Specific Behaviors of Young Healthy Children During Toilet Training and Their Associations With Functional Constipation: A Cohort Study

Objectives: To assess the association between specific toilet training (TT) behaviors and functional constipation (FC) in young, healthy children. Methods: This cross-sectional descriptive study distributed 2917 questionnaires to parents of healthy children across 38 nursery schools in Flanders. Parents were given questions regarding their child's TT and TT-related behaviors such as stool toileting refusal (STR), hiding, and requesting a diaper for defecation, along with questions about current stool issues, which involved assessing stool consistency using the Bristol Stool Chart. Results: From a 42.1% (n = 1228) response rate, 1218 questionnaires were analyzed. Parents reported that during TT, 23.6% (n = 285; 95% confidence intervals [CIs], 21.2–26.0%) of their children refused to defecate on a potty, 13.0% (n = 157; 95% CI, 11.2–15.0%) hid while defecating, and 9.7% (n = 117; 95% CI, 8.1–11.5%) asked for a diaper to defecate. The prevalence of FC was 16.8% (n = 204; 95% CI, 14.7–19.0%). Chi-square tests showed significant associations between each of these TT behaviors and FC. The odds on FC was 2.8 (95% CI, 1.8–4.2) times higher when the child asked for a diaper, 3.2 (95% CI, 2.3–4.3) times higher in the presence of STR, and 3.7 (95% CI, 2.6–5.4) times higher for those who hid. Conclusion: Refusing to defecate, hiding, and asking for a diaper have a significant association with FC, especially when multiple behaviors are present. These findings are clinically relevant for parents and pediatricians, aiding them in understanding behaviors that can be associated with FC and raising awareness to identify potential signs.