When we were planning to have our third child, we made a conscious decision to not use disposable diapers. We felt sheepish that we had already contributed 2 children’s worth of diapers to our nation’s landfills. Unfortunately, washing and drying cloth diapers could triple the amount of work for us. Further, exchanging disposable diapers for energy- and water-consuming laundering was not an environmentally guilt-free option. How did we as humans take care of children before disposable diapers? Researching this question, we soon learned about elimination communication (EC).
EC, also known as natural infant hygiene, is the practice of using the infant’s natural timing and cues to recognize when they need to defecate or urinate. By identifying these cues, caregivers can coordinate elimination in the toilet rather than in a diaper. Contrary to the notion that infants relieve themselves randomly and constantly throughout the day, infants naturally eliminate at predictable times, such as on waking or after feeding. Caregivers can incorporate audio cues (soft whistle or hum) to associate with the act of eliminating. With practice, many children learn to eliminate when they are in proper position and hear the cue. EC is not a new concept. Humans have been doing this for millennia and still do in most resource-limited regions. As little as 3 to 4 generations ago, most Americans did as well. So, why has the pendulum in mainstream American culture swung so far away from EC?
The disposable diaper was first patented in 1955.1 In 1962, pediatric developmental specialist Dr T. Berry Brazelton published a seminal paper outlining why parents should avoid pushing their child prematurely to toilet training.2 He based his recommendations on the physical and psychological developmental milestones required for children to consciously become toilet trained. He demonstrated that most children are ready by the age of 2 to 3 years. Pediatricians have embraced this child-driven approach and helped countless families use Brazelton techniques for toilet training.3 By the 1980s, most US children were using disposable diapers. As family lives become busier, the convenience of disposable diapers has become a virtual necessity. Now, there are an estimated 27.4 billion disposable diapers used in the United States each year.4
As we look at an increasingly smaller world, the reliance on disposable diapers as a society is quickly reaching a critical environmental point. The United States alone creates more than 3.4 million tons of used diaper waste each year.4 Disposable diapers may take more than 500 years to degrade4 and now are thought to comprise a large portion of the Pacific trash vortex. Disposable diapers are expensive. On average, they cost families nearly $1000 per year of use.4 As children start toilet training, they face a daunting challenge, as they have been trained to eliminate into diapers since birth. Caregivers then spend the next 1 to 2 years teaching them to unlearn this behavior. There needs to be a paradigm shift, such that pediatric clinicians and caregivers understand that options other than diapers even exist. EC is natural, generates no landfill or ocean waste, and is free.
EC has potential health benefits. Avoiding soiled diapers and promoting more complete bladder emptying at a younger age may reduce the risk of urinary tract infections.5,6 Furthermore, Dr Bender’s clinic is filled with children suffering from recurrent methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections. MRSA thrives in warm, moist environments. Diapers provide the ideal incubator. Although manufacturers of diapers tout their ability to remain dry even after urination, the plastic outer layer ensures that moisture does not escape. Children frequently stay in soiled or wet diapers for hours, rubbing and irritating the skin. Wipes and creams further contribute to diaper dermatitis. These and other factors lead to skin breakdown, which allows MRSA to invade and cause abscesses.7 Although guidelines for how to treat MRSA skin and soft tissue infections are available,8 the best way to prevent these abscesses is to get children out of diapers.
Other benefits of EC reported by families include better communication with their infant. Similar to cues regarding hunger and tiredness, the need to eliminate can be understood by caregivers as well. Many families report saving time by not having to change diapers or carry all of the paraphernalia that goes with them. When the child is developmentally ready to toilet train, those who have done EC make the transition easily and may enjoy the independence. Others have observed that toddlers who don’t wear diapers can learn to walk more naturally, without a thick layer of padding between their legs.9 EC-trained children are thought to have better awareness and control of the bladder, with more complete emptying.5 Anecdotally, they have less nocturnal enuresis. These and the other potential benefits of EC have been rarely studied due to limited awareness and funding.
Dr Brazelton himself has praised the benefits of EC techniques, but cautioned that American society is not prepared or structured favorably for EC to work more broadly.10 The process of EC is time-consuming initially. In a society in which we frequently do not have the luxury of spending the first 2 years of life always together with our children, the convenience of diapers is undeniable. EC is not for everyone. Families should not be made to feel bad if they elect not to do it. However, as people become aware of this technique and become cognizant of the long-term financial and environmental effects of the use of diapers, more caregivers may be comfortable with trying EC. We find that when we discuss EC with others, many are shocked that early toilet training is even possible. Interestingly, it is the grandparents and great-grandparents of young families who are the biggest supporters of EC. These experienced caregivers frequently share that EC was much easier than the diapers that families use today.
It was admittedly hard work, and we felt a certain amount of social stigma, but we elected to use the EC method with our daughter in conjunction with cloth diapers. During those first weeks of life, we regularly attempted toilet time at awakening and after each feed accompanied with a short whistle. This was often followed by her naturally relieving herself. By the end of 1 month, we were only having 1 to 2 “misses” per day. Having this extra bond with our daughter and avoiding washing the cloth diapers were definitely rewarding. Once our parental leave was over, our caregiver jumped right in and continued where we had left off. Her own Taiwanese grandmother later told her that she had used EC with her when she was an infant. By 6 months of age our daughter no longer required any cloth diaper back-ups and we carried little with us when going out. By the time she was 18 months old and developmentally ready, she transitioned seamlessly into using the toilet independently.
Our worthwhile experience with EC compels us to offer our perspective as working parents and physicians. We strongly feel that this underrecognized approach to toilet training could be beneficial to US families in terms of child health, convenience, and expense. It further helps Americans struggling to protect the environment for our children and generations to come. Although cloth diapers generate less environmental waste than disposable diapers, and allow toddlers to be more aware when they have soiled themselves, they are potentially more work and do not address the health concerns of diaper use. Providers who care for children should learn more about EC and incorporate this alternative into their discussions with young and growing families.
Note: Dr Bender is a pediatric infectious diseases specialist, and Dr She is a pathologist and medical microbiologist. They are married and are raising 3 children in Los Angeles, California.
Drs Bender and She conceptualized, researched, and jointly wrote the manuscript as submitted.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.