Take it from a Pediatric Urologist: The UK’s New Potty Training Push Will Backfire
- Steve Hodges, M.D.
- 1 day ago
- 14 min read
By Steve Hodges, M.D.
Few topics spark more controversy than potty training, a developmental milestone that, in the age of social media, has become a competitive sport. Now the UK government has weighed in with a campaign asserting it’s “best” for children to ditch diapers between 18 and 30 months of age.
The campaign, while well-meaning, spells bad news for kids and, ironically, good news for the diaper industry.
The government's downloadable potty-training guide buys into common myths about bowel and bladder health and is sure to cause:
•More cases of enuresis (bedwetting and daytime wetting) and encopresis (chronic poop accidents)
•Greater need for extra-large — and extra expensive — pull-ups
•More cases of emotional and physical child abuse due to due parental frustration
How so? Well, the government’s directive will prompt many parents to initiate toilet training before their children are mature enough. As a result, more kids will develop chronic constipation, and this condition will go undetected. The unluckiest will develop enuresis and/or encopresis and spend many distressing years navigating the fallout. Nothing crushes a kid’s self-esteem like having accidents at school, avoiding slumber parties, or wearing pull-ups as a teenager.
Sounds alarmist, eh?
Folks who’ve never dealt with enuresis or encopresis in their own families will brush off my warnings. After all, the UK’s advice sounds so logical and reasonable. And the benefits of training a 1 ½- or 2-year-old seem hard to quarrel with: Save money on diapers! Save landfill space! Let teachers do their jobs, rather than waste classroom time dealing with their students’ diapers.
What could go wrong?
More than you can imagine.
The UK guide is based on such a fundamental misunderstanding of toilet training that I feel compelled to counter with my perspective, even if I’m shouting into the wind.
From the UK guide: We understand that all children develop at their own pace, but research shows it’s best for your child’s bowel and bladder health to stop using nappies, including reusable nappies, pull-ups and training pants, between 18 and 30 months,
My take: The guide does not cite any research supporting its claim, so I can’t analyze their evidence. (Convenient!) But as a pediatric urologist familiar with the published research, I can tell you this: It’s absolutely not “best for bowel and bladder health” to stop using diapers between 18 and 30 months or on any other specific timeline. Training a child on the younger end of this age range is especially risky business.
Now, there’s no bright line separating an inappropriate age from an appropriate age to toilet train. What matters is the child’s maturity, not age. Certainly, you can place a 1- or 2-year-old on the toilet at the right moment, and they will pee or poop right then and there. But using the toilet when instructed to do so is entirely different from having the judgment to respond promptly and independently to nature’s call.
That is the key to healthy bladder and bowel development.
Emptying your bladder when you feel the urge, typically every few hours, promotes healthy bladder growth in children. And evacuating your bowels fully, on a daily basis ,allows the rectum, the end of the colon, to maintain its sensation and elasticity.
But most toddlers, particularly those under age 2, do not possess the independent judgment I’m talking about.
Once children are introduced to the toilet, at whatever age, they make some enlightening discoveries: They can control when they poop and pee, and they have the power to override these urges with some timely squeezing.
Many young children capitalize on these newfound superpowers and begin to delay pooping (and peeing) in favor of more interesting pursuits, like finger painting or racing Matchbox cars. Pretty soon, a child who was pooping cow patties daily like clockwork is straining to squeeze out a big, hard log every other day. Constipation has commenced. Simultaneously, many kids start holding their pee, a habit that, over time, thickens the bladder wall and can lead to compromised bladder capacity and bladder over-activity.
But the UK’s potty guide overlooks this whole common scenario.
The push to toilet train between 18 and 30 months appears to be based on the “window of opportunity” theory, popularized by Oh Crap! Potty Training. As that book’s author explains it, there’s a “window of opportunity for effortless potty training,” and if you miss the window, you’ll end up with a “potty refuser.” According to Oh Crap, “It’s really hard to potty train children over three. They have free will and they know how to use it.”
The UK guide uses less provocative language to make the same point: “The longer you wait, the harder it can be for your child to learn the new routine and feel confident without nappies.”
This assumption is simply wrong.
When children over age 3 struggle with toilet training, it is not because they’re willful or so coddled by diapers that they “lack confidence” without them or can't "learn the new routine."
It’s because these kids are chronically constipated! X-ray their abdomens, as I do, and you’ll see a stool-filled rectum stretched to the point of losing sensation and tone. These children aren’t getting the signal to poop and can’t fully evacuate, anyway. Toilet training a child with a floppy rectum is futile and frustrating for everyone involved.
Research conducted at my clinic (not cited by the UK government!) points to the risks of potty training toddlers.
Our study of 112 children found that those toilet trained before age 2 had triple the risk of developing chronic constipation and daytime enuresis compared to children trained between ages 2 and 3. This was no surprise. Enuresis develops because the enlarged rectum presses against and aggravates the bladder nerves, causing the bladder to spasm randomly and empty without warning.
In addition, our study found that the children who trained after age 3 — the “late” trainers — were not, in fact, potty “refusers.” They were constipated, as confirmed by x-ray.
When kids struggle to potty train, parents are blamed for waiting “too long.” But our data and my experience suggest the opposite is true: Parents who wait longer do so because their kids are constipated. Most of these folks tried to initiate toilet training earlier but had to throw in the towel.
Many parents beam with pride when their children master the toilet before their peers, but having a potty prodigy can be a disaster in the making. The most seriously constipated among my patients tend to be those who trained earliest and most easily. In other words, they’ve been in charge of their toileting — when to hold, when to let it out — the longest.
The UK Guide: Make sure your child is not constipated – they should be doing a soft poo regularly (at least every other day). If you think your child might be constipated, it is important to get help with this before stopping nappies.
My take: Kudos to the UK government on this one! Problem is, their definition of constipation falls way short, so countless cases will go undetected.
Here’s the thing: a child can poop soft stool every day can still be severely constipated. Even children who meet the Rome IV criteria, a “gold standard” list of symptoms used to diagnose constipation, can be super backed up. That’s why I x-ray my enuresis patients.
But most doctors don’t, especially in the UK. (My private online support group includes many UK parents who simply cannot persuade their doctors to order an x-ray.) So, many children with enuresis and encopresis are under-treated or misdiagnosed, their conditions attributed to behavioral or psychological problems.
The push to toilet train at age 1 ½ or 2, in conjunction with the medical establishment’s failure to connect toileting accidents with constipation, puts children at risk for blame, shame, and physical abuse. I have a huge collection of media articles about children humiliated, beaten, burned, jailed, and even murdered after their parents became fed up with their accidents. Just this week, a Georgia woman was sentenced to life in prison for beating her 4-year-old to death because he was having accidents. This case isn’t an outlier.
While the UK guide recognizes that some children are constipated prior to toilet training, it disregards the fact that toilet training itself is prime time for constipation to take hold. Parents are usually none the wiser. Folks are so busy celebrating the prospect of a diaper-free future (I’ve been there!) that they don’t notice the subtle signs of a clogged rectum or, more likely, never learned about them.
From the UK guide: Some children will show signs that it is the right time to stop using nappies. For example, they may know and tell you when they are weeing and the gap between wees will be at least an hour. But many children will not show clear signs, and most will never ask to stop wearing nappies.
My take: Dismissing the concept of readiness is misguided, though common. Oh Crap! Potty Training mocks the idea, arguing that waiting around for these signs to surface causes “potty training drama.”
In my experience, children who show interest in using the toilet and notice a wet or dirty diaper are far less likely to struggle with toilet training than those who don’t. The process goes even more smoothly if the child can pull their pants on and off without help and communicate when they need to pee or poop. These kids have fewer barriers to responding immediately when the urge strikes.
Children tend to develop these abilities closer to age 3 than to age 2, and I urge parents to watch for these signs rather than declare, randomly, “Today we’re starting potty training!”
I’m not saying every child with no history of constipation will end up constipated if they toilet train at 20 months. Many kids skate by, no worse for the wear. But I’ve treated thousands of patients who did not.
From the UK guide: Toilet training is about learning skills, and these can be taught with extra help and/or a clear routine.
My take: This guidance sounds innocuous but is sneakily harmful. Toilet training is actually not about “learning skills”; it’s about having the wisdom to pee and poop when the urge strikes. That wisdom tends to come with maturity, not instruction.
Schools that assume potty training is about “learning skills” tend to establish policies that, inadvertently, lead to the humiliation of children and parents alike. I see this all the time. One of my patients was suspended from preschool at age 3 1/2 for having “too many” accidents. Her mom was told to “work more closely” with the girl and give her “more one-on-one attention” so she could master potty skills. But the girl didn’t need more training. She needed suppositories and laxatives to resolve the giant mass of stool that an x-ray showed was clogging her rectum.
Here's a preschool policy another mom showed me:
If a child has multiple accidents in a day or over a period of days, and we realize a child is not fully toilet trained, then we may ask that parents keep the child home for a week or two to complete toilet learning. If accidents persist, families may be asked to leave school.
Sending kids home for a week to work on their potty skills is like sending dyslexic children home for a week to work on their reading. The effort will fail, because lack of skill isn’t the problem. The term “not fully potty trained” is a misnomer.
READ: “Potty Regression,” “Potty Refusal,” “Not Fully Potty Trained": Why These Terms Should be Canceled
From the UK guide: It’s really important that children are out of all nappies well in advance of starting Reception year in school. The only exception should be children with a diagnosed medical need, such as a bladder or bowel condition.
My take: The above guidance will actually create bladder and bowel conditions! But in most cases, the “medical need” will go unrecognized.
Now, I agree that children with a healthy bowel and bladder should not be wearing diapers at age 4, the typical age UK children begin Reception. The problem lies with the terms “really important” and “well in advance.”
These directives will prompt many parents to initiate training as early as 18 months, especially given the UK’s assurances that “readiness” is irrelevant. Naturally, parents will want to ensure their child has loads of time to master potty “skills” before school starts. But here’s the rub: Potty training isn’t an ability, like riding a bike, that gets locked in once things “click.”
Things can unravel big-time. A child who nailed potty training at age 2 may become a kindergartener with severe daytime enuresis and/or encopresis and soaked pull-ups every night. What appears to be potty training “regression” is actually a progression of constipation.
This progression goes unnoticed because most constipated children don’t tell their parents or teachers they’re having difficulties. Most have no idea something is amiss, especially if painful pooping is all they’ve experienced. (That was my experience as a child.) And the early signs of constipation — the need to pee urgently or too frequently, for example — are not well known to adults.
It is quite common for constipation to take root and/or escalate during preschool or kindergarten. Preschool often marks the first time children are spending the day, or half a day, away from family. They may not feel comfortable interrupting their teacher during story circle to announce they need to go potty or may not want to climb out of their awesome fort to journey over to the restroom.
They may decide, subconsciously, that it’s just easier to squeeze that poop back where it came from and save the whole hassle for another day. When this becomes habit, stool piles up in the rectum, forming a hard, dry mass that makes pooping hurt. Pooping becomes an even lower priority — until the child loses the ability to sense the urge altogether.
It can take a few years before the rectum becomes enlarged enough to trigger accidents. So, it’s no surprise kindergarten is often when enuresis or encopresis surfaces or accelerates. In elementary school, students suddenly have fewer toileting reminders, more worries about interrupting the teacher, greater odds of being teased, larger and more intimidating restrooms, and more hours away from home. Constipation that may have been held at bay often reaches a point of critical mass, literally.
The UK guide: 83% of children were out of nappies by 18 months in the 1970s and 1980s. Today, 1 in 4 children aren’t toilet trained when they start Reception.
My take: Lots to unpack here! Let’s start with the second part: that 25% of UK children aren’t toilet trained by age 4. To use a Britishism, poppycock! Or, another one of my favorites: Bullocks!
First of all, this statistic assumes children in pull-ups “aren’t toilet trained.” But virtually all these kids have indeed been instructed on the ins and outs of using the toilet, usually by conscientious parents who wonder, “What am I doing wrong?”
Second, I do not believe that 25% of UK 4-year-olds wear pull-ups to school. I have never seen a published study supporting this or any similar figure, even though numbers like this and bandied about in the media.
Heck, every fall, when school starts, my "potty training" Google alert sends me a new version of the same old story. Here's a sampling:
•Teachers wasting time potty training kids because parents are too lazy or busy to teach them at home” (2016)
But when you look closely, this “concerning education trend” always comes down to a handful of teachers reporting that a handful of their students are show up at school in pull-ups. When a Utah legislator proposed a law requiring children to be toilet trained prior to entering kindergarten, the media reported classroom accidents in Utah had “sharply increased” or even “doubled.” But when asked to provide data, the lawmaker admitted, “It’s largely anecdotal right now.”
Meantime, the small minority of parents whose children really do need to wear pull-ups to school are vilified in social media. One commenter called the mom of 3-year-old in pull-ups a “lazy person who wants to dump the kid off so she can shop and drink Starbucks.” Another posted, “It’s narcissistic for parents to insist that their untrained child has to be indulged.”
While the UK guide offers a supportive tone, it’s not a huge leap from “It’s really important to train your child between 18 and 30 months” to “If your 3-year-old still wears pull-ups, you’re a drain on society.”
What about those statistics from the 1970s? Well, it’s true that in that half a century ago, children were out of diapers earlier. But 50 years ago, far fewer kids spent all day away from a parent. In 1970, just 20.5% of 3- and 4-year-olds were enrolled in preschool (for 3-year-olds alone, the figure was 12.9%); 45 years later, the figure was 52%.
In 1967, 10% of kindergarteners attended full-day programs; in 2018, the number was 81%. In some states, like Oregon, virtually 100% of kindergarten classes run all day.
I totally support full-day kindergarten! But many of my patients will not use the toilet at school, ever. They routinely hold their pee and poop 8+ hours. This is a habit most developed in preschool or kindergarten.
Bottom line: When you’re a toddler at home with a parent most of the day, the barriers to successful toilet training are far lower than when you’re in daycare or preschool. The ubiquity of preschool is not the only reason more children today struggle with constipation toilet training than they did half a century ago — for example, today’s ultra-processed, constipating diets don't help. But the 21st century is not the time to be pushing parents to toilet train their 18 months-olds.
The statistics cited by the UK government do not support their push for early toilet training. Comparisons 1970 are misleading.
The UK guide: Every year £400 is spent by British families on nappies and wipes alone - potty training earlier would save you all of that.
My take: Boy, I could introduce you to loads of parents whose adventures in early toilet training cost them a fortune that would not otherwise have been spent. One UK mum posted in our private online support group: “[Our daycare] kept pushing and starting doing nappy-free time there, so we felt we had to stop nappies at home, too. All the mums in the mum's groups were talking about toilet training. I still regret toilet training so early. It seemed initially successful, but she ended up with constipation, daytime and nighttime wetting.”
Another mom posted: “I was influenced by another mom to start at age 2. My son was fine for about 2 to 2.5 years. He pooped daily and had no accidents. Then the accidents came. Almost 3 years later we are still dealing with this.”
Children with enuresis and encopresis go through more pull-ups than you can count. Many who parents wait for their child to “outgrow” accidents end up purchasing XXL pull-ups for an extra decade.
Meanwhile, the diaper industry invests heavily in advertising campaigns to normalize bedwetting so parents don’t question the purchases. Goodnites calls their extra-large pull-ups Nighttime Underwear, as if it’s no big deal for a 13-year-old to need their product. Pampers' Ninjamas campaign features a British pediatrician telling kids bedwetting is of no concern: "Don’t worry, it’s fine,” and “Don’t fret. It’ll stop eventually.”
To its credit, the UK potty guide instructs parents to speak to speak to a healthcare professional if their child isn’t dry at night by age 5. Unfortunately, in my experience, these visits do not result in appropriate treatment, as many healthcare professionals assure parents, “Don’t worry, she’ll outgrow it,” or at best, offer inadequate treatment such as PEG 3350 (Miralax).
Doctors either overlook the connection between constipation and accidents or dramatically underestimate the extent of the constipation, so kids end up on the Miralax merry-go-round, missing out on treatments that will relieve them of the need for pull-ups. The “cost savings” argument is a fallacy.
The UK guide: Once your child has stopped using nappies in the daytime, it’s time to think about nap times. Being nappy free at nap times will help prepare your child to be dry at night. . . Most children are dry at night by the age of 5, but for some it can take longer.
My take: You can’t “train” a child to become dry during naptime or at night. Dryness develops naturally. If it doesn't, you can bet the child is constipated.
The UK guide claims parents can promote dry nights by restricting fluids an hour before bedtime and establishing a consistent bedtime routine. Again, poppycock! If these remedies actually resolved an overactive bladder, my clinic would not exist. Children with a healthy, stable bladder can drink water right before bed and have no problem staying dry till morning.
The UK guide also urges parents to “avoid waking your child and taking them to the toilet as this encourages them to wee during sleep.” Whoever wrote that is confused. I agree overnight wake-ups are a bad idea — this practice does nothing to remedy enuresis and only disrupts the child’s sleep. However, wake-ups do not “encourage” the child to “wee during sleep.” That’s nonsense.
Much of the UK’s guide is nonsense, and I worry about the damage the campaign will do to British families.
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