Potty-Training Problems

Accidents happen, whatever method you use and however quickly your child learns. When one does, clean up quickly, making very little of it. Console your child if she is upset, and do not punish, scold, or shame her. If accidents are so frequent you can see training will be unsuccessful, stop at once and put your child back in diapers. Try again in a few weeks or a month, when you think the child is ready.

A child who is completely potty trained sometimes has accidents when she is ill. Sometimes a child regresses -- seems to forget entirely control of bowels or bladder or both. Regression sometimes accompanies or follows an illness.

A child who regresses (or one who can't seem to master the control training requires, though apparently ready) may have a lactose intolerance or other food intolerance or allergy or a urinary infection. The latter is usually accompanied by pain and a burning sensation when urinating and sometimes also by changed color or a foul odor in the urine. If you suspect a physical problem, consult your doctor.

In most cases, regression has an emotional, rather than a physical, cause. It may occur when a new baby comes into the house, when someone close to the family dies, when parents separate or divorce, or at some other stressful time. It's best to go along with it as best you can: Do not show anger or scold, but put your child back into diapers without comment.

Nighttime bladder control usually comes later than daytime control, although some children go through the night dry even before they are daytime-trained. Good control is needed because a child who sleeps through the night may have to wait as long as 12 hours. You may want to encourage nighttime control by holding back on liquids before bedtime and getting her up when you go to bed. Bed-wetting (enuresis) is considered a real problem only after a child is about six years of age.

Potty training is a major milestone in your child's life, but some parents can put too much pressure on the stage and make it harder on their child. If you follow our simple potty training advice, your child will be well on his way to independence.

How to Start Potty Training

The most common order for potty training is bowel control first, then daytime bladder control, and, later, nighttime bladder control, but all children do not follow that pattern. If your child has bowel movements at a regular time most days, you may have him trained in that department long before you try for bladder control; some parents try with good success when their children are about 18 to 24 months old.

A good time to try for a child who is not regular is about 30 minutes after a meal. Sit with your child for a few minutes, perhaps reading a book as you wait, but only as long as the child is willing. Be prepared for your child to feel proprietary about his feces, and be careful not to imply they are dirty or bad in any way. Some children are upset when their feces are flushed away, and some are frightened of the flushing noise. If your child is one of these, you may decide to flush only after he has left the bathroom.

One reason some children have trouble managing bowel control is that they are constipated. Constipation is not so much a matter of infrequency of bowel movements (having as few as three or four normal movements a week is perfectly natural for some children) as it is of hard stools that are painful and difficult for a child to pass. Discomfort makes a child hold back and compounds the problem. To help a constipated child, decrease his intake of milk and milk products and increase whole grain and dried fruit in his diet. Prune juice is helpful for a child who will drink it. If constipation continues, see your doctor for advice.

Summer is the best time to start potty training, if you have a choice, because the fewer clothes a child must bother with, the easier the process is. As often as you can, let your child wear underpants only to cut down the problems of dealing with outer pants or skirts and shirts.

You may find it helpful to plan to concentrate heavily on training for about a week, staying close to home with your child and not trying to accomplish much of anything else. The 24-hour method of training, advanced a few years ago by two psychologists, who designed it first to help persons with mental retardation (Nathan Azrin and Richard Foxx, Toilet Training in Less Than a Day), is championed by some parents and disapproved of by others. It involves very concentrated effort from both child and parent, and some believe it is overly manipulative and somewhat punitive. Potty training in one day may be too good to be true, as reports of the timing of success vary.

Your ultimate objective is to get your child to go into the bathroom alone when he needs to, pull down his pants, clean himself when finished, pull up his pants, empty the pot if one is used, and flush the toilet. Obviously, all this self-care does not occur at first, and you may help and remind your child to use the bathroom, and even lead your child physically to the bathroom for some time. The best times to give reminders or to take a child to the bathroom are when he first wakes in the morning, before and after naps, 30 minutes after meals, and before bed.

Children usually urinate about eight times a day and more often when they are excited or tired. Remember that part of potty training is teaching your child good habits of hygiene -- careful and thorough hand-washing and, for girls especially, wiping from front to back instead of the reverse (to prevent urinary tract infections).

When to Potty Train a Child

You will suspect your child is ready for potty training if wearing a wet or soiled diaper has become uncomfortable and distasteful to him or if he sometimes tells you or lets you know in some other way that urination or defecation is about to take place. Before you start, let the child observe you and any sibling in the bathroom; an older brother or sister is usually a great role model and an enthusiastic one. Get several pairs of underpants -- the looser, the better -- and let your child practice pulling them up and down. Look in your bookstore or library for some of the excellent potty-training books available for children, and read them to your child.

Decide whether your child will use a potty chair or the big toilet, with or without an adapter. The advantages of the potty chair are that it is childsize, close to the floor, and easy to get on and off. The adapter takes no extra space, doesn't need emptying, and allows your child to skip the middle step of changing from the chair to the big toilet. Simply teaching your child to use the big toilet is, of course, easiest of all, if the child is large enough and not frightened.

If you choose the potty chair, look for one in which the pot removes easily for emptying; you want your child to take over this task as soon as possible. If you opt for the seat adapter, consider one that folds up conveniently for travel. If your child is a boy, you need a shield, either built-in or attachable, to deflect the flow of urine because boys do not stand up to urinate at first. Do not use a chair or adapter that has a shield for a little girl; instances of injury to the labia have been reported. If you decide on the potty chair, set it up some time before you start training your child so it becomes familiar. Let the child sit on it, fully clothed, if he or she wishes, when you are in the bathroom together.

Another decision you must make concerns terminology. Children can handle the words for body parts easily enough, but the words urinate and defecate are more difficult, and they or substitutes for them will, of course, be used far more frequently. Most families settle on more casual words, such as pee and BM. Remember, there is a fine line between the acceptable and the crude; a word or term that sounds cute coming from a two year old may not be so at all from a five year old.

Still another decision to make regards rewards for successful performance during potty training. Parents disagree; some disapprove heartily of using material rewards for the accomplishment of what they see as a natural and normal step in development, while others see no harm in the practice and think it helps inspire a child to earlier success.

Among the latter, there are those who reward their children with treats, such as cookies, nuts, or raisins, and those who prefer to use small, inexpensive presents instead of food. One material gift all children get is a supply of "big girl" or "big boy" pants, often introduced with some fanfare by parents and usually thrilling to a child. Some parents who don't believe in any kind of concrete reward other than potty-training pants like to mark a child's progress with colored stars on a calendar.

All parents do agree that praise is a highly suitable and effective reward. Praise generously, they say, but not so lavishly your child begins to think of bowel and bladder control as earth-shaking achievements, more important than they really are and, possibly, as tools to manipulate their parents.

Hopefully now you've assessed that you and your child are ready to start potty training. In the next section, we will learn how to begin the process.

Potty-Training Overview

Potty training is a developmental skill your child cannot master until he is physically and mentally ready, however anxious you may be to have a "grown-up" child and be through with diapers. Actually, the process of potty training is perhaps more properly called potty learning, since your child teaches himself. Your part is to provide the setting and materials, a description of the methods used, and the necessary encouragement.

Among parents who keep close track of such events and brag a bit, the age at which their children were potty trained is almost as important as the age at which they slept through the night. Some studies show the average child is usually potty trained at about 30 months, but comparing your child with another is a waste of time; the differences among children in mastering this skill are vast. Girls are usually potty trained before boys of the same age, but a boy may be trained at age two and a girl not until age four.

The advantages of having a potty-trained child are obvious, and many parents consider starting training when their child is about the age of two, if the child seems ready. It's advisable to back off quickly, however, if your timing seems to be wrong. The self-esteem of a child who cannot yet succeed in this test of control suffers, and the anxiety engendered may lead to extended bed-wetting problems. In this article, we will answer your potty-training questions and offer you some potty-training tips over the following sections:

When to Potty Train a Child

There's a lot of debate around when you should potty train a child. Some parents take pride in having their child potty trained as soon as they possibly can. The truth is, pressuring your child to begin potty training before he is ready can only cause emotional pain and trauma that is completely unnecessary. In this section, we will show you how to read some of the signs that your child may be giving you that it is time to begin potty training.


How to Start Potty Training

Though your child might begin to display signs that he is ready to move on from diapers, this does not mean they are ready to embrace potty training. The concept might be strange or even scary to your child, and it is up to the parent to create an atmosphere that is encouraging and comfortable. On this page, we will offer some tips to make starting potty training easier. We will show when to begin toilet training, how you should arrange you time while training, and how you should prompt your child to go to the bathroom.


Potty-Training Problems

Potty-training accidents are bound to occur. Just like any of the new skills that your child will master over the years, toilet training takes patience and time. On this page, we will look at common potty-training problems and show you how to deal with them. Most accidents usually take place at night while the child is sleeping or when they are sick. However, in some cases, potty-training regression may have an emotional, instead of a physical, cause.

Well-Baby Care

During your baby's first three years of life, she will see her doctor a number of times. These visits are important to check that she is growing and developing appropriately. Her doctor will ask you a number of questions about how the baby is doing, and he will examine your baby, checking for normal growth and looking for problems.

Routine and regular checkups are particularly important for your baby during her first three years of life. Problems found at this age, if not treated early, may have serious implications for her later in life.

It used to be that your baby's doctor would see her for the first time within 24 hours of her birth. For some babies, this may still be the case. But with changes in insurance and hospitalization coverage, most new babies leave the hospital with their mother 24 to 48 hours after the birth.

So the first time the doctor sees the baby is now commonly at her first visit to the doctor's office. Most doctors like to see the new baby when she's one to two weeks old.

Whenever your baby and her doctor first meet, the doctor will perform a complete physical examination of the baby and talk to you about your pregnancy, labor, and delivery. If you smoked, took any drugs (prescribed or recreational), or drank any alcohol, you need to tell this to the doctor. These factors may affect your baby's health and growth.

When you visit the doctor's office, the doctor's staff will probably ask you some questions before you see the doctor. Here are just a few samples: How is the baby feeding? Is she sleeping well? Does she seem to have any problems with her bowels? Does she have any skin problems? They will also measure your baby's growth, including her weight, length, and head circumference (the distance around her head). The doctor goes over all this information and may ask more questions.

Next comes the examination of your baby. With your baby completely undressed, the doctor will examine your baby's heart, lungs, abdomen, arms and legs, eyes, ears, nose, throat, and everything in between. Essentially, the doctor will examine your baby from head to toe -- though not necessarily in that order.

Rarely are there any surprises found at this visit, although occasionally a congenital abnormality (a birth defect) is found that was not apparent when the baby was in the hospital. At this age, no immunizations are given.

During her first month, the baby changes a lot. You will have many questions and concerns about your new baby, and this visit gives you the opportunity to ask them. Write down your questions ahead of time so you don't forget anything. Never be afraid or ashamed to ask a question; the doctor should take time to address all your concerns. Your doctor can also give you advice on taking care of your new baby, such as feeding and sleeping instructions and safety tips.

Regular Office Visits

Doctors like to see infants at regular intervals to monitor their growth, development, and health. Regular visits are important because they improve the chance of finding any health problem early so appropriate treatment can begin immediately. Although your doctor may have a slightly different schedule of visits, most infants are seen when they are 2, 4, 6, 9, 12, 15, 18, and 24 months old, and then once a year until they are of school age.

In addition to the doctor physically examining your baby, a nurse or the doctor will measure the baby's weight, head circumference, and body length. These measurements are important for monitoring your baby's growth. Each is plotted on a growth chart. These charts are the best way to determine if your baby is growing well. If your baby's rate of growth is abnormal, follow-up is necessary.

The doctor will also ask you questions about your baby's behavior and development. The doctor looks for certain developmental milestones -- features babies usually demonstrate at certain ages. It's important to understand these milestones are only guidelines, but if a baby consistently fails to reach them by certain ages, further investigation is necessary.

After the Second Year

As your baby grows, he does not need to visit the doctor routinely as often as when he was an infant. Yearly visits are for the same reasons as the earlier ones -- to make sure your child is growing and developing as he should and to provide you with an opportunity to ask questions. New topics become important, although you may need to discuss many of the old ones, such as behavior and eating, again.

The Well-Baby Examination

Your doctor's well-baby examination consists of many different parts, each designed to discern certain information. You may have to watch closely to see the doctor perform each part of the exam because the doctor has probably developed tricks and techniques for making the exam as comfortable for your baby as possible.

While the doctor may just seem to be simply talking to your infant, he or she is carefully checking the baby's skin or eyes. Some doctors like to have the baby on the examination table; others prefer that a parent hold the baby. If you prefer to hold your baby during the examination, most doctors will respect your choice; however, the doctor may require your baby to be on the table during some portions of the exam.

Here are some of the major areas your doctor considers and what he or she looks for:

General Appearance: cleanliness, problems associated with poor nutrition, alertness


Skin: good color, rashes, bruises, swelling, condition of hair and nails


Head: shape, softness of the anterior fontanel (soft spot)


Eyes: "lazy eye," good movement, light reflexes, vision (when child is old enough to understand)


Ears: irritation or infection of the ear canals or middle ear


Nose: congestion, discharge


Mouth: condition of gums, tongue, throat, tonsils


Neck: swelling of the thyroid or lymph nodes, mobility


Heart: rate and rhythm, murmurs


Lungs: breathing rate and pattern, abnormal noises, air exchange, movement of the chest wall


Abdomen: bowel sounds (normal stomach gurglings), enlarged organs or tenderness


Genitals: in girls -- normal appearance of external genitals, redness; in boys -- normal appearance of penis (if circumcised, check that it has healed well; if not, check that foreskin is normal), both testicles in scrotum


Arms and Legs: normal movement and color, any swelling and discoloration


Hips: in infants-normal placement in sockets


Pulses: equal femoral pulses-located in the groin region above each leg


Muscles: muscle movement and coordination, tone, strength


Doctor visits will be a commonplace, and sometimes scary, thing as your child gets older. But regular medical care will ensure that your child is always healthy and happy.

Choosing an Infant Healthcare Provider

If possible, you should try to meet with several doctors before you have your baby. This gives you an opportunity to find out what they are like -- their style, their approach, their fees, and so forth. Most doctors encourage this and usually don't charge for the visit.

Note that if you participate in a managed healthcare organization (HMO, PPO, or others), your choices are limited to those doctors participating in your specific managed care program. You should still meet with a few of them, so you can choose from among those available through your insurance carrier.

If you already know you want to see a particular doctor, be sure he or she participates in your program. Otherwise, you may be responsible for charges which could have been covered under your insurance program.

Questions to Ask

When you go for the get-acquainted visit before your baby is born, you should bring a list of questions. The prenatal interview appointments usually last from 10 to 15 minutes, so you will not have the opportunity to discuss all your questions. Decide on a few areas that interest you the most and discuss those. Take notes, and follow up on any answers you don't understand.

Be aware of the doctor's style and how he or she answers the questions. Do you feel secure picturing this person as your child's health care provider? Are his or her style and philosophy compatible with yours?

Here is a list of some questions you might ask:

What hospitals do you use?

You may want to be sure the doctor uses the hospital you prefer. If he or she prefers a hospital far from your home, find out why. Perhaps that hospital offers special services or has a different approach to taking care of children. You may find the approach or services worth the inconvenience.


What hours is your office open?

With medicine becoming more competitive, doctors are doing more to attract and keep patients. This includes offering evening and Saturday office hours. If a doctor's office hours are inconvenient for your family, you may want to find another doctor.


What services do you provide in your office?

Many doctors now provide a number of services in their offices to make obtaining appropriate health care for your child more convenient for you. For example, they may take blood samples there to save you a separate trip to a hospital laboratory; they may even perform some laboratory tests at the office. Many doctors also perform hearing and vision tests in their offices. The more done in the office, the fewer places you may have to take your child. (Although, if an abnormality is found during a test conducted in the doctor's office, you may have to go to a hospital laboratory for further testing.)


Do you conduct all the examinations or do you use the services of physician assistants or nurse practitioners?

The presence of these physician extenders is really an added bonus. Remember that they often have more time to spend answering any questions you may have about your child's health and development. Unlike doctors, these professionals are not usually called away to handle emergencies, so you may have to spend less time in the waiting room. They refer any questions or problems to the doctor, so your child in no way receives lesser professional care.


What should I do if my child gets sick at night or on the weekend and I can't reach you?

Most doctors arrange to have other physicians cover for them when they are taking some time off or are out of town. Be sure the doctor has such a system. Find out who the covering doctors are because you may have to deal with them. Be wary of a doctor who tells you to take your sick child to the emergency room when he or she is not around.


How do I fit into the care of my child?

Some doctors encourage parental education and awareness and want parents to actively participate in the medical care of their children. They may even provide newsletters, pamphlets, or other educational materials or services to parents. Other doctors want to be completely in charge and make all the decisions without input from parents. You need to know the doctor's feelings in this area. If they conflict with yours, the doctor probably isn't right for you.


What type of training did you receive?

Any doctor should be willing to tell you about his or her training -- medical school, residency, and any special training. It is a good idea to ask if the doctor is board-certified -- that is, if he or she has demonstrated, by completion of certain requirements and passage of an examination, competency in a specialty. You may also want to ask what measures the doctor takes to keep up with the latest information and developments in the specialty. Does he or she attend conferences? Take continuing medical education courses?


What are your fees?

Different doctors may charge different fees for the same services. If you have health insurance, contact your insurance carrier to find out the extent of your coverage. Some insurance carriers reimburse at a higher rate if the doctor or hospital belongs to a specific network or organization. Find out about any such policies before you choose your baby's doctor.

After you have visited with a few physicians, talk to friends and coworkers. Find out what doctors they see and why. If they have a doctor that you visited, ask them the questions you asked the doctor (especially about service and availability), and see if you get the same answers. When you have all this information, you are in a position to make an educated decision.

Once you decide, let the doctor's office know. Find out if the office needs any information about you. If another doctor has any records of your children, arrange for them to be sent.

After all this work, there's still a chance you'll decide, after a few visits, that your new doctor isn't what you expected. You should discuss this with him or her. Try to explain why you aren't satisfied. Maybe a misunderstanding has occurred that is easy to correct.

Your doctor's reaction to what you say is important. If the reaction is anger or rudeness, you should look for another doctor. Don't feel obligated to continue to see a doctor with whom you disagree on some important matter, such as approach, treatment, or fees.

When you change doctors, you should get your child's old medical records. Contact the former doctor's office to ask staff to send the records to the new doctor. Physicians do this as a service to all patients. Most states require doctors to do this: The law says the contents of the records belong to the patient even though the actual records belong to the physician.

Most likely, you will be asked to send your request in writing and, to comply with federal regulations, to fill out a form allowing your child's former doctor to release the records to the new doctor.

Infant Healthcare Providers

Pediatricians, practitioners, pysician extenders, clinics -- the world of medical care for babies can be confusing. And you'll want to sort it out, because your baby will get sick. The trick is to pick one healthcare professional who serves as the point person for all your baby's needs, and, fortunately, the process boils itself down pretty easily.

Family Practitioners and Pediatricians

Two different physician specialists care for babies -- family practitioners and pediatricians. Both types of physicians have completed a residency (extra training after graduation from medical school).

A family practitioner's training covers all areas of medicine, including adult medicine, pediatrics, obstetrics, and surgery. A pediatrician's residency focuses entirely on pediatrics, and in their practice pediatricians specialize in the care of children and adolescents only.

Pediatricians have more training in childhood illness than any of the other providers. Compared with the family practitioner, the pediatrician has spent more time dealing with very ill children and with children who have special problems. Most pediatricians generally see their patients through the teenage years. Their staff and their waiting rooms are geared for children.

Family practitioners, on the other hand, can care for your entire family -- from the very young to the very old. Most family practitioners encourage this approach. They find it easier to treat an individual if they know the whole family.

Both pediatricians and family practitioners can take care of normal children equally well; however, if your child has special problems, a pediatrician is usually preferred. In addition, a family practitioner would refer any serious illnesses to a physician with more pediatric training.

Other Healthcare Providers

Other healthcare providers are also available for babies and children. These are nurse practitioners and physician assistants -- often collectively referred to as physician extenders.

Nurse practitioners are registered nurses who take one or two years of further training in physical examination, diagnosis, and prescribing medicines. Many work with physicians, although in some areas, they may practice by themselves.

Pediatric nurse practitioners are nurse practitioners who have taken additional training in clinical pediatrics. They specialize in well-child care and the treatment of common illnesses. They tend to be very capable in the areas of children's development and emotional needs and parenting concerns and often conduct classes in these areas. All nurse practitioners refer serious problems to physicians.

Physician assistants graduate from a two-year program in which they learn many of the same skills as the nurse practitioner. Many have a medical background, having worked as a laboratory technician, respiratory therapist, or other health care worker.

In most states, nurse practitioners and physician assistants perform the same functions; however, although a nurse practitioner may prescribe medications, a physician assistant cannot do so without a doctor's approval.

Physician extenders often work in clinics or groups, with physicians available for consultation and referral. Many private physicians also employ physician extenders who see children in the office for routine health care. Physician extenders often can spend more time talking with you, answering your questions, and teaching you what you need to know.

Settings for Child Care

These healthcare professionals work in different settings with their own advantages and disadvantages. Private care, such as from your own physician, tends to be more personalized, more convenient, and more expensive. Children's health clinics cost less to those with low incomes and usually offer good care, although you may experience more waiting and less continuity of care with the same practitioner. Children's health clinics are largely staffed by physicians taking their specialty training in family medicine or pediatrics.

Well-child clinics, such as those sponsored by the public health department, provide free or low-cost checkups and immunizations, but usually little care for the sick child. They are often staffed by physician extenders.

After looking into the types of care, decide which you want to investigate and make appointments to get to know the people involved. Ideally, try to do this at least a few weeks before your baby is due.

Infant Healthcare Overview

One of the most important decisions you'll make about your baby's health is selecting his or her doctor. It's important to find a doctor you feel comfortable with -- someone whom you can talk to and who is willing to answer your questions. After all, you will turn to this doctor for help often, and even when your baby is healthy you'll be making regular visits. In the following pages you'll learn who the different doctors are, how they care for your baby, and how to pick the one that's right for you.

Infant Healthcare Providers

There are two main types of doctors who specialize in infant care: pediatricians and family practitioners. In addition to choosing between them, you'll also be choosing from among different settings for your child's health care. Find out how these two types differ from each other and from other healthcare professionals.


Choosing an Infant Healthcare Provider

Before you settle on a doctor, you'll want to know about his or her style, if he or she can work on your schedule, and who serves as backup if the doctor can't be reached, among other things. This page gives you many good questions to ask during your interviews with potential doctors for your baby.


Well-Baby Care

Once you've chosen the right person, he or she will want to see your baby often. During the first couple years of life, even visits for regular checkups are frequent. The doctor will want to check your baby's eyes, ears, nose, vital organs, arms and legs, and other things for normal development. On this page, you'll learn how often you can expect to see the doctor, and what to expect at these visits.