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A Prospective Study of Age at Initiation of Toilet Training and Subsequent Daytime Bladder Control in School-Age Children

Joinson, Carol PhD*; Heron, Jon PhD†; Von Gontard, Alexander MD‡; Butler, Ursula MRCPCH§; Emond, Alan MD, FRCP, FRCPCH*; Golding, Jean PhD*

Journal of Developmental & Behavioral Pediatrics:
doi: 10.1097/DBP.0b013e3181ba0e77
Original Article
Abstract

Objective: 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.

Method: 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”).

Results: 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.

Conclusion: 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.

Author Information

From the *Department of Community Based Medicine, University of Bristol, Bristol, United Kingdom; †Department of Social Medicine, University of Bristol, Bristol, United Kingdom; ‡Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany; §Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom.

This study was specifically funded by a grant from the Big Lottery Fund (title: The causes and consequences of childhood wetting and soiling: clues to improving the social & educational experiences for children with bladder & bowel difficulties; reference: ERIC BS15 8DB) and has been carried out in collaboration with the charity ERIC (Education and Resources for Improving Childhood Continence).

Received February 2009; accepted July 2009.

Address for reprints: Carol Joinson, PhD, Department of Community Based Medicine, University of Bristol, Cotham House, Cotham Hill, Bristol BS6 6JL, United Kingdom; e-mail: Carol.Joinson@bristol.ac.uk.

© 2009 Lippincott Williams & Wilkins, Inc.