As a group of early years professionals, paediatric nurses, researchers and child development experts, we must respectfully challenge Dr Hodges’ recent claims about early toilet training in your ‘Big Debate’.
Dr Hodges asserts that children trained before age two have ‘a significantly elevated risk of developing chronic constipation’. However, the available research evidence suggests the opposite. A 2017 study of over 1,200 children found a significant association between constipation and older age of starting toilet training (Albaramki et al.). Similarly, a comprehensive review by Li et al. (2020) of over 24,000 children found that initiating toilet training after 24 months may lead to a higher prevalence of lower urinary tract dysfunction.
We agree wholeheartedly with Dr Hodges that constipation is a serious issue that can cascade into various toileting problems. However, this is precisely why we advocate for earlier awareness and involvement in children’s toileting. A gradual, child-centred approach beginning when a child can sit independently (typically six to nine months) allows caregivers to spot and address potential issues early, while helping children develop body awareness and positive associations with toileting.
This approach is fundamentally different from intensive training methods. We wouldn’t expect a child to go from never having walked to running marathons in three days. Similarly, toilet learning is a gradual process that builds on developing skills and awareness over time.
Both UK and international research supports this perspective. A large UK prospective study following children from birth to age seven found that children toilet trained before age two were more likely to achieve daytime bladder control by age five compared to those trained later (Joinson et al., 2009). This aligns with findings from other cultures: Vietnamese children demonstrated significantly more bladder control than their Swedish peers at 12 months (Duong et al., 2013), while research from Thailand showed successful completion of toilet training by an average age of 1.9 years (Benjasuwantep and Ruangdaraganon, 2011).
For early years settings, this evidence-based approach means working proactively with parents to support gradual skill development from an early age, rather than waiting for signs of readiness. This aligns with how we approach other developmental milestones – offering consistent, gentle opportunities to practise and build confidence over time.
The current crisis in school readiness, where significant teaching time is lost to toileting support, demonstrates the urgent need for evidence-based approaches. We call on early years settings to embrace their crucial role in supporting earlier toilet learning, ensuring better outcomes for children’s health, development,and education.
Signed on email
by Cheryl Hadland, chair, GECCO.org.uk; Sam King, CEO, Tops Day Nurseries Ltd, Aspire Training Team; Professor Catherine Meehan FRSA, president, OMEP UK; Rebecca Mottram, children’s nurse and specialist potty training expert, Go Potty;
Zoe Raven, CEO, Acorn Early Years; Caroline Taylor, CEO, Merrygorounduk (Bright Bots); Alina Lynden, postgraduate researcher and independent potty training consultant; Elisabeth Whitebread, founder, Sprout Innovation; Peter Williams, founder, ecbabies.org; Laura Tingey, head of early years and compliance, Acorn Early Years
Caring for twos
Re: ‘Early years staff admit to lacking confidence to lead a two-year-old room “effectively”’ (NW online, 9 January)
This very important stage creates lots of big emotions that means that children need lots of help in regulating themselves. Co-regulation, good modelling, simple consistent language and professional love helps. Staff
that are calm, always have the interest of the child at the heart of everything they do, provide
a safe space will allow toddlers to grow and learn.
Empowering staff to feel more confident in their abilities is key. Rather than throw someone in at the deep end, take the time to get them to watch you, then try for themselves and let them give you the answers.
Remind staff to play to their strengths and show passion to children. If they love to read books, dance, do art, gardening or theatre shows, bring these things to life.
Sarah Camp, by email
