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The evidence base
At ERIC, we strive for all our information, tools and resources to be clear, up-to-date and reliable. It’s very important that the health information we provide for anyone caring for a child with a continence condition is accurate and evidence based.
We also use research evidence to inform decision-making and enable better health, care and wellbeing for children and young people affected by bladder and bowel problems.
The following are references for the key pieces of research, recommendations and studies that have informed our resources and messaging grouped by condition:
Bedwetting
Neither waking nor lifting children and young people with bedwetting, at regular times or randomly, will promote long‑term dryness. Waking of children and young people by parents or carers, either at regular times or randomly, should be used only as a practical measure in the short‑term management of bedwetting. NICE Guidance: Bedwetting in under 19s
- Bedwetting in under 19s - www.nice.org.uk/guidance/CG111
Guidance on the assessment, care and treatment of children and young people up to the age of 19 with bedwetting. - Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs Butler RJ et al (2005) BJU International 96 404-410
- Examining the effectiveness of parental strategies to overcome bedwetting: an observational cohort study July 2017, Mariusz T Grzeda, Jon Heron, Kate Tilling, Anne Wright, Carol Joinson.
- Factors predicting atypical development of nighttime bladder control: a prospective cohort study. Journal of Developmental and Behavioral Pediatrics. Published 13 October 2015. Sullivan S, Joinson C, Heron J.
- The role of early childhood psychological factors in determining risk for enuresis at school age in a UK cohort. Joinson C, Sullivan S, von Gontard, Heron J. European Child and Adolescent Psychiatry. Published 21 August 2015.
- Mental health problems, stressful life events and new-onset urinary incontinence in primary school-age children: a prospective cohort study. Warne N, Heron J, von Gontard A, Joinson C.Eur Child Adolesc Psychiatry. 2023 Apr 24. doi: 10.1007/s00787-023-02211-x. Online ahead of print.PMID: 37095371
- A prospective cohort study of biopsychosocial factors associated with childhood urinary incontinence. Joinson C, Grzeda MT, von Gontard A, Heron J.Eur Child Adolesc Psychiatry. 2019 Jan;28(1):123-130. doi: 10.1007/s00787-018-1193-1. Epub 2018 Jul 6.PMID: 2998084.
- Stressful Events in Early Childhood and Developmental Trajectories of Bedwetting at School Age. Joinson C, Sullivan S, von Gontard A, Heron J.J Pediatr Psychol. 2016 Oct;41(9):1002-10. doi: 10.1093/jpepsy/jsw025. Epub 2016 Apr 11.PMID: 27072719
- Early childhood psychological factors and risk for bedwetting at school age in a UK cohort.Joinson C, Sullivan S, von Gontard A, Heron J.Eur Child Adolesc Psychiatry. 2016 May;25(5):519-28. doi: 10.1007/s00787-015-0756-7. Epub 2015 Aug 21.PMID: 26294078 Free
Further links to research publications can be found on this page of the World Bedwetting Week website.
Constipation and Faecal Incontinence (soiling)
Randomised controlled trials (RCT) indicate that increasing fibre is not an effective treatment for constipation in children. Hard stools can precede and predict later fibre intake. Genetic inheritance explains most childhood constipation. Challenging the view that lack of fibre causes childhood constipation.
- Constipation in children and young people: diagnosis and management - www.nice.org.uk/guidance/cg99
Guidance to support the early identification, positive diagnosis and timely, effective management of constipation in children and young people. - The Cost of Constipation Report (produced by the Bowel Interest Group).
- ‘Review of organic causes of fecal incontinence in children: evaluation and treatment’ Expert review Ambartsumyan L, Nurko S (2013) Gastroenterology and Hepatology 7, 7, 665-667
- Challenging the view that lack of fibre causes childhood constipation Tappin, D., Grzeda, M., Joinson, C. J. & Heron, J. E., 10 Mar 2020
- Early childhood risk factors for constipation and soiling at school age: an observational cohort study. Heron, J., Grzeda, M. T., Tappin, D., von Gondard, A. & Joinson, C., 2018,
- Chronic constipation in infants and children. Singapore Medical Journal; Ho JMD, How CH (2020) 61:2, 63-68.
- Dysfunctional elimination behaviours and associated complications in school-age children. Kistner M (2009) Journal of School Nursing; 25:2, 108-116.
- Empirically derived patterns of pain, stooling, and incontinence and their relations to health-related quality of life among youth with chronic constipation. Klages KL et al (2017) Journal of Pediatric Psychology; 42: 3, 325-334.
- Functional constipation in children: challenges and solutions. Levy EI et al (2017) Pediatric Health Medical Therapy; 8, 19-27.
- Evaluation and treatment of constipation in children and adolescents. Nurko S, Zimmerman LA (2014) American Family Physician; 90: 2, 82-90.
- Constipation in pediatrics: a clinical review. Pawasarat A, Biank VF (2021) Paediatric Annals; 50:8, e320-e324.
- Constipation in children: fibre and probiotics. Tabbers MM, Benninga MA (2015) British Medical Journal Clinical Evidence; 0303.
- ‘Review of organic causes of fecal incontinence in children: evaluation and treatment’ Ambartsumyan L, Nurko S (2013) Expert review Gastroenterology and Hepatology 7, 7, 665-667
- Psychosocial risks for constipation and soiling in primary school children.
Joinson C, Grzeda MT, von Gontard A, Heron J.Eur Child Adolesc Psychiatry. 2019 Feb;28(2):203-210. doi: 10.1007/s00787-018-1162-8. Epub 2018 May 10.PMID: 29748737
Bladder conditions and urinary incontinence
Children who wet themselves both during the day and at night are more likely to have bladder and bowel problems in adolescence if left untreated. Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study.
- Urinary tract infection in under 16s: diagnosis and management - www.nice.org.uk/guidance/cg54
Guidance on the care and treatment of babies, children and young people under 16 with a urinary tract infection (UTI). - A prospective cohort study of biopsychosocial factors associated with childhood urinary incontinence Joinson, C., Grzeda, M. T., von Gontard, A. & Heron, J., 6 Jul 2018, (E-pub ahead of print) In: European Child and Adolescent Psychiatry. 8 p.
- Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study Heron, J., Grzeda, M. T., von Gontard, A., Wright, A. & Joinson, C., Mar 2017, In: BMJ Open. 7, 3, 10 p., e014238.
- Mental health problems, stressful life events and relapse in urinary incontinence in primary school-age childhood: A prospective cohort study Warne, N., Heron, J. E., von Gontard, A. & Joinson, C. J., Aug 2022.
- A smartphone app for supporting the self-management of daytime urinary incontinence in adolescents: Development and formative evaluation study of URApp
Whale, K., Beasant, L., Wright, A., Yardley, L., Wallace, L., Moody, L. & Joinson, C. J., 15 Nov 2021, In: JMIR Pediatrics and Parenting. - URApp: smartphone app to aid bladder training in young people Joinson, C. & Whale, K., 1 Oct 2020, In: Journal of Community Nursing.
Toilet training and health outcomes
There is evidence that initiating toilet training after 24 months is associated with problems attaining and maintaining bladder control. It is possible that delaying the onset of toilet training until after 2 years prolongs the exposure time to potential stressors that could interfere with the acquisition of bladder control, resulting in delays in achieving continence and susceptibility to relapses in daytime wetting. A prospective study of age at initiation of toilet training and subsequent daytime bladder control in school-age children.
- Can evidence-based medicine change toilet-training practice? Wu HY. 2013. Arab J Urol. 11(1):13-18
- Mrad et al. 2021. Toilet training methods in children with normal neuropsychomotor development: A systematic review. Journal of Pediatric Urology. 17. 10.1016
- Yang S.S., Zhao ,L.L., Chang, S.J. 2011. Early initiation of toilet training for urine was associated with early urinary continence and does not appear to be associated with bladder dysfunction. Neurourol Urodyn. 30(7):1253-7
- Schum, T.R., McAuliffe, T.L., Simms, M.D., Walter, J.A,. Lewis, M., Pupp, R. 2001. Factors associated with toilet training in the 1990s. Ambulatory Pediatrics 1: 79–86.
- Instruction, timeliness, and medical influences affecting toilet training. Brazelton, T. B., Christophersen, E. R., Frauman, A. C., Gorski, P. A., Pool, J. M., Stadtler, A. C., et al. 1999. Pediatrics, 103, 1353−1358
- Why is toilet training occurring at older ages? A study of factors associated with later training. J Pediatrics. Blum, N.J., Taubman, B., Nemeth, N. 2004. 145:107–11
- Collis D, Kennedy-Behr A, Kearney L. 2019. The impact of bowel and bladder problems on children's quality of life and their parents: A scoping review. Child Care Health Dev. 45(1):1-14.
- Taubman, B., Blum, N.J., Nemeth, N. 2004. Stool toileting refusal: a prospective intervention targeting parental behavior. Arch Pediatr Adolesc Medicine. 157:1193–6.
- van Nunen, K., Kaerts, N., Wyndaele, J.J., Vermandel, A., Hal, G.V. 2015. Parents' views on toilet training: A quantitative study to identify the beliefs and attitudes of parents concerning TT. J Child Health Care. 19. 2:265-74.
- Van Aggelpoel, T., Vermandel, A., Fraeyman, J., Massart, M., Van Hal, G. 2019. Information as a crucial factor for toilet training by parents. Child Care Health Dev. 45.3:457-462.
- Bakker E, Van Gool JD, Van Sprundel M, et al. 2002. Results of a questionnaire evaluating the effects of different methods of toilet training on achieving bladder control. BJU International. 90:456–61
- Barone, J.G., Jasutkar, N., Schneider, D. 2009. Later toilet training is associated with urge incontinence in children. Journal Pediatric Urology. 5:458–61
- Chenm J,J,, Ahn, H.J., Steinhardt, G.F. 2009. Is age at toilet training associated with the presence of vesicoureteral reflux or the occurrence of urinary tract infection? Journal Urology.182:268–71
- Joinson, C., Heron, J., Von Gontard, A., et al. 2009. A prospective study of age at initiation of toilet training and subsequent daytime bladder control in school-age children. Journal Development Behaviour Pediatrics. 30:385–93
- Li, X., Wen, J.G., Xie, H., Wu. X,D,, Shen. T., Yang, X.Q., Wang, X.Z., Chen, G.X., Yang, M.F., Du, Y.K. 2020. Delayed in toilet training association with pediatric lower urinary tract dysfunction: A systematic review and meta-analysis. Journal Pediatric Urology. 16.3:352.e1-352.
- Bakker, E., Wyndaele, J.J. 2000. Changes in the toilet training of children during the last 60 years: The cause of an increase in lower urinary tract dysfunction? British Journal of Urology 86: 248–252.
- Bakker, E., Van Gool, J., Van Sprundel, M., Van der Auwera, J.C., Wyndaele, J.J. 2002. Results of a questionnaire evaluating the effects of different methods of toilet training on achieving bladder control. British Journal of Urology International 90: 456–461.
- Barone, J.G., Jasutkar, N., Schnieder, D. 2009. Later toilet training is associated with urge incontinence in children. Journal of Pediatric Urology 20: 1–4.
- Luxem, M., & Christophersen, E. (1994). Behavioral toilet training in early childhood: Research, practice, and implications. Journal of Developmental and Behavioral Pediatrics,15, 370–378
- Taubman, B. 1997. Overflow encopresis and stool toileting refusal during toilet training: A prospective study on the effect of therapeutic efficacy. Journal of Pediatrics 131: 768–771.
- Zickler, C. F., & Richardson, V. 2004. Achieving continence in children with neurogenic bowel and bladder. Journal of Pediatric Health Care, 18, 276−281.
- Ollendick, T.H., King. N.J., Frary, F.B. 1989. Fears in children and adolescents: reliability and generalizability across gender, age and nationality. Behaviour Research Therapy. 27:19-26
- Van Aggelpoel T., De Wachter, S., Van Hal, G., Van der Cruyssen, K., Neels, H., Vermandel, A. 2018. Parents' views on toilet training: a cross-sectional study in Flanders. Nursing Child Young People. 11;30. 3:30-35.
- Joinson, C., et al. 2006. Psychological differences between children with and without soiling problems. Pediatrics 117, 5, 1575-84.
- Kaerts, N., Van Hal, G., Vermandel, A., Wyndaele, J.J. 2012. Readiness signs used to define the proper moment to start toilet training: a review of the literature. Neurourol Urodyn. 31. 4:437-40
- Douglas & Blomfield. 1958. Children Under 5.
- Duong, T.H., Jansson, U.B., Holmdahl, G., Sillén, U., Hellström, A.L. 2013. Urinary bladder control during the first 3 years of life in healthy children in Vietnam--a comparison study with Swedish children. Journal Pediatric Urology. 9 (6 Pt A):700-6.
- deVries, M.W., deVries, M.R. 1977. Cultural relativity of toilet training readiness: a perspective from East Africa. Pediatrics. 60. 2:170-7
- Benjasuwantep, B., Ruangdaraganon, N. 2011. Infant toilet training in Thailand: starting and completion age and factors determining them. Journal Medical Association Thai. 94, 12:1441-6.
- Rugolotto, S., Sun, M., Boucke, L., Calo, D.G., Tato, L. 2008. Toilet training started during the first year of life: a report on elimination signals, stool toileting refusal and completion age. Minerva Pediatrics. 60. 1:27e35.
- Sun, M., Rugolotto, S. 2004. Assisted infant toilet training in a Western family setting. Journal Development Behavior Pediatrics. 25. 2:99-101.
- Hellstrom, et al. 2001. Early potty training advantageous in bladder dysfunction. Decreases the risk of urinary tract infection. Lakartidningen 111, 98 (28-29) 3216-9.
- Jansson, U.B., Hanson, M., Sillén, U., Hellström, A.L. 2005. Voiding pattern and acquisition of bladder control from birth to age 6 years--a longitudinal study. Journal Urology. 174. 1:289-93.
- Joinson, C .et al. 2009. A Prospective Study of Age at Initiation of Toilet Training and Subsequent Daytime Bladder Control in School-age Children. J. Dev & Behav Pediatrics 30 (5) 385-393.
- Shai-Dei Yang, S. et al. 2001. Early Initiation of Toilet Training for urine was associated with early urinary continence and does not appear to be associated with bladder dysfunction. Neurology and Urodynamics. (30) 12523-1257.
- Jordan, G.J. 2014. Elimination communication as colic therapy. Med Hypotheses. 83.3:282-5.
- Jordan, G.J., Arbeau, K., McFarland, D., Ireland, K., Richardson, A. 2020. Elimination communication contributes to a reduction in unexplained infant crying. Med Hypotheses. 142:109811.
- Duong, T.H., Jansson, U.B., Holmdahl, G., Sillén, U., Hellstrom, A.L. 2010. Development of bladder control in the first year of life in children who are potty trained early. J Pediatr Urol. 6.5:501–505
- Dombroski, K. 2018. Learning to be affected: Maternal connection, intuition and “Elimination Communication” Emotion, Space and Society, 26:72-79
- Blum, N.J. et al.2003. Relationship between Age at Initiation of Toilet Training and Duration of Training. Pediatrics (111) 4. 810-814.
- Barone, J. et al. 2009. Later toilet training is associated with urge incontinence in children. Journal Pediatric Urology (5) 458-461.
- A prospective cohort study of biopsychosocial factors associated with childhood urinary incontinence. Joinson C, Grzeda MT, von Gontard A, Heron J.Eur Child Adolesc Psychiatry. 2019 Jan;28(1):123-130. doi: 10.1007/s00787-018-1193-1. Epub 2018 Jul 6.PMID: 29980842 Free PMC article. 12
- Jon Heron, Mariusz Grzeda, David Tappin, Alexander von Gontard, Carol Joinson. Early childhood risk factors for constipation and soiling at school age: an observational cohort study. BMJ Paediatr Open. 2018 Feb 21;2(1):e000230. doi: 10.1136/bmjpo-2017-000230.
Psychological impact of continence conditions
Incontinence in young people is challenging to manage. Young people may need to try a range of treatments before their symptoms improve. Due to challenges in treatment, there is an increased risk of poor adherence. 'What does that mean?': a qualitative exploration of the primary and secondary clinical care experiences of young people with continence problems in the UK.
- 'What does that mean?': a qualitative exploration of the primary and secondary clinical care experiences of young people with continence problems in the UK Whale, K., Cramer, H., Wright, A., Sanders, C. & Joinson, C., Oct 2017, In: BMJ Open.
- Psychological Problems in Children with Bedwetting and Combined (day and night) Wetting: A UK Population-Based Study Joinson, CJ., Heron, J., Emond, A. & Butler, R., Jun 2007, In: Journal of Pediatric Psychology.
- Effects of urinary incontinence on psychosocial outcomes in adolescence Grzeda, M. T., Heron, J., von Gontard, A. & Joinson, C., Jun 2017, In: European Child and Adolescent Psychiatry.
- The psychological effects of incontinence in children Joinson, CJ. & Heron, J., Sept 2007, In: Continence UK Journal.
- Psychological differences between children with and without soiling problems Joinson, CJ., Heron, J., Butler, U. & Von Gontard, A., May 2006, In: Pediatrics.
- Psychological Problems in Children With Daytime Wetting Joinson, CJ., Heron, J., von Gontard, A. & the ALSPAC Study, T., Nov 2006, In: Pediatrics.
- Hägglöf, B., Andrén, O., Bergström, E., Marklund, L., & Wendelius, M. 1998. Self-esteem in children with nocturnal enuresis and urinary incontinence: Improvement of self-esteem after treatment. European Urology, 33 (Suppl 3), 16−19
- Butler, R. J. 2001. Impact of nocturnal enuresis on children and young people. Scandinavian Journal of Urology and Nephrology, 35, 169−176.
- Continence Problems and Mental Health in Adolescents from a UK Cohort.
Gordon K, Warne N, Heron J, von Gontard A, Joinson C.Eur Urol. 2023 May 27:S0302-2838(23)02818-X. doi: 10.1016/j.eururo.2023.05.013. Online ahead of print.PMID: 37248139 - Paediatric incontinence: early identification and treatment needed to prevent mental health problems Joinson, C., Richardson, D., Rayner, J., Fowler, S., Lynden, A. Nov 2023 PolicyBristol, University of Bristol
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