Elimination Communication (EC) is a natural infant hygiene practice that involves recognizing and responding to babies’ elimination cues from birth.
Rather than relying solely on diapers, caregivers learn to interpret their infant’s signals and offer opportunities to eliminate in appropriate receptacles. This approach has gained increased attention as research reveals both benefits and considerations for modern families.
What is Elimination Communication?
Elimination Communication involves three core components: timing, signals, and cues. Parents observe their baby’s natural elimination patterns, watch for physical or behavioral signals indicating the need to eliminate, and use consistent verbal or audio cues to associate the act with toileting.
Unlike conventional potty training, EC is not about the child actively holding urine or feces. Instead, it focuses on communication between caregiver and infant, with the caregiver responding to the baby’s natural elimination needs by providing appropriate positioning and location.
Evidence-Based Benefits
Reduced Bladder and Bowel Dysfunction
The most significant research finding comes from a large Chinese study of over 10,000 children aged 4-10 years. Children who began EC within the first 12 months showed remarkably lower rates of bladder and bowel dysfunction (BBD) compared to those who never practiced EC: 1.36% versus 15.71%. This represents more than a ten-fold difference in long-term urological health outcomes.
Additionally, children who stopped using disposable diapers within 12 months had a BBD prevalence of 2.79%, compared to 4.38% for those who continued diaper use beyond 24 months. A separate study involving 13,500 Chinese children found that early EC initiation (before 12 months) was associated with a 79.6% reduction in disposable diaper dependence.
Improved Bladder Function
Research comparing Vietnamese children (where EC is culturally practiced) with Swedish children found that early elimination communication helps develop more complete bladder emptying. This is medically significant because incomplete bladder emptying can lead to urinary tract infections and other complications.
By 24 months, 98% of Vietnamese children had achieved independent bladder control, while only 55% of Swedish children reached this milestone by 36 months. This suggests that early elimination awareness may accelerate natural development rather than forcing premature control.
Reduced Infant Distress
Studies indicate that EC practice may contribute to reduced unexplained infant crying and colic symptoms. Research by Jordan and colleagues found that elimination communication helps address underlying physiological discomfort that may manifest as fussiness, particularly when babies need to eliminate but cannot communicate this effectively.
Developmental Considerations and Safety
Physiological Readiness
Current pediatric understanding indicates that children develop voluntary bladder and bowel control gradually. While infants under 12 months have no voluntary control over elimination, and limited control between 12-18 months, most children don’t achieve full control until 24-30 months. The American Academy of Pediatrics traditionally recommends beginning toilet training at 18-24 months.
However, research suggests this timeline may reflect cultural practices rather than physiological limitations. EC proponents argue that the practice works with natural elimination reflexes rather than requiring voluntary control, similar to how infants can coordinate sucking and swallowing without conscious control.
Expert Perspectives and Concerns
Pediatric pelvic health specialists express mixed views on EC. Dr. Quiara Smith, a pediatric occupational therapist, cautions that many children who practiced EC experience bowel and bladder issues during toddlerhood and school age. She notes that EC “does not follow typical development and physiology.”
Conversely, medical professionals who have studied EC suggest that when practiced correctly – focusing on communication rather than training – it can be beneficial. The key distinction is avoiding coercion and maintaining realistic expectations about infant capabilities.
Practical Implementation Strategies
For Newborns to 6 Months
Observation Phase: Begin with 2-4 hours of diaper-free observation time daily to identify elimination patterns. Most newborns eliminate frequently and predictably, often immediately after feeding or upon waking.
Basic Positioning: Use the classic EC hold – baby’s back against your torso with hands supporting under each thigh, knees bent. This squatting position facilitates natural elimination.
Cue Development: Introduce consistent verbal cues like “sss” or “pss pss” sounds during elimination to create associations.
Timing-Based Offers: Offer potty opportunities during natural transition times – upon waking, before/after feeds, during diaper changes, and before baths.
For Mobile Babies (6-12 Months)
Increased Independence: Introduce small potties that babies can sit on independently while maintaining close supervision.
Signal Recognition: Watch for more sophisticated signals like pausing activities, vocalizing, or moving toward the potty area.
Routine Integration: Incorporate potty offers into established daily routines to create predictable patterns.
For Young Toddlers (12-18 Months)
This age group presents unique opportunities and challenges, as it coincides with the Montessori “sensitive period” for toilet learning.
Modified Approach: Use the “hybrid plan” which combines EC principles with gentle teaching elements:
- Preparation Week: Introduce daily potty sits and eliminate diapers for 30 minutes daily
- Intensive Days: Schedule 1-2 completely diaper-free days for concentrated learning
- Transition: Move to underwear during waking hours with nighttime diaper backup
Active Teaching: Unlike pure EC with younger babies, this age group benefits from learning practical skills like sitting independently, walking to the potty, and beginning clothing management.
Addressing Resistance and Challenges
Common Resistance Patterns
Potty Resistance: When babies begin refusing the potty, this often indicates developmental transitions or the need for increased independence. Solutions include:
- Providing privacy while maintaining safety supervision
- Moving to the regular toilet to prevent escape
- Temporarily reducing frequency of offers
- Focusing on connection and reducing pressure
Developmental Strikes: Resistance phases are normal and typically coincide with major developmental leaps like crawling, walking, or language development. During these periods, maintain minimal potty offers while prioritizing the parent-child relationship.
Problem-Solving Strategies
Incomplete Evacuation: If babies eliminate immediately after leaving the potty, ensure adequate time on the potty and proper positioning.
Schedule Disruptions: When routines change, temporarily increase diaper use while maintaining core timing-based offers.
Multiple Caregivers: Ensure all caregivers understand basic EC principles and timing patterns for consistency.
Gradual Transition to Independence
Wrapping Up EC (15-18 months)
The transition from supported EC to independent toileting requires specific strategies:
Privacy Provision: Allow toddlers bathroom privacy while ensuring safety, which supports developing autonomy.
Skill Building: Teach practical independence skills like clothing management and proper sitting during calm, non-urgent moments.
Expectation Adjustment: Shift from catching elimination to supporting self-initiation and independence.
Equipment and Environmental Modifications
Age-Appropriate Equipment: Transition from handheld potties to stable, child-sized potties or toilet seat reducers.
Accessible Clothing: Choose clothing that facilitates quick changes – avoid complicated buttons or tight fits.
Consistent Setup: Maintain potty accessibility in primary living areas to reduce barriers to use.
Cultural Context and Modern Adaptation
Elimination Communication remains the predominant infant hygiene method in many cultures worldwide, particularly in developing countries where disposable diapers are less accessible. In these contexts, EC is typically practiced from birth as a normal caregiving function.
Modern Western adaptation of EC requires balancing traditional practices with contemporary lifestyle demands. Research suggests that even part-time EC practice provides benefits, making it accessible for working parents or those unable to commit to full-time implementation.
The practice aligns with attachment parenting principles by promoting increased responsiveness to infant cues and enhanced parent-child communication. However, experts emphasize that EC should enhance rather than stress the caregiving relationship.
Conclusion and Recommendations
Evidence suggests that Elimination Communication, when practiced responsively and without coercion, can provide significant benefits for infant urological health and family bonding. The most compelling research demonstrates substantially reduced rates of bladder and bowel dysfunction among children who practiced early EC.
Key principles for successful implementation include:
- Starting with realistic expectations and flexible commitment levels
- Focusing on communication rather than performance
- Adapting methods to individual family circumstances and infant temperament
- Maintaining positive caregiver-infant relationships as the primary goal
- Seeking guidance from experienced practitioners when encountering challenges
While not suitable for every family, EC represents a evidence-supported approach to infant hygiene that honors both physiological development and natural communication patterns. The growing research base continues to support its potential benefits when implemented thoughtfully and responsively.
Citations
https://themontessorifamily.com/elimination-communication-or-toilet-learning-without-a-diaper/
https://www.tinyhood.com/expert-articles/potty-training/how-to-potty-train/elimination-communication-an-overview-and-what-experts-say
https://www.thebump.com/a/elimination-communication
https://www.healthline.com/health/parenting/elimination-communication
https://pmc.ncbi.nlm.nih.gov/articles/PMC8196082/
https://godiaperfree.com/how-do-i-start-ec-or-toilet-learning-with-a-young-toddler-12-18-months-old-aka-late-start-ec/
https://www.communityeconomies.org/sites/default/files/2019-04/Learning%20to%20be%20affected%20sharing%20version%20Dombroski.pdf
https://godiaperfree.com/worldwide-ec-survey-results-what-nuria-discovered-surveying-over-1000-ec-families-around-the-world/
https://www.thenappylady.co.uk/news/what-is-elimination-communication.html
https://parentingscience.com/infant-toilet-training/
https://pmc.ncbi.nlm.nih.gov/articles/PMC9869372/
https://www.reddit.com/r/ScienceBasedParenting/comments/pm52gx/studies_on_elimination_communicationnatural/
https://rebeccamottram.com/2018/03/16/the-dangers-of-early-potty-training-do-they-really-exist/
https://www.eliminationcommunicationbabies.com/explore/posts/517492-elimination-communication-research-study-and-
https://eric.org.uk/about/the-evidence-base/
https://huckleberrycare.com/blog/potty-training-methods-which-is-best-for-your-child
https://www.motherandbaby.com/baby/development/elimination-communication/
https://godiaperfree.com/10-golden-rules-for-observation-time/
https://godiaperfree.com/my-baby-resists-the-potty-and-pees-on-th-floor-right-after-what-do-i-do/
https://www.thenappygurus.com/blog/what-is-elimination-communication-ec.html
https://www.wonderbaby.org/articles/elimination-communication
https://godiaperfree.com/how-to-solve-potty-resistance-during-wrap-up/
https://godiaperfree.com/help-we-have-complete-resistance-part-2/
https://www.mother.ly/baby/baby-health/what-is-elimination-communication/
https://godiaperfree.com/infant-potty-training-in-indigenous-africa-how-people-potty-their-babies-in-countries-without-diapers-part-1/
https://www.nature.com/articles/s41598-021-91704-3
https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2022.1053118/full
https://www.siccr.org/wp-content/uploads/2015/08/toilet_training_july_2015_en.pdf
https://www.youtube.com/watch?v=h1t1Sa7qSz8
https://www.ohbaby.co.nz/baby/growth-and-development/elimination-communication
https://www.thenappylady.co.uk/news/elimination-communication-a-beginners-guide.html
