Elimination Communication

Traditional practice in Asia and Africa

A 2004 case report in a pediatrics journal states that in the Western world independent toilet training usually starts at 18 months or later, whereas in Asia and Africa assisted toilet training traditionally starts between one and three months and is completed within approximately one year. This is a statement made in the introduction to a single case report, and it does not describe the practice in any particular community in detail.

Research in Vietnam gives a more specific picture. In a longitudinal study of 47 healthy children, mothers were reported to be potty training the children from the newborn period, with 70 percent doing so in the newborn period and 100 percent by 12 months. The authors describe this as a tradition of early potty training in that population, and report that diapers were used only rarely.

Description in Western settings

The 2004 case report describes a male infant in a family in Italy who began caregiver-assisted toilet training at 33 days. The caregiver observed his bowel movement schedule and cues, and the authors report that successful bowel training was completed at five months. A 1985 behavioral study in the United States had earlier reported a program for four infants aged 3.1 to 6.6 months, all of whom completed the training before age one year with no negative side effects reported by the authors.

A 2014 hypothesis paper uses the name elimination communication, notes the alternative names natural infant hygiene, infant potty training, baby-led potty training and assisted infant toilet training, and proposes a possible link with infant colic. The sources reviewed do not trace how the contemporary parent-led movement and its books and groups developed, so this page does not date that revival.

Names in use

The 2014 hypothesis paper gives elimination communication, or EC, as the main term and lists natural infant hygiene, infant potty training, baby-led potty training and assisted infant toilet training as other names. The Vietnamese studies and the 1985 behavioral study use potty training or toilet training of infants without the EC label, and the 1985 study frames its method as training infants to cue their mothers.

Contrast with conventional toilet training

Pediatric guidance uses toilet training or toilet learning for a process usually begun in the toddler years and directed at the child learning to control the bladder and bowel. The American Academy of Pediatrics describes the average age at which toilet training begins in the United States as between 2 and 3 years, while the Canadian Paediatric Society says most children start between 2 and 4 years. Elimination communication differs in that the caregiver, rather than the child, responds to signals during infancy.

What the sources describe in general terms

Sources describe the approach as attention by the caregiver to cues and timing. The 2014 paper lists cues such as types of crying, squirming, straining, wriggling, grimacing, vocalizing and an intent look at the caregiver. The case report states that the caregiver observed the infant's bowel movement schedule and cues, and vocal signals were used to prompt elimination. This page does not give instructions for doing this.

In the Vietnamese study, mothers used a whistling sound at certain times to remind their children to eliminate and frequently checked for signs of need. The authors conclude the process was achieved through ongoing communication between parent and child.

Relation to other parenting approaches

Elimination communication is a member of the Machipedia family page Parenting Approaches, which places it alongside related pages such as Attachment Parenting, Babywearing, RIE Parenting and Gentle Parenting. The sources reviewed for this page do not study elimination communication in connection with those approaches, so no link between them is asserted here.

Colic hypothesis

The 2014 hypothesis paper proposes that timely elimination may increase infant physical comfort and so reduce colic symptoms, on the reasoning that colic may be functionally related to a decrease in stooling frequency. It presents this as a hypothesis and notes that few well-designed randomized trials show efficacy of any therapeutic method for colic. No study of this proposal was found among the sources reviewed.

Urinary tract suggestion

The Vietnamese bladder study authors suggest that potty training in infancy may be beneficial for small children with urinary tract infections or renal scars. This is a suggestion drawn from observations in healthy children, and it has not been tested in children with those conditions in the studies reviewed here.

Infant potty training studies

The evidence on infant-begun toileting is small. Searches of PubMed for elimination communication and infant potty training returned a handful of records, and no randomized trial of elimination communication was found among them. The available reports include a single-infant case report, a four-infant behavioral study from 1985, a hypothesis paper and a series of observational studies in Vietnam.

In a longitudinal study of 47 healthy Vietnamese children followed every three months, post-void residual urine decreased with age and was less than 7 ml on average by 9 months. A later comparison with 57 Swedish children reported that 98 percent of the Vietnamese children had completed potty training at 24 months while 5 percent of the Swedish group had begun daily potty training, and that complete bladder emptying was seen from 9 months in the Vietnamese group and from 36 months in the Swedish group. The authors conclude that daily potty training affects emptying ability positively. The two groups differ in culture and setting, so the studies cannot separate the effect of training from other differences.

Early versus later toilet training

A 2020 systematic review and meta-analysis of 10 observational studies with 24,121 participants aged 5 to 17 reported lower odds of lower urinary tract dysfunction in children who began toilet training at a younger age, with an odds ratio of 0.71 (95 percent confidence interval 0.63 to 0.81). The authors note that definitions of the age of initiation varied greatly, that no randomized trials were included, and that larger longitudinal studies are needed. The studies concerned toilet training generally, and the review does not report on elimination communication.

A 2018 prospective cohort study of 8,751 children in the ALSPAC cohort examined trajectories of urinary incontinence from age 4 to 9. The authors report that later initiation of toilet training was not associated with bedwetting alone, but was associated with the other incontinence trajectories, and that constipation was associated with delayed bladder control. Association in this design does not show cause.

A 2008 review in a family medicine journal states that most research on toilet training is descriptive, and that newer studies suggest no benefit of intensive training before 27 months of age, with mastery of the required developmental skills occurring after 24 months. These conclusions concern child-directed toilet training in toddlers, and the review does not address infant-begun approaches.

Pediatric guidance on readiness

The American Academy of Pediatrics states that children show signs of bladder and bowel control generally between 18 and 24 months, that toilet training struggles occur when children choose not to use the toilet, and that children can succeed in their own time. It adds that toilet training can begin as soon as parents and children want to start. The Canadian Paediatric Society says that some children are ready as young as 18 months, that parents should follow the child's cues, and that a child cannot be rushed.

The 2008 review notes that the Brazelton child-oriented approach assesses readiness by physiologic maturity, ability to respond to external feedback and internal motivation, and that the American Academy of Pediatrics incorporates components of it into its guidelines. The guidance reviewed does not address toilet training in the first months of life, and the Academy's own page on methods says any technique may work and that parents do not need to choose a single one.

Reported concerns and care boundaries

The Canadian Paediatric Society advises against punishing or overreacting to accidents, notes that a child who finds passing stool in a potty difficult may become constipated, and recommends talking to a doctor if a child withholds stool, has pain or blood in the stool, or shows signs of a urinary problem. The 1985 study authors reported no negative side effects among four infants. None of the sources reviewed reports a systematic study of harms from elimination communication, so its stress effects on infants or caregivers, hygiene issues and handling risks are not measured in them.

Guidance from pediatric bodies is directed at toddlers. Anyone with questions about an infant's bowel or bladder health, or constipation, should consult a pediatrician, and nothing on this page replaces that advice. No statutory regulation or training standard for elimination communication was found.