Voiding dysfunction is common in children. Recently, we found in our clinical practice that more and more children over 5 year old were disturbed by the day time urinary incontinence (DUI) in the last 10 years in China with unclear reasons. Early toilet training (voiding training) used to be popular in Chinese families, but nowadays this habit is gradually disappeared with modern life (increase usage of disposable diaper (DD)). We hypothesized that delay toilet training and using DD in infants may be responsible for the increase of DUI prevalence in children. Consequently, the aim of this study is to investigate Influence of delay toilet training and increase of using DD on day time voiding and defecation control in infants and children in Mainland China.

The study retrospectively investigated the effects of using diapers and the beginning time of voiding training since newborn on the DUI in children in China. The questionnaires included sociodemographic data, family caregivers’ information, and the main information of toilet training, using diapers and DUI in children. The DUI definition accords with the ICS definition. Through anonymous questionnaires, children aged from 5 to 12 were investigated retrospectively in kindergartens and primary schools selected randomly from Henan province, Shenzhen city et al. According to the beginning time of voiding training after infants born, children recruited this study were divided into 5 groups: group A≤6 (months), group B, 6-12 (months), group C, 12-18 (months), group D, 18-≤24 (months), group E, ≥24 (months).The prevalence of DUI was compared between groups.

A total of 10400 questionnaires were assigned actually and 8560 were valid for statistical analysis, the effective response rate is 82.31%. The prevalence of DUI was 3.52% (301/8560) , whereas the prevalence of those in 5 groups (A, B, C, D, E) was 2.48%, 2.36%, 2.45%, 4.61%and 4.25%, respectively, increased with delay of toilet training. In A1, B1 and C1 group, the prevalence of voiding dysfunction was significantly lower than the other two groups (P≤0.01). In A2 group, the prevalence of voiding dysfunction was significantly lower than the other four groups (P≤0.01).(All information have been showed in Table1 and Table2).

It has been reported that brain development has been involved in the regulation of bladder function in neonatal period. Meanwhile, it is believed that voiding training is closely related to the establishment of voiding reflex. The influence of voiding training on the voiding dysfunction and fecal incontinence had been reported by Glicklich, et al and it was found that improper urination training could lead to psychological enuresis, urinary incontinence and fecal incontinence. In addition, studies have shown that infants can acquire independent voiding nerve control at 9 months after birth, which can serve as the theoretical basis for early voiding training, and at the same time, it has shown that infants can voiding independently at 12 to 15 months[1]. Bakker E found that delayed voiding training will increase the risk of voiding dysfunction similarly [2]. A British cohort study also found that voiding training after age 2 increased the risk of daytime incontinence and delayed access to voiding control [3]. Accepting the similar study also found that start voiding training in infants before 1 year old is better for establishing the urinary control than those of more than 2 year old. Obviously, the best toilet training time should began before 12 months. 
Therefore, theoretically the early toilet training will be beneficial for early establish voluntarily voiding control. Present study further discloses the relationship between the voiding training and voiding dysfunction providing a basis for starting voiding training in the early stage of life.

Voiding training performed early in infants is beneficial to development of voiding management, declining the occurrence of voiding dysfunction in children period.

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