Elimination Communication:

Diaper-Free in America
Jeffrey M. Bender, MD,a,b Rosemary C. She, MDc

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 childrens worth of diapers to our nations 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 infants 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
aChildrens Hospital Los Angeles, Los Angeles, California; and
Departments of bPediatrics and cPathology, Keck School of Medicine,
University of Southern California, Los Angeles, California
Drs Bender and She conceptualized, researched, and jointly
wrote the manuscript as submitted.
DOI: https://doi.org/10.1542/peds.2017-0398
Accepted for publication Feb 28, 2017
Address correspondence to Jeffrey M. Bender, MD,
Department of Pediatrics, Childrens Hospital Los Angeles,
4650 Sunset Blvd, MS 51, Los Angeles, CA 90027. E-mail:
jbender@chla.usc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-
4275).
Copyright 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they
have no financial relationships relevant to this article to
disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have
indicated they have no potential conflicts of interest to
disclose.
To cite: Bender JM and She RC . Elimination Communication:
Diaper-Free in America. Pediatrics. 2017;140(1):e20170398

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PEDIATRICS Volume 140, number 1, July 2017:e20170398 PEDIATRICS PERSPECTIVES
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
Benders 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.
2 Bender and She
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
dont 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
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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.
Abbreviations
EC:elimination communication
MRSA:methicillin-resistant
Staphylococcus aureus
References
1. Morin GV, inventor; Chicopee
Manufacturing Corporation, assignee.
Waterproof disposable diaper. United
States Patent US 2699170 A. January
11,1955
2. Brazelton TB. A child-oriented approach to
toilet training. Pediatrics. 1962;29:121128
3. Stadtler AC, Gorski PA, Brazelton TB;
American Academy of Pediatrics.
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PEDIATRICS Volume 140, number 1, July 2017
Toilet training methods, clinical
interventions, and recommendations.
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13591368
4. Real Diaper Association. Diaper facts.
Available at: http://realdiapers.org/
diaper-facts. Accessed February 1,
2017
5. Duong TH, Jansson UB, Holmdahl G,
Silln U, Hellstrom AL. Development
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6. Sugimura T, Tananari Y, Ozaki Y, et al.
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8. Liu C, Bayer A, Cosgrove SE, et al.
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9. Theveniau N, Boisgontier MP, Varieras
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645192504/A-newold-way-to-toilet-train-
baby.html. Accessed February 1, 2017
3
 Elimination Communication: Diaper-Free in America
Jeffrey M. Bender and Rosemary C. She
Pediatrics; originally published online June 21, 2017;
DOI: 10.1542/peds.2017-0398
Updated Information & including high resolution figures, can be found at:
Services /content/early/2017/06/19/peds.2017-0398.full.html
References This article cites 7 articles, 2 of which can be accessed free
at:
/content/early/2017/06/19/peds.2017-0398.full.html#ref-list-1

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2017 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Elimination Communication: Diaper-Free in America
Jeffrey M. Bender and Rosemary C. She
Pediatrics; originally published online June 21, 2017;
DOI: 10.1542/peds.2017-0398

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/early/2017/06/19/peds.2017-0398.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2017 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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