It is seen as absolutely normal and acceptable for a child to still have accidents up to the age of five. Developmentally they should be able to control their bladders when they are about six, during the day and also during the night. When they struggle to do this a diagnosis of enuresis might be considered by your physician. There are many physical problems that should be excluded by a medical professional before this diagnosis can be made:

• An urinary tract infection
• Constipation
• Small bladder
• Diabetes
• Slow development of the Central Nervous System
• Hormonal problems
• Abnormalities in the urethral valves in boys or ureter in boys and girls
• Abnormalities of the spinal cord
• Stress.

Enuresis is seen as primary when the accidents continue from baby years on, or as secondary when it starts happening after your child had six months of being accident free. Enuresis seem to be more common with boys than girls and includes both involuntary and intentional accidents.

How can I help my child?

• Limit your child’s fluid intake before bedtime
• Get him to go to the loo at the start of the bedtime routine and again just before going to bed
• A reward system for dry nights or days, for instance a sticker chart, works very well
• Get your child to help you to change his clothes and sheets or let him sleep in his own bed on towels to not wake him too much with the changing of sheets
• Night lights and a lit bathroom helps children feel safe to find their way to the toilet
• Some parents feel that waking their child to go to the loo, just before they go to bed, prevents accidents
• Constipation should be treated, because it can lead to accidents
• Refrain from giving any caffeinated drinks before bedtime
• Do not revert to using diapers at night
• Bed wetting alarms teaches children to wake up when they wet their beds
• DO NOT PUNISH your child for accidents, it will only lead to low self esteem and cause more stress for your child
• Assure your child that accidents can happen to anyone.

When should I consult my doctor?

• It is necessary to go to the doctor when your child suddenly start having accidents after being dry for six months.
• When he starts wetting his pants during the day
• When accidents are accompanied by misbehavior at home or at school
• When he complains of burning when he urinates or when he has to urinate more frequently than usual
• When he eats or drinks more than usual (possible indication of diabetes)
• Swelling of the feet or ankles
• A child who has accidents after the age of 7 warrants a doctor visit.

Treatment usually involves behavior modification and medication should really only be considered as a last resort, seeing that this will usually resolve itself.

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The debate hinges around issues like when the right time it to potty train your child and how long the process should be.  Some theorists believe leave your child naked and a victim of his own wee and poop, whilst others believe that the child should set the pace.  All this confusion and frustration building up between the will of the parent and the natural response of the child, led to the point where potty training problems currently are the 2nd most common provocation for fatal child abuse in the US.

Just to add to the debate, I decided to share my take on potty training.  The following are the abilities your child will need to be able to start potty training from a physical perspective:

• He must be able to sit
• He must be able to walk
• He must be able to stand independently
• He must have the ability to follow simple instructions
• He has to have the physical dexterity to pull down his pants.

From a more emotional aspect it is necessary for a child to show an interest in potty training and the toilet, as well as being cooperative.

Indicators that your child is ready to be toilet trained in addition to the above is:

• When there seems to be some bladder control. This is when you find that the diapers stay dry for periods of 2 – 3 hours at a time.
• When his bowel movements come at predictable times.
• When your child asks to be changed or indicates that he feels uncomfortable in the dirty diaper.
• When expresses interest in underwear and how toilets work.

My suggestions as to the HOW is:

1. Buy a potty.  Involve your child in the purchase.  If he shows more of an interest in the toilet than a potty, let him choose the inner seat of the toilet and a bench to reach it easily.  Make it clear to your child it is his – give him a sense of ownership.
2. Change your child’s diapers often in order for him to get used to the feeling of being dry.  It might be advisable to switch to cheaper diapers at this point to emphasize the feeling of being wet or soiled.  New expensive diapers draw fluid away from the skin and lock it underneath a protecting layer.
3. Start a routine of sitting on the potty.  Your child has to be comfortable with the potty.  Start off sitting on the potty fully clothed, moving to sitting on it with a diaper and then bare-bottomed.  Do not ever force your child to sit on the potty.
4. Model toilet behavior to your child. Let your child accompany you to the loo.  Show them how to wipe, flush and put the toilet seat down.  Answer all questions honestly.
5. Teach him toilet words.  There are many different ways to refer to urinating and bowel movements, choose the ones that you feel comfortable with.
6. Start putting your child on the potty at times when you suspect that he would need it.  After nap time and about 20 minutes after meals are usually good times to start with.
7. I took both my children to the potty once every 30 to 40 minutes.  I allowed them to sit for as long or short as they wished for.  Never prevent a child from getting up from the potty.
8. Keep an encouraging attitude despite accidents.  More important:  Expect accidents!
9. Once some control is established, remind them to go to the potty at certain times.
10. Reward your child with brand new underwear after the first successful attempt.  I found that Barbie and Spiderman works extremely well!
11. Keep your child on a high fiber diet and increase his fluid intake.  This will make urinating and bowel movements easier, increasing the chances of successful attempts.  Every successful attempt will give your child a sense of achievement, leading to him being more confident about his abilities.
12. Do not punish your child for accidents and do not reward with anything else than things naturally associated with toilet behavior.

Training your child at night might be a different matter.  I would suggest keeping diapers on at the beginning, until you find that your child stays dry.  During naptimes I would however let them sleep without a diaper.

When major events happen in a child’s life, they often do regress and bladder control is often one of the developmental areas in which the do go back a few paces.  Stay encouraging and soon, despite many accidents he will be up and going again!