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).
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.
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).
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.
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.
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:
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.
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
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).
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.
Click here to read more about this
infant toilet training method.
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
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
The timing of these milestones varies by individual.
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
Bladder training can be more difficult.
small bladder capacities and process large volumes of liquid. They
urinate frequently, and it can be hard to tell when they are about to
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.
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
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.
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
Next, consider the mess.
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
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?
bottom line, I think, is that many people who practice infant toilet
training have a different attitude about dealing with infant waste.
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
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.
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.
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.
Since writing this article, I've seen a few claims made about infant toilet training that merit discussion.
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.
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
existing scientific evidence suggests Freud was wrong. It doesn't seem to matter much either way.
If you ever get advise 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
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.
Undecided? There are plenty of other times to start training. For other options besides
infant toilet training, check out my article on different potty training ages.
References: The science of infant toilet training
Bachelard M, Sillen U, Hansson S, Hermansson G, Jodal U, and
Jacobsson B. 1998. Urodynamic pattern in infants with urinary tract
infection. Journal of Urology, 160: 522-6.
deVries MW and deVries
MR. 1977. Cultural relativity of toilet training readiness: A
perspective from East Africa. Pediatrics, 60: 170-177.
2000. “Gift from the gods: A Balinese guide to early child rearing," in A
world of babies: Imagined childcare guides for seven societies (J.
DeLoache and A. Gottlieb, eds.) New York: Cambridge University Press,
Geollner MH, Ziegler EE, and Fomon SJ. 1981. Urination during the first three years of life. Nephron., 28: 174-178.
G, Persson D Mattsson S and Lindstrom S. 2000. Voiding pattern in
healthy newborns. Neurourology and urodynamics, 19: 177-184.
RH, Gianciaruso M, and Prader A. 1978. Development of intestinal and
bladder control from birth until the 18th year of age. Longitudinal
study. Schweiz Med Wochenschr, 108: 155-160.
Largo RH and Stutzle
1977. Longitudinal study of bowel and bladder control by day and at
night in the first six years of life. I: Epidemiology and interrelations
between bowel and bladder control. Dev Med Child Neurol, 19: 598-606.
H-N. 2000. “Never leave your little one alone: Raising an Ifaluk
child," in A world of babies: Imagined childcare guides for seven
societies (J. DeLoache and A. Gottlieb, eds.) New York: Cambridge
University Press, pp. 199-231.
Schaefer CE and diGeromino TF 1997. Toilet training without tears. New York: Signet.
Sillén U. 2001. Bladder function in healthy neonates and its development during infancy. Journal of Urology, 166(6): 2376-81.
Sonna L. 2005. Early-start potty training. New York: McGraw-Hill.
PM, Lancioni GE, Ball, TS, and Oliva DS. 1985. Shaping self-initiated
toileting in infants. Journal of applied behavior analysis, 18: 303-308.
JG and Tong EC. 1998. Cystometry in infants and children with no
apparent voiding symptoms. British Journal of Urology, 81: 468-473.
CK, Godley ML, Ho, CK, Ransley PG, Duffy PG, Chen CN, Li AK. 1995. Some
new insights into bladder function in infancy. British Journal of
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