Urinary bladder control during the first 3 years of life in healthy children in Vietnam – A comparison study with Swedish children
Introduction
The development of bladder function and the way healthy children achieve bladder control have been addressed in several studies during the last decade. This knowledge is important to understanding first what is abnormal and then being able to imitate a normal pattern in children with congenital bladder anomalies and dysfunction.
Studies have shown that toilet training changes the physiological functions involved in micturition. The bladder capacity increases, the coordination between the bladder and sphincter improves, and the emptying of the bladder becomes complete [1], [2], [3], [4]. Before having bladder control, the child often has residual urine and frequent voiding of small urinary volumes [5], [6], [7].
This knowledge emanates from studies performed during the last decades and has also been shown in a longitudinal study of healthy children in Sweden who were followed from the age of 3 months–6 years [2], [6]. Results from this latter study indicate that the frequency of voiding decreased over time, the voided volumes increased and the post-residual urine decreased marginally until the age at which bladder control was achieved, at around 3.5 years. A large variation in the voided volumes of individual children was identified; indicating that bladder emptying was not an automatic function without influence from the brain. The study also indicated that the children had signs of arousal when it was time to void already in early infancy, supporting the concept that the brain influences the bladder function already from birth [7], [8]. Such arousal at voiding already in the neonatal period was previously reported in a study from Hong Kong using electroencephalography [9].
In a study of healthy children in Vietnam, who were followed from newborn up to 12 months of age, 81% of the mothers had started toilet training their children already at the age of 3 months, and, by the age of 12 months, all the children were potty trained on a regular basis. Almost all the children voided without residual urine at the age of 9 months, probably as a result of this early training [10]. Two-way communication was used between the mother and child. The mother looked for signs of when the child had a need to void and responded to it by holding the child in a sitting position. This was done often, every one or 2 h. The voiding was supported by a whistling sound from the mother [11]. In the Swedish study [2], [6] however, the child-oriented method was used. In this method the parents waited for the right time to come and for the child to be mature enough to be diaper free. The potty training procedure often took place during the summer and the child was encouraged, in co-operation with the parents, to practice using the potty or toilet [12].
The aim of the present study was to make a direct comparison between a cohort of children subjected to early potty training and a group subjected to late potty training, with special reference to age for the disappearance of the physiological dyscoordination and improvement in emptying ability. The direct research question is whether there are benefits regarding bladder function variables when potty training children earlier than is traditionally done in the Western World.
Section snippets
Subject and methods
The study has a longitudinal design. Mothers of healthy newborn children in Vietnam were consecutively informed about participating in the study when attending health check-ups for their children at the National Hospital of Pediatrics (NHP). After written informed consent had been obtained from the parents, the children were investigated at the hospital. Permission for the study was obtained from the ethical committee at the NHP. Preliminary results had been published previously from the first
Analysis
Post-void residual urine, reported in milliliters, was estimated by ultrasound by considering the bladder as a rectangular box and multiplying all three variable dimensions: width, height, and depth, to obtain the actual bladder volume [13].
Variables were reported using descriptive statistics. Continuous variables were described with the mean, SD, median and range, and categorical variables with numbers and percentages. For comparisons between the two groups, the Mann–Whitney U-test was used
Results
In the group of 47 healthy Vietnamese children, 26 (55%) were boys and 21 (45%) girls. The participants attended each session up to their sixth visit (18 months), and the number then decreased. In the group of 57 Swedish children, 34 were girls (60%) and 23 (40%) boys with a variation in attendance (Table 1).
During the 4-h voiding observation, the children in both groups were breastfed one to several times together with snacks or a light meal. At the age of 24 months, breastfeeding had stopped
Potty training during the first 3 years of life
The ages at which the mothers started daily potty training of their children differed significantly between the groups. According to Vietnamese tradition, mothers are supposed to start potty training from infancy. This was not in concordance with what the Swedish families did. In the group of Vietnamese children, potty training started early, and 98% were on daily potty training at the age of 9 months. At the age of 18 months, potty training was complete for 58%, meaning that the children did
Frequency of micturition
The frequency of voiding decreased over time in both of the studied groups. The Vietnamese group had fewer voiding than the Swedish group of children up to the age of 18 months (Fig. 1). The children in the Vietnamese group voided 2–6 times (mean 3.5) at 3 months of age during the 4-h observation period, and the number decreased slightly to a mean of 3 times at 24 months (Fig. 1).
Bladder volumes
The voided volumes increased according to age in both the Vietnamese and the Swedish group of children. The voided volume varied for each child during the 4-h observation period as well as between the children. A comparison between the groups showed a lower bladder volume capacity for all ages in the Vietnamese group compared with the Swedish group. Table 2 shows both the lowest bladder volume and the highest volume triggering voiding in the Vietnamese children compared with the Swedish
Emptying abilities
Interrupted voiding was found, but it disappeared in both groups when potty training was a daily routine. In the group of Vietnamese children, interrupted voiding was rare and detected in just one child at the age of 9 months, and it was not found from the age of 12 months. In the Swedish group, the events of interrupted voiding lasted longer, but a gradual decrease was seen to the age of 24 months, but at the age of 36 months it was still seen in two children (Fig. 2).
Post-void residual urine
Discussion
In this study, which compares healthy Vietnamese and Swedish children, a significant difference in age between daily potty training and also bladder control was found, at approximately one year in the Vietnamese children and two years later in the Swedish children. Improvements in bladder emptying accompanied the age of daily potty training, probably due to the simultaneous disappearance of the interrupted voids, meaning that the Vietnamese children had complete emptying earlier. Physiological
Conclusion
The results show that it is possible to potty train infants with good outcomes.
Not using nappies may facilitate the potty training process.
Potty training performed daily affected the emptying ability positively: at the age of 9 months, no residual urine was found. These results differ significantly from the group of Swedish children.
The frequency of voiding was lower in the Vietnamese children than in the Swedish group. Bladder volumes increased by age in both groups, but in the Vietnamese
Conflict of interest statements
The authors of this paper have no financial or personal relationship that inappropriately has influenced our actions.
Ethical considerations
Voluntary participation and informed consent were a requirement for inclusion in the study. The benefit of this study exceeds the risk in our judgment. Permission from the head of the hospital, and the ethical committee at the National Hospital of Pediatrics in Hanoi, was obtained.
Acknowledgments
We thank Nils-Gunnar Pehrsson and Mattias Molin for their excellent help with the statistical analyses.
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2020, Journal of Pediatric UrologyCitation Excerpt :The family history of incontinence was not separately assessed in our sample. In preschool and school children, differences in toilet behavior, as well as socialization could also additionally influence achievement of bladder and bowel control [25,21]. The point of initiation of toilet training does seem to also influence the bladder and bowel control development, as well as the duration of toilet training [26,27].
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2017, Journal of Pediatric UrologyCitation Excerpt :One factor might be the age of the children, which was close to age for potty training, which is an age when residual can be unpredictable. Residual has been shown to decrease after potty training, when the child starts to have voluntary control of voiding [10,18]. This has been shown earlier both in healthy children and children with high-grade VUR [19].