to 'go' in a certian situation or wait to get home (portable potty ever ready :-) ) Fortunatey she is there mornings only so it hasnt led to anything negative. Could this be leading down the route of the dangers of sending your child to nursery rather than what age you 'potty train'?...
Yes Gwyn you are missing the point a bit. As Daria explained ECd babies do wear nappies, it is not a problem! However, to offer a chance not to not soil themselves even just focussing on an hour a day is a healthy and respectful act that works with the baby's natural instincts and bodily functions. There is very little rushing around, getting to the flower pot on time (lol). Different at different ages but when they are babies its more often you take them when you think they may need to go shortly, then they choose whether ir not to 'go' so at your 'conveninence'. A baby/toddler signalling to go gives you plenty of time to react. We had a potty in the mainly used rooms of the house, and a portable potty (they are fab!) that went in my handbag, so offering when out and about was very quick and easy. Perhaps I struggled with a poor smeared bum as it only happened a handful of times, so didnt know what to do! lol
@Dr. Hodges: My daughter was ec'd and she has chronic constipation and enco. I don't believe that her holding has anything to do with the way she was brought up to use a potty, but more with the dramatic difference between her home and nursery environment (as you mention in your article). I was working and she went to nursery for 3 consecutive 10 hour days per week. For a long time she had a daily bowel movement first thing in the morning and all was well. But her pattern changed (with teething, I suspect). She became less predictable - not a big deal at home, but problematic at nursery where she simply didn't poo (though she used the potty for wees, so the opportunity was there). For three days on the trot, every week, she held out. She was around 18 months old at the time. She's now approaching five and has been in full time school for 6 months. We've managed because we use Dr Collins' Soiling Solutions protocol to keep her clean and give her a chance to heal. She's doing well but it's not over. To those on here who are fighting the good fight for ec - a practice which I firmly believe in and have used with all three of my daughters - please don't disregard the points made in this article purely because they don't apply to you. You get so in tune with your own child that you second guess them almost without thinking - as most parents do when they potty train early, even in a more 'conventional' manner. Yes, your child will tell you when they need to go. But you also notice those early signs of agitation and are ready to step in and provide an appropriate place to help them out. But do you not think that your child is capable of holding if they decide they want to and there's no one there looking out for them? I bet they are...
One very important point that is being overlooked here is that ECd babies nearly always (I have heard of ONE case with Western EC families where this was not true) use diapers as back-up - and that's 'OK'! There is no reprimand if the child has 'misses' and child is not made to feel guilty or 'bad' for doing so (obviously likewise positive affirmation for 'catches' is not common practice either as the absence of positive affirmation = negative affirmation/reprimand). I think a whole lot of information is missing in this article about what EC actually is and yes, further studies would be a very good thing.
You need to adjust her diet or add fiber supplementally or miralax or the generic alternatives. It's important that they not learn to have negative associations with going, so try and keep it soft as possible.
That's all good but there's not a preschool I know of, except one which only takes special needs, that doesn't have the 3 yo requirement. And in ours, they started mass training them mid- year in the 2 yo class. We have had the constipation problems you describe and the holding but I feel like it's a choice between that and working, money, and socialization for my daughter.
This is a really interesting article as I am in exactly the situation you describe. My little girl has been wanting to go to the potty to makes a "poop" as you say and always gets very anxious about it but does go after a few minutes (although not always) I have noticed that she is constipated and sometimes it is painful for her so I can only think she is holding it in and getting constipated. My question is what to do as she is the one who doesn't want to poop in her nappy. I keep the nappy on all the time and take her to the potty when I notice she is pushing. Should I stop doing that? I really want to avoid the problems you have mentioned. Thanks
A, maybe I'm missing the point of EC, but I still believe it's easier to let my children (i have two under two) poop and pee in the diaper and change it then to drop everything to get my child to the potted plant, sink, toilet, in enough time. A peed in disposable (and many cloth diapers) doesn't need to be changed every time there is pee, and poop isn't all the tough to clean off a bum.
@ Dr. Hodges: I would love to see a study like the one you mentioned, but I'm a little puzzled by your description. My understanding is that a proper scientific study requires all variables to be controlled except one. Yet your proposal has three different systems being used ( EC, early and late potty training) but only one using measures to avoid constipation. Wouldn't correct use of the scientific method require all groups using these measures? Otherwise, how could you tell if the differences could be attributed to differences in potty methods or differences in constipation control measures? That's like trying three different diets and only prescribing exercise with the third, then proclaiming the third diet best. Didi I read it wrong or did you really just propose a study that blatantly favors your own hypothesis even in the briefest description? Or has the correct method for research studies changed since I went to school?
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