Infant toilet training: An evidence-based guide

2006-2010 Gwen Dewar, Ph.D., all rights reserved Throughout much of the non-Western world, infant toilet training is the norm. In India, China, Southeast Asia, Eastern Europe, the arctic, and parts of Africa and Latin America, parents leave baby bottoms uncovered (Boucke 2003; Sonna 2006; deVries and deVries 1977). Diapers are considered unnecessary, even disgusting. When babies have to eliminate, parents hold them over a preferred target (e.g., a toilet, an outdoor latrine, or simply open ground) until business is done. How do parents know when their babies need to go? By paying close attention. In these “bare-bottom" cultures, babies spend much of their days being carried around. Parents learn to read their babies' cues, and (eventually) babies learn to hold back until their parents give them the signal—usually a special vocalization, like “sheee-sheee" or “shuuuus" (Boucke 2003; deVries and deVries 1977). Sometimes called “elimination communication," this method is now being adopted by some parents in the United States and other Western countries. Are these babies toilet trained? Yes, if by “toilet trained" we mean that infants go where their parents want them to go. But babies can’t walk, wipe, or dress themselves. Clearly these infants are NOT completely toilet trained in the sense of being capable of taking independent trips to the toilet. Full toilet independence comes later, after the kids learn to walk, follow verbal instructions, manipulate clothing, wipe, and so forth. So "elimination communication" is not what most Western parents mean by “toilet training." Nevertheless, for some people, it has many advantages. Benefits of infant toilet training Infant toilet training depends on establishing close communication about the baby's frequent needs to eliminate. It's time-consuming, but potentially rewarding in the same way that communication about feedings can be rewarding. Infant potty training also means:

• Eliminating diaper rash and diaper-related infections
• Saving money on diapers and diaper paraphernalia
• Generating fewer non-biodegradable, disposable diapers
• Using less energy to wash and dry cloth diapers, and—very possibly—
• Reducing rates of urinary tract infection later in life (for details, see this evidence-based article about the timing of toilet training)

In addition, parents who train early avoid many pitfalls. When children have spent years wearing diapers, parents face these problems:

• Older kids have learned to ignore body signals and must relearn them
• Older kids are used to wearing soiled diapers and may resist change
• Older kids are more likely to test your authority (the “terrible twos")
• Older kids’ urine is stinkier, making accidents less pleasant to clean

Infant toilet training: When and how Some parents start right after birth (Boucke 2003). Others wait until 3-6 months (Schaefer and DiGeronimo; Smeets et al 1985). Either way, infant toilet training is based on the following basic steps:

1. Observe the baby’s body signals before he voids. For example, your baby may squirm, shudder, make faces, or change his breathing patterns. Many parents keep their baby’s bottom uncovered to make observation easier. If so, parents can keep an absorbent cloth under the baby’s bottom to make clean-up easier. But parents may also keep their baby in diapers while they learn to identify the signals. Either way, you’ll need to invest time in close observation. In many parts of the world, this comes easily because parents carry their babies most of the time.
2. Once you recognize your baby’s body signals, hold your baby over a preferred receptacle while she eliminates. For very young babies, some parents use bowls or sinks (Boucke 2003; Sonna 2006). If your baby can sit up by herself, consider placing her directly on a potty chair. But before seating her, get her to look at the chair first. This will help her learn to associate her urges with the potty. This infant toilet training method was used very successfully in a Dutch study of 4 infants aged 3-6 months (Smeets et al 1985). I provide a more detailed account below.
3. Teach the baby to associate certain cues with elimination. In many parts of the world, parents make a characteristic sound or gesture while the baby voids. Babies learn to associate the sound with the action and, eventually, parents can use the signal as an invitation to void. In the Dutch study reported by Smeets et al, parents used the potty chair as the cue.

Following these steps, parents can achieve daytime dryness early in life. In cultures that traditionally practice infant training, infants complete training between 6-12 months (Boucke 2003; deVries and deVries 1977). Western parents who try infant toilet training may take longer (Boucke 2003). However, infants in the Dutch study all completed training before 12 months (Smeets et al 1985). Although many parents prefer an open-ended approach to infant toilet training, some parents might like to follow a more structured program. The study by Smeets and colleagues (1985) represents such a program. Baby plumbing: The science of baby bladders Infants can learn to “hold it back" for a brief time and then void on cue. But how is this possible? Many people assume that babies have no control their bladders and bowels. Recent research contradicts this idea. Bladder and bowel control usually develops in the following sequence. First bowel movements become more regular and less frequent. Next, bowel control develops. Then day-time bladder control emerges. Finally, children gain full night time bladder control (Largo and Stutzle 1977). The timing of these milestones varies by individual. One study reported that only 20% of children attained “complete" bladder and bowel control by age 2 (Largo et al 1978). But infant potty training does not require “complete" control--just the ability to briefly delay voiding. This requirement is met rather easily for bowel movements. After the newborn period, bowel movements are relatively infrequent, and the warning signs of an impending bowel movement are pretty easy to read. Bladder training can be more difficult. Infants have small bladder capacities and process large volumes of liquid. They urinate frequently, and it can be hard to tell when they are about to pee. In addition, some young infants may have trouble coordinating their muscles. They can contract the bladder wall (which increases pressure inside the bladder) and they can relax the urinary sphincter (which opens the urethra and permits urine to flow outside the body). But they may have trouble doing both at the same time. As a result, such infants may not completely empty their bladders with every voiding (Yeung et al 1995; Sillén et al 1996; Bachelard 1998). But this doesn’t mean that babies pee in a random, haphazard way. The muscles of the bladder wall are usually stable, contracting only around the time of urination (Yeung et al 1995; Wen and Tong 1998). Infants don’t pee during quiet sleep, but when they are awake or waking (Yeung et al 1995; Wen and Tong 1998). Moreover, newborn bladders don’t leak easily. When researchers tried to provoke healthy newborns to urinate by manually pressing their bladders, the bladders didn’t leak (Gladh et al 2000). These findings contradict the idea that infant bladders are totally uninhibited (Sillén 2001; Yeung et al 1995). And they help explain why infant potty training-—relative dryness achieved through parental supervision-—is possible. Infant urination is not merely an automatic reflex (Sillén 2001; Yeung et al 1995). But isn’t infant toilet training time-consuming and messy? The short answer is: Yes. Infant toilet training depends on the close proximity and vigilance of the caregiver. It is unquestionably time-consuming. At birth, the average infant pees approximately 20 times a day (Geoller et al 1981). The frequency decreases over time, so some authors recommend that parents delay infant training until the third month (Schaefer and diGeronimo 1997). However, bladder capacities vary, and some infants void very frequently throughout the toddler period. Other infants dribble soft stools throughout the day. Parents must weigh these factors accordingly. Next, consider the mess. Although infant waste is less smelly than toddler waste (Sonna 2006), it’s still messy. Some advocates argue that infant toilet training is less messy than diapering, because diapering forces the parent to clean up every time a baby poops (DiaperFreeBaby.org 2006). But I think this misses the point that concerns most Westerners, which is that diaper-free babies may soil furniture, rugs, and other items that are rather difficult to clean. Parents can minimize the mess by keeping babies away from such items. Alternatively, they can adopt the Smeets procedure for infant toilet training, or simply keep their babies in diapers during the early phases of training. Yet millions of people practice infant toilet training without using diapers at all. How do they do it? The bottom line, I think, is that many people who practice infant toilet training have a different attitude about dealing with infant waste. From Kenya (deVries and deVries 1977) to Bali (Diener 2000), parents don’t consider the occasional accident a big deal. Nobody minds much if a little baby urine gets on their clothes or floor. Accidents happen. And cleaning up is part of parenting. Just as important, traditional, “diaper-free" societies are often more tolerant of small children eliminating in public. Local customs make it easier for parents to train. In China, young children wear pants with an open seam in the back so kids can squat and go when it suits them. Among the Ifaluk of Oceania, toddlers can pee just about anywhere as long as it’s outside (Le 2000). Attitudes and customs in the West are less supportive of infant potty training. This needn't deter motivated Western parents. But it's obvious that infant training isn't for everyone. Whether you plan to train early or late, you will need to exercise patience, good humor, and gentleness. There will be accidents and setbacks. No one should attempt infant toilet training without a clear understanding of the work involved. Lessons for the West Despite the difficulties, some parents are proving that it’s possible to practice infant toilet training in the West. Books, websites, and online communities offer advice and psychological support. Savvy parents swap tips about where to buy Chinese-style training pants or how to survive car travel. For these parents, the advantages of infant toilet training—no diapers, no rashes, close parent-child communication—make the extra work worthwhile. And for parents who don’t plan to train their infants, “elimination communication" is nonetheless instructive. It reminds us that diapers are not a necessary or natural part of infancy. Nor is diaper rash or diaper dependency. Babies who never wear diapers don’t have to be cajoled back out of them when they are older. Unwarranted claims Since writing this article, I've seen a few claims made about infant toilet training that merit discussion. First, I can find no evidence that infant toilet training makes people into better, more sensitive parents. Nor have I run across any studies suggesting that potty training of any kind--infant or otherwise--improves the parent-child relationship. I assume that the term "elimination communication" refers to communication about elimination, not emotions or profound ideas. If people think it implies more than that, they shouldn't. Second, I've not found any studies suggesting that infant toilet training--when carried out in the manner noted above--has any long-term developmental significance for infants. In other words, there isn't any scientific literature addressing whether it's better or worse to potty train a baby. Before I read the research on potty training--and there isn't much--I assumed that early training is harmful. But the existing scientific evidence suggests Freud was wrong. It doesn't seem to matter much either way. If you ever get advice about potty training based on Freud, be very skeptical. A person who cites Freud is probably not well-informed about the research on toilet training. Finally, it bears repeating that "infant toilet training" is a misleading term. Babies don't get trained in the way that older children do. Instead, parents learn to anticipate when their babies are ready to void and babies learn that a specific sound means "go ahead and urinate now." Recommended books on infant toilet training Laurie Boucke provides a detailed account of infant toilet training in her how-to book, Infant Potty Training: A gentle and primeval method adapted to modern living (2002; White-Boucke publishing). Her book includes photos and sketches illustrating techniques, as well as a section on cross-cultural studies. An abridged version of this book is available under the title Infant potty training: With and without diapers—the natural way (2003; White-Boucke publishing). If you want to try infant toilet training, I recommend you read one of these books.