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To the Editor.—
Toilet training is normally considered a milestone in child development and rearing. Very little evidence-based literature is available on this topic, and many studies are retrospective or based on personal experience only. Therefore, we read with interest the prospective study by Blum et al,1 in which the authors discuss the relationship between age at initiation of toilet training and duration of training. One of the main issues in toilet training was age at initiation. Since Brazelton published his well-known paper in 1962,2 in western countries toilet training is started after 18 months of age ("later is better"), when motor milestones, psychological attitudes, and sphincter control are achieved. Recent American Academy of Pediatrics (AAP) toilet training guidelines recommend to start toilet training at 18 months of age as well.3 Moreover, there has been concern that early toilet training could be related to important adverse effects.2 However, other studies have shown that toilet training completion can be obtained much earlier and without any side effects when an early initiation is provided.4–7 An early toilet training is even recommended in cases of congenital vesicourethral reflux.8 Blum’s article is the first prospective study that confirms that earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal. However, the age of subject enrollment was between 17 and 18 months, which is according to AAP recommendations. Usually, toilet training is considered early if the initiation is before 1 year of age,4–6 when a different approach is provided. At this early age, the approach is based only on the cues and signals provided by the child to the caregiver and the timings of voidings. It is interesting to note that a child-oriented approach is accepted for toilet training only, not for education, eating habits, wearing cloths, and so on.
We would like to discuss the definition of "intensive" toilet training as well. According to the available literature, the mean number of voidings decreases from 
20 times per day during the first month of age to 10 per day at 3 years of age.9 Other recent literature has clearly confirmed these data.10–11 Thus, we think that children at 18 months need to be asked about toilet much more than 3 times in order not only to be "intensive" but also to follow their normal toileting habits. The best solution is to observe which is the stage of bladder maturation (eg, how many times the child voids) and then set the number of times we ask the child about going to the toilet.
One more comment is about subject enrollment, because the authors did not exclude those children involved in research market studies on diaper products. We would like to know more about the ethnicity of the subjects, which is related to different toilet habits and which is not described in the article.
The authors found that there was no difference in the percentage of side effects between the two groups and that early initiation correlates with longer duration and early completion. However, we noted that the percentages of side effects in the control group were always higher than the "early" approach group. Therefore, we wonder if these differences would have been greater with a proper intensive and earlier approach.
REFERENCES
Division of Gastroenterology and Nutrition Children’s Hospital of Philadelphia University of Pennsylvania Medical School Philadelphia, PA 19104, USA
In Reply.—
We appreciate Drs Rugolotto and Sun’s interest in our toilet training research. They correctly note that, within the context of children beginning toilet training after 18 months, we did not find any problems associated with earlier toilet training except that it took longer. In addition, it may have one potential benefit in that children completed toilet training at an earlier age. Drs Rugolotto and Sun also point out that toilet training that is based on caregivers recognizing signals and cues from the child can be completed much earlier than families even began training in our study. Clearly, our study offers no data on the advantages and disadvantages of this approach to toilet training, and our use of the term "early toilet training" is only used as a contrast to those who started later in our study. Although the type of early toilet training described by Drs Rugolotto and Sun is the norm in some cultures,1 if a parent’s goal is for the child to initiate elimination in the toilet independently, an approach that assures that the child has the skills to do this seems most reasonable. Drs Rugolotto and Sun suggest that this is somehow different than the approach that is taken for other skill-based child-rearing issues. We strongly disagree. In fact, most individuals easily accept a child-oriented approach to these other skills. We do not ask children to eat with utensils or dress themselves in the first year of life, and we do not encourage intensive behavioral interventions to teach these skills at that time. Why should toilet training be any different?
Drs Rugolotto and Sun also question our use of the word "intensive" to describe a situation in which parents are asking their child to use the toilet >3 times per day. Again our goal was to contrast this with the common situation in which parents are only asking their child to use the toilet at convenient times such as bath time and/or before getting dressed in the morning. We would agree that much more intensive approaches have been described in the literature2,3 and in no way intended to compare what the parents in our study were doing with these other approaches.
To our knowledge, none of the patients were participating in market research studies related to diaper products, although we did not specifically ask this question. We do not have racial or ethnic data other than what was already provided in the description of the sample.
Drs Rugolotto and Sun suggest that because those who began intensive toilet training (by our definition) before 27 months tended to have slightly lower rates of constipation, toileting refusal, hiding during training, and stool withholding, than those who started after 27 months, an earlier and more intensive approach may have been even more advantageous. This interpretation goes well beyond what can be supported by the data. All the differences discussed to support their interpretation were small, and none came close to being statistically significant (P > .10 in all cases). Furthermore, children were not randomized to early or late intensive training. Thus it is possible and perhaps likely that children whose parents began intensive training prior to 27 months differed from those whose parents elected to begin intensive training after 27 months and that these differences, as opposed to the intensity of the toilet training, account for the small differences discussed.
REFERENCES
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