The association of age of toilet training and dysfunctional voiding

Bowel and bladder function in infant toilet training (BABITT) - protocol for a randomized, two-armed intervention study

BACKGROUND

In the last decades, the average age for toilet training has increased in the western world. It is suggested that the postponed initiation of toilet training is a contributing factor to problems related to bowel and bladder control. Functional gastrointestinal and urinary tract disorders are prevalent in childhood, causing suffering in affected children and for their families, and consuming healthcare resources. To evaluate whether assisted infant toilet training can prevent functional gastrointestinal and urinary tract disorders in young children, we are conducting a randomized intervention study with a 4-year follow-up.

METHODS

This randomized two-armed intervention study will include 268 Swedish infants recruited at six child healthcare centers in Region Dalarna located in the central part of Sweden. The intervention entails parents being instructed and practicing assisted infant toilet training with their child. Children are randomized to start assisted infant toilet training at 0-2 months or at 9-11 months of age. The primary objective is to determine the efficacy of assisted infant toilet training initiated at 0-2 months on the prevalence of functional gastrointestinal disorders (defined as infant colic, infant dyschezia and/or functional constipation) up to the age of 9 months. Secondary objectives are to evaluate whether assisted toilet training initiated during the first year of life reduce the prevalence of functional gastrointestinal disorders (defined as functional constipation, gastrointestinal symptoms and/or stool toileting refusal) and urinary tract disorders (defined as bladder dysfunction and/or urinary tract infections) up to the age of 4 years. Furthermore, infant-to-mother attachment, parental stress, the toilet training process and overall parental experiences will be evaluated/explored.

DISCUSSION

This protocol article presents the rationale and design of a randomized two-armed intervention study that will determine the efficacy of assisted infant toilet training on functional gastrointestinal disorders up to the age of 9 months. Furthermore, the study will evaluate whether assisted infant toilet training during the first year of life can prevent functional gastrointestinal and urinary tract disorders in children up to 4 years of age. If effective, assisted infant toilet training could be recommended in child healthcare settings and new evidence-based guidelines on infant toilet training could be implemented.

TRIAL REGISTRATION

The study protocol was retrospectively registered at ClinicalTrials. gov  ( NCT04082689 ), initial release June 12th, 2019).

Personal and familial factors associated with toilet training

Purpose:

Toilet training (TT) is an important marker in a child's physical and psychosocial development. The present study aimed to evaluate aspects associated to delayed TT.

Material and Methods:

We interviewed 372 parents of children who had completed TT up to 48 months before the interview. The questionnaires were applied at school exits when parents went to pick their children up and at public parks. Questions included demographics, aspects related to TT, dysfunction voiding symptom score and evaluation of constipation.

Results:

The interviews were performed at a mean of 15.3±10.4 (0 to 47) months after the end of TT. Girls accounted for 53% of the sample. The mean age at finishing TT was 31.6±9.3 months and similar in both genders (p=0.77). TT occurred before school entry in 45.7% of the children and medical advice for TT was sought only by 4.8% of the parents. No association was observed of age at completing TT and presence of lower urinary tract symptoms (LUTS) (p=0.57) and/or constipation (p=0.98). In the univariate analysis, prematurity (OR=2.7 [95% CI 2.3-3.1], p <0.0001) and mothers who work outside their household (OR=1.8 [95% CI 1.4-2.3], p <0.0001) were associated to delayed TT.

Conclusion:

Children completed TT at a mean of 2 years and 7 months of age. The age of completing TT was not related to LUTS and/or constipation. Premature children and those whose mothers work outside the home finish TT later.

Prevalence and risk factors of nocturnal enuresis among children ages 5-12 years in Xi'an, China: a cross-sectional study

BACKGROUND

Nocturnal enuresis (NE) has a negative impact on children's health and imposes a long-term burden on families. With economic development and cultural improvements, parents and medical professionals pay more attention to NE. The aim of this study was to investigate the prevalence and risk factors of NE among children ages 5-12 years in Xi'an, China.

METHODS

A stratified cluster sampling method was used to conduct a cross-sectional study of NE in 10 kindergartens and 20 primary schools in Xi'an. We used univariate analysis to compare the prevalences of characteristics such as gender, duration of disposable diaper (DD) use, toilet training onset time, daily living habits, academic performance, and family history of NE. Logistic regression analysis was used to calculate odds ratio and to determine risk factors of NE.

RESULTS

The study included 6568 children ages 5-12 years, of which 262 (3.99%) had NE. The prevalence rates of NE decreased with age, with the highest prevalence at age 5 (9.09% for boys; 6.03% for girls). However, the prevalence increased with duration of DD use. Children experienced more NE if they never accepted toilet training (7.83%) or if they drank sugary beverages during the day (5.36%). Sleep disorders, sweets intake, drinking low amounts of plain water during the day, and family history of NE, were statistically associated with NE.

CONCLUSION

NE was closely associated with a family history of NE, being male, long-term use of DD, delayed toilet training, drinking sugary beverages and/or consuming little plain water, and sleep disorders. A supportive parental attitude towards NE and timely medical treatment can improve the quality of life of enuretic children.

A prospective cohort study of biopsychosocial factors associated with childhood urinary incontinence

The objective of the study was to examine the association between biopsychosocial factors and developmental trajectories of childhood urinary incontinence (UI). We used developmental trajectories (latent classes) of childhood UI from 4-9 years including bedwetting alone, daytime wetting alone, delayed (daytime and nighttime) bladder control, and persistent (day and night) wetting (n = 8751, 4507 boys, 4244 girls). We examined whether biopsychosocial factors (developmental level, gestational age, birth weight, parental UI, temperament, behaviour/emotional problems, stressful events, maternal depression, age at initiation of toilet training, constipation) are associated with the trajectories using multinomial logistic regression (reference category = normative development of bladder control). Maternal history of bedwetting was associated with almost a fourfold increase in odds of persistent wetting [odds ratio and 95% confidence interval: 3.60 (1.75-7.40)]. In general, difficult temperament and behaviour/emotional problems were most strongly associated with combined (day and night) wetting, e.g. children with behavioural difficulties had increased odds of delayed (daytime and nighttime) bladder control [1.80 (1.59-2.03)]. Maternal postnatal depression was associated with persistent (day and night) wetting [2.09 (1.48-2.95)] and daytime wetting alone [2.38 (1.46-3.88)]. Developmental delay, stressful events, and later initiation of toilet training were not associated with bedwetting alone, but were associated with the other UI trajectories. Constipation was only associated with delayed bladder control. We find evidence that different trajectories of childhood UI are differentially associated with biopsychosocial factors. Increased understanding of factors associated with different trajectories of childhood UI could help clinicians to identify children at risk of persistent incontinence.

Early Behavioral Risks of Childhood and Adolescent Daytime Urinary Incontinence and Nocturnal Enuresis

OBJECTIVE

To investigate whether infant temperament and childhood internalizing, externalizing, and inattention symptoms increase the likelihood of daytime urinary incontinence or nocturnal enuresis at 10 years and adolescence (11.9-17.8 years).

METHOD

Data were from a longitudinal cohort of 1119 healthy Chilean children. We assessed behavioral symptoms at infancy, 5 years, and 10 years and their relationship with subsequent daytime urinary incontinence and nocturnal enuresis.

RESULTS

Daytime urinary incontinence and nocturnal enuresis occurred in, respectively, 3.3% and 11.4% at 10 years and 1.1% and 2.7% at adolescence. Difficult infant temperament was associated with increased odds of 10-year daytime urinary incontinence. Inattention at 5 years was associated with increased odds for nocturnal enuresis at 10 years and adolescence. Internalizing and externalizing symptoms at 5 years were associated with increased odds of 10-year daytime urinary incontinence and nocturnal enuresis. Internalizing and externalizing symptoms at 10 years were associated with adolescent nocturnal enuresis.

CONCLUSION

Temperament and internal/externalizing symptoms may be risk factors for school-age and adolescent urinary incontinence.

Stressful Events in Early Childhood and Developmental Trajectories of Bedwetting at School Age

Objective To examine whether early stressful events are associated with developmental trajectories of bedwetting. Methods This is a prospective cohort study comprising 8,761 participants from the Avon Longitudinal Study of Parents and Children. Stressful events were measured using a maternal questionnaire completed at 3 time points before their child was 4 years old. The association between stressful events and trajectories of bedwetting from 4 to 9 years was examined using multinomial regression. Results The association with stressful events was strongest for the frequent persistent bedwetting trajectory (wetting at least twice a week up to age 9). A 1 standard deviation increase in the stressful events score was associated with a 29% (13–47%) increase in the odds of experiencing frequent persistent bedwetting compared with normal attainment of nighttime bladder control. Conclusions Clinicians and parents should be aware that continence is a developmental outcome that is associated with high levels of stress in the family.

Lower Urinary Tract Dysfunction in Elementary School Children: Results of a Cross-Sectional Teacher Survey

PURPOSE

Lower urinary tract dysfunction in school-aged children is common and yet data are lacking on current teacher practice regarding bathroom use and daytime incontinence during classroom hours. We determined the prevalence of elementary school teachers who promote lower urinary tract health and identified predictors for and against such behavioral promotion.

MATERIALS AND METHODS

We performed an electronic cross-sectional survey among self-identified teachers using targeted social media advertisement during a 1-week period in July 2014. The empirical survey tool consisted of 27 questions and collected data on 5 principal domains, including 1) teacher demographics, 2) rules and regulations on water intake and bathroom use during classroom hours, 3) characteristics of school bathrooms in terms of safety, supervision and suitability for use, 4) experience with and management of students with daytime incontinence and 5) training on the topic of lower urinary tract health. Predictors for promoting lower urinary tract health were identified by multivariable logistic regression.

RESULTS

Of the 4,166 teachers who completed the survey 88% indicated that they encourage students to hold urine. Despite strict bathroom protocols 81% of teachers allowed children unlimited access to water. Of the teachers 82% reported never having undergone any professional development on bathroom regulations for children. Overall only 24% of surveyed teachers met criteria for promoting lower urinary tract health. The odds of promoting lower urinary tract health decreased with ascending grade level (OR 0.80, 95% CI 0.76-0.84). Conversely it increased if teaching experience was greater than 5 years (OR 1.66, 95% CI 1.39-1.98) or professional development on the subject had been received (OR 1.42, 95% CI 1.18-1.70).

CONCLUSIONS

Of elementary school teachers 76% are not promoting lower urinary tract health in school-aged children. Professional development training on the topics of lower urinary tract dysfunction and/or lower urinary tract health may be beneficial, particularly for educators who teach higher grades and those with less teaching experience.