What's potty about early toilet training?

I have returned to work after eight months' maternity leave following the birth of my daughter. These have been months filled with wishing people would forget that I am a doctor and treat me like any new mother, and wishing that others would remember that I am a doctor and stop treating me like an idiot. With motherhood comes not only a new baby but endless good advice. So it is always a good idea to challenge perceived wisdom. One area I would like to tackle is the issue of toilet training.

In the West, a toddler learns to toilet train any time after 18 months, the average being around two and half years. This has been the case for the past 40 years, following work done in the late 1960s which developed the idea of child readiness—physiological, emotional, and social. This child centred approach was in stark contrast to the parent centred strict toileting of the 1930s, which was felt to have adverse behavioural consequences. My own opinion is that the development of disposable nappies, which also occurred in the late 1960s, allowed the child centred approach to establish itself as the unchallenged standard. “Later is better” may not have been so easy if all you used were terry cloths.

Yet disposable nappies are an environmental disaster; 2.5 billion disposable nappies are sold each year in the United Kingdom (and many billion disposable diapers are sold in the United States). They make up 2-3% (400 000 tonnes) of landfill in the UK. An average child will use more than 5000 disposables in two and a half years. Local councils are desperately trying to reduce their landfill tax bills and are setting up schemes and moneyback offers to encourage parents to use washable cloth nappies. However, the Environment Agency's life cycle report on disposables and washables (2001) failed to show a significant environmental benefit of one over the other (though the study did not look at the impact of disposables on landfill). The main environmental impact of disposables is in their manufacture; for washables it is the energy used in washing and drying.

Little if no work has been done on the merits of getting your baby used to a potty before one year of age. And though for many the idea of putting a baby on a potty seems faintly absurd and rather futile, babies without nappies are the norm in many parts of the world. If you live in the West and are affluent you are more likely to wait till the child is over two and a half to toilet train. This is almost certainly because the longer you leave it the “quicker” the training will be, and this no doubt appeals to busy working parents. Yet there is some evidence that delaying potty training can lead to increased problems of stool holding, potty refusal, and constipation. Early potty training (under 18 months) is advised for infants with bladder dysfunction and ureteric reflux, as getting babies out of nappies improves their bladder volumes and aids full voiding. There are also concerns of possible male infertility through increased scrotal temperature associated with disposable nappies.

When my daughter was four months old, my mother told me I should put her on the potty before it was too late and she became more interested in exploring. I later found out that my mother was describing a technique known as infant potty training or elimination communication. Some mothers do start training from birth. I found it easier to start when my daughter was old enough to be supported on a potty chair. Infant potty training has three main elements:

• Look for cues that your baby is toileting—this may be a cry, a grimace, contracting the abdominal muscles, writhing, straining, getting suddenly fretful

• When you see any of these signs, put the baby on the potty. As the baby wees or poos, make an associating sound (for example, a grunt, or “whoosh” noise), and then congratulate them on what they have done

• Keep doing this, but then build in times when you will regularly toilet them—for example, after a sleep, after a meal, before bedtime. Sit them on the potty and make your associating sound, and if they do anything then congratulate them.

Elimination communication is not training as such: it is a method of dealing with a baby's bodily functions. I believe the benefits of allowing a young baby to start associating a potty with elimination as early as possible are vast, not only for their own health but for the environment and their skin. Having soiled, offensive nappies sitting against a baby's skin and then smelling out the bin becomes almost a thing of the past. Allowing this technique to remain the preserve of the poor in the developing world and a few “hippy” mothers in the West now seems absurd. It's time to review the 40 year old theories on potty training, and for more work to be done on the benefits of getting babies out of nappies.

The benefits of allowing a young baby to start associating a potty with elimination as early as possible are vast, not only for their own health, but for the environment and their skin.