Handy guide Toilet training

Promoting healthy bladder and bowels

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For Parents, Health Visitors, Public Health Nurses�and Community Nursery Nurses

Advice for parents Are you ready?

Are you able to prioritise the time? Its good to have a quieter time where you may be at home more to give your child time to support toileting.

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Read story books on toilet training and/or apps with your child so they are aware of what to do, also keep it fun, you may want to think of a reward system that works for you and your child.

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Is your toilet suitable? Is it welcoming? What equipment works best for you? Do you need a toilet seat and step or do you want to try a potty or both?

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Keep all equipment for toileting in your bathroom so your child sees that toileting happens in a bathroom. Consider a referral to OT for children who may need additional equipment.

Pull ups vs pants vs nappies? Pull ups are just like a nappy they are just a different shape. Using nappies/pull ups could cause confusion and prolong the process unnecessarily.

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Pants will become wet so be prepared for accidents - they will happen!

Have lots of spare pairs of pants on hand.

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You need to have clothes for your child that they are able to pull up and down easily.

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Be consistent

Questions for parents

• Is your child aware of wees and poos?
• Do they have a regular, working bowel with no signs of constipation?
• Do they eat a good balanced diet and drink plenty of fluids to keep their bowels and bladder working well?
• Have you noticed that they are able to hold their bladder for several hours, with dry nappies or pants?
• Can your child manage their own clothes and dressing when they use the toilet? If not you can begin to practice this
• Can your child manage to wipe themselves? This may take time and lots of practice so its good to start encouraging self care skills like Washing their hands and flushing the toilet.

Advice for parents Adult led

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• Avoid saying ‘do you need the potty/toilet?’ �Say ‘it’s time to use the potty’ every 2 hours
• Child to sit on toilet or potty for a minute of their age
• Have a selection of toys or books within the bathroom to keep child occupied when sat on toilet/potty
• Stay with your child when they are sat on the toilet/potty Talk to them, sing to them
• Boys to be sat on toilet. This is important as the language around wees and poos might mean that they ask do  a wee but may in fact mean a poo.  Also standing for wees may contribute to constipation and stool withholding
• Remember to reward each step however small, keep it positive and be aware of how you are feeling. Have realistic expectations- your child is learning a new skill so this may take time.

The correct way to sit on the toilet

• Children need to feel secure when they are sat on the toilet
• Their feet need to be secure on the ground or step
• Their knees need to be higher than hips or semi-squat
• They should lean forward with their elbows resting on their knees.

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Things to watch out for!

If a child is leaning back, they could be stool-withholding.

Keep the fluids up keep the bladder full

Water is best or alternatively sugar-free, very diluted squash

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Minimum 6-8 glasses a day*

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Keep water available throughout the day

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Avoid fluids with caffeine in such as tea, coffee, fizzy drinks and limit milk to 2-3 small cups a day.

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Eat 5 portions of fruit and vegetables*

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Watery fibre may be good for some children such as cucumber, watermelon, melon

Eat a balanced diet

• Having a balanced diet that includes fibre from fruit, vegetables, cereals (like oats, wheat and bran) and wholemeal bread keeps the bowel healthy
• Fibre helps to retain fluid in the poo and will keep it soft and easier to push out
• Include a variety of high-fibre foods in the family’s diet such as wholemeal/granary bread, fruit and vegetables
• Include dried/canned fruit in natural juice, fresh fruit eaten with the skin on as well as vegetables, particularly beans, peas, sweetcorn and pulses such as lentils
• Choose a higher-fibre breakfast cereal such as Weetabix or plain shredded wheat, or porridge
• 2 to 5 year olds need around 15g of fibre a day*

Keeping active

Exercise sends blood to the gastrointestinal tract which helps move food waste through the bowels quickly and easily

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Running around and playing will help keep the bowels healthy. Aim for 30 minutes of activity a day

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Lack of physical activity can cause your child’s bowel to become sluggish and lead to constipation.

Bowels What is normal?�Normal is type 4, 3 times a day to

4 times a week

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• Refer to Bristol Stool Scale (see image) to identify stool type
• Check how often stools are passed per day/week. Use Bowel chart on N drive to record for 2 weeks and complete on S1 continence template
• Consider size: large, med, small?
• Does child experience pain or distress on passing stool?
• Record where stool is passed toilet, nappy, pants?
• Are the pants clean or soiled? if soiled how often ?
• Note any current medication

Symptoms constipation in children�

Two or more of the following resulting in ‘yes’ answers indicates constipation

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• Does the child have a bowel movement fewer than 3 times a week?
• Does the child pass large, hard stools?
• Does the child pass rabbit droppings? type 1?
• Have you noticed any soiling?
• Does the child have a poor appetite that improves after passing a stool?
• Does the child experience abdominal pain that comes and goes with the passage of stool?
• Is there evidence of retentive posturing? Straight-legged, tiptoed, back arched?
• Does the child have anal pain? Bleeding? Cracks or tears?

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Other indicators constipation

• regular and foul-smelling wind
• foul-smelling stools
• a painful tummy or bottom
• a distended (i.e. swollen or bloated) tummy
• lack of energy
• unhappy, angry or irritable mood
• day or night time wetting
• urinary tract infection 

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Soiling What is it?

• Severe constipation can cause faecal impaction When a very big poo or build-up of poo gets stuck in the rectum, the lowest part of the bowel
• Faecal impaction causes the rectum to stretch and the sensation of needing the toilet is reduced. When stretched, the rectum becomes floppy, making it more difficult to pass a large poo
• Impaction can lead to faecal soiling or overflow where small bits of poo break off into the child’s pants or soft, sometimes runny poo leaks around the large blocked mass in the rectum. Soiling is often mistaken by parents for diarrhoea
• A child who soils shouldn’t be seen as lazy; they have no control over it, can’t feel it and often don’t smell it either

GP When to refer

Sometimes when things don’t go to plan there can be a medical reason so it is always good practice to refer to the GP for ongoing issues such as:

• For treatment of constipation and soiling Medication may need to be prescribed by the GP
• Suspected Urinary Tract Infection Urine needs to be tested and if infection is detected then medication will need to be prescribed by the GP
• Stool withholding if ongoing, this could lead to constipation and impaction. This will also need to be assessed by GP to ensure no physical or medical reason for the child to be withholding
• Pooing in the nappy This may need further investigation as, amongst other things, it could be an indicator of constipation (overflow).

Additional needs �Planning a toilet training programme

• You may have to start by putting your child on the toilet at 1.5 hours to catch any results or 20/30 minutes after a meal and before bed.
• What toys or objects will keep your child sat on the toilet for a short amount of time?
• Work out a way of communicating ‘it’s time to use the toilet’ This can be by Makaton signing, Picture Exchange Communication (PEC’s), by using an object of reference or verbally
• Reward your child for small steps no matter how small
• Dress your child in clothes that are easy to remove
• Keep you routine regular It may take a lot longer for each small step but keep going and don’t give up!

Emotional issues The impact on a child’s ability to be fully toilet trained

• For some children if there is a regression in toilet training progress this can be a sign that all is not ok for them
• Have there been changes in your child's life? From changing rooms in nursery or a bereavement?
• Life circumstances can impact on all children differently Some children could regress and wet or soil, some could withhold leading to constipation.
• Are parents struggling to manage emotionally with wetting or soiling or do they need support?

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Be aware In some situations regression in toileting could be a sign of possible safeguarding concerns.

References and other resources

Advice, resources and support for parents and professionals

www.eric.org.uk

www.bbuk.org.uk

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History taking (p11)

www.nice.org.uk/guidance/cg99

Overview | Urinary tract infection in under 16s: diagnosis and management | Guidance | NICE

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Food and drink guidance (p7, 8)

www.nhs.uk/news/food-and-diet/six-to-eight-glasses-of-water-still-best

www.nhs.uk/change4life/food-facts/five-a-day

www.nhs.uk/live-well/eat-well/the-eatwell-guide

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References and other resources

• Toilet training

ERIC's Guide to Potty Training | ERIC

Thinking about wee and poo now you've reached the age of 2 | ERIC

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• Constipation and soiling

Bowel Resources - Bladder & Bowel UK (bbuk.org.uk)

Guides to children's bowel and bladder problems | ERIC

Bladder & Bowel UK’s metaphorical stories about Henny

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References and other resources

• Day and night time wetting

Bladder Resources For Children - Bladder & Bowel UK (bbuk.org.uk)

Bladder & Bowel UK’s metaphorical stories about Elly

Bladder and Bowel UK’s bladder resources for children

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• SEND and Sensory

Guides to children's bowel and bladder problems | ERIC

Bladder and Bowel UK’s ready or not toilet training resource for children with additional needs

RADAR Key for Accessible Toilets | Disability Information Bureau (dibservices.org.uk)

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References and other resources

Constipation - Soiling and treatment (p13)

www.youtube.com/watch?v=9WqxJqLmKao

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• SEND and Sensory
• www.cerebra.org.uk/help-and-information/guides-for-parents/toilet-training

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• Radar Key scheme for SEND www.disabilityrightsuk.org/shop/official-and-only-genuine-radar-key
• Poo goes to Pooland app https://play.google.com/store/apps/details?id=uk.nhs.ntw.poogoestopooland&hl=en_GB

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More information on the Gloucestershire Hospitals NHS Foundation Trust Paediatric Bladder and Bowel Care Team can be found here>

Contact the team:

Email: ghn-tr.paediatricbladder-bowelproducts@nhs.net  for product enquiries�Email: ghn-tr.paediatricbladder-bowelcareteam@nhs.net for general enquiries or referrals 

Tel: 0300 422 5308

• The NSPCC has some guidance on understanding continence issues and providing care on their Learning pages: Continence issues and safeguarding | NSPCC Learning
• Bladder and Bowel UK has some interesting resources for managing continence in schools here>

Professionals links