Here I was peacefully teaching my 10-18 month potty workshop this past weekend and along comes Dr. Steve Hodges on HuffPost telling parents, “Don’t Potty Train Your Baby” by asserting that Elimination Communication causes stool withholding (what?!) and that waiting longer for potty learning has no consequences (he simply does not believe the many studies *below* which suggest the opposite). One article in the Huffington Post catches like wildfire and suddenly early potty-ers like me are wrong along with an entire planet full of parents who practice infant elimination communication. [Update: years later, this same Hodges article, in various forms, still circulates widely and so I keep updating this article].

The point of the following article will be to separate what Dr. Hodges knows scientifically from merely his opinions on potty learning as well as to remind parents:

A) THERE ARE ZERO STUDIES THAT SHOW EARLY POTTY LEARNING OR E.C. TO BE HARMFUL.

B) THERE ARE MULTIPLE STUDIES SHOWING LATE POTTY TRAINING TO BE HARMFUL

Lets be very clear that on the age of potty training, Dr. Hodges has published exactly 1 study of 110 children in a pediatric urology practice. He was able to posit a correlation (not prove) that kids who started potty training at 24 months rather than around 30+ months might be more likely to hold pee and poo in which may have led to their medical dysfunctional voiding issues. This clearly has absolutely nothing to do with babies who learn Elimination Communication (which by definition starts way before 24 months), except that Hodges has decided to make a far reaching assumption. We are talking about an MD who also believes the best way to support overactive bladder and chronic constipation in children is a daily enema. 

Everything I have read in years of collecting research* points to THE OPPOSITE OF DR. HODGES OPINION: Stool withholding is more prevalent the LATER a child learns potty. I am deeply concerned that by reading this article, parents will further push back potty learning and that will cause further widespread UTIs, bowel withholding and infection, constipation and bedwetting almost into the preteens. I know the research, anthropology and biology behind Elimination Communication and Early Potty and from 20 years of working with small children as a toddler preschool teacher and director, as a childcare specialist and consultant and parent. My practice has been, among other things, helping typical healthy children navigate toileting. His practice has mainly been finding bowel obstructions and causes of acute urinary tract infection in sick children.

Hodges is using the research he knows best (on stool withholding and nighttime incontinence in children with major medical challenges), taking a large jump and conflating stool withholding problems with the age of potty learning.  Dr. Brazelton took a swift jump just like this in the late 1950’s when he conflated the forcing/shaming/suppository stuffing and punitive parenting methods of time with the age at which parents were starting potty.

Since Dr. Brazelton began speaking about the “Readiness Method” of potty (and since Pull-Ups in the 80’s and 90’s paid him to act in their ads), the age of beginning potty learning has gone up dramatically, and the amount of time it takes to learn potty from start to finish now takes a year on average and the rates of stool withholding, constipation, urinary tract infection and diaper rash infections have sharply risen.

I don’t want to be at odds with Dr. Hodges. I’ve looked back at articles he has written and while I can’t find a study of his to back up his claim that the many of his patients with stool withholding problems were the ones who potty trained around 2 years had more stool withholding problems than those who trained at 3 (maybe it was actually harsh parenting and not the age?) – I have noticed that this doc has a great heart. He, like me, is very concerned about the increase in bedwetting, stool withholding and constipation of children. However, I don’t understand why he is failing to see the bigger cultural picture here – that what has constantly risen parallel alongside these bedwetting and withholding problems is the age of beginning potty training.

Apparently Dr. Hodges has never heard of  Dr. Jill M. Lekovic MD who recently spent years compiling the medical, psychological, sociological and anthropological literature about toilet training from all over the world and put it into a book called “Diaper Free Before 3.”   Dr. Lekovic is not a friend of mine and she’s not super crunchy like me either – she’s not into extended breastfeeding and she doesn’t love cloth diapers, but I can still recognize that she wrote a very medically thorough book urging parents to begin potty learning earlier to protect the health of their children. Dr. Hodges, you should read it!

First, let’s talk about what Dr. Hodges does know. He tends to say, “In my experience” in his article which is valid. There are plenty of other pediatricians and pediatric urologists whose work I have read (below) who have had a different experience. Dr. Hodges believes that he has both experience and research to say that full bowels at night cause bedwetting and this is his primary area of concern and research.  Now, I didn’t see the images of full bowels during sleep on X-RAY, so I have to let him have this one. But I do also know that a previous study from the Pediatric Journal of Urology shows that there is a very significant and accepted genetic component to nighttime bedwetting which Dr. Hodges doesn’t mention here.

STOOL WITHHOLDING:

Dr. Hodges said, “Chronic holding is a damaging habit, and in my experience, children trained early — especially before age 2 — are more prone to developing this habit than kids trained around age 3, though kids trained later are certainly not immune from holding, and early trainers are not destined to become holders.”

If 2-year-olds are more likely to withhold than 3-year-olds, what is the theory as to why that would be true? And it certainly sounds like he was talking about a difference between a 2-year-old who has not had infant elimination practice and a 3-year-old who has also not had infant elimination practice, so why is he telling parents who practice Elimination Communication that they are wrong? Has he treated children who have stool withholding problems that you believe came from infant elimination communication? No. Of course not, or he would certainly quantify it with a chart and quickly prove his point. The truth is: HEALTHY BABIES WHO LEARN POTTY EARLY AND GENTLY DON’T HAVE STOOL WITHHOLDING ISSUES. PERIOD. Stool withholding is something that often comes from issues of constipation, anxiety and/or in children who learn potty after the age of 2. 

Dr. Hodges just needs an education on E.C. and early potty. You see, when babies are taken to the potty frequently to empty bladder and bowels (as is done in E.C. families, most of whom are extremely attentive to these needs and not cruelly making their children wait – as you suggest) – they are learning to go to the potty and empty frequently, an extremely healthy lifelong habit. When we let older children decide if or when they will start using the potty, we create toddlers who hold it because they are busy and don’t want to go.

And that is why I teach parent-led gentle early potty (starting between 10-18 months of age when they can begin communicating about their needs) for those who didn’t, for whatever reason, start EC earlier.  When breastfed babies gradually learn to hold poop or pee for very short periods of time and gradually learn to communicate to parents to get them to the potty, they are slowly and gradually building the muscle control they already inherently have.

Dr. Hodges goes on to posit that learning to “put off peeing and pooping” (meaning hold it until you can’t hold it anymore) is the definition of toilet training. WHAT?  Then we are not talking about the same thing here. EC is about helping a child learn to make frequent trips to the bathroom to eliminate by beginning early that way – putting them on a pot frequently.  I certainly agree that holding it for long periods of time is a major problem!  And although this doctor says he has some anecdotal evidence from his practice that some kids who are potty trained a little earlier are the ones with bowel challenges, he does not state what method these families used, how harsh the parents were or whether any of them practiced elimination communication in infancy. But if he’d like to provide more than one case study or some numbers from his practice or a study looking at withholding in toddlerhood and having practiced early potty/EC before 15 months, I’d love to read it.

CONSTIPATION

As I said above, I believe stool withholding to be a problem stemming from constipation that hurts or from parentally-imposed anxiety around toileting.  Even a normal bowel movement that is slightly large can be uncomfortable at any age. No matter the age of potty learning, starting potty during a bout of constipation might lead to associating potty with pain and subsequently the child not wanting to poop on the potty. Toddlers who eat a lot of dairy and not enough fiber or who resist drinking water will have more constipation. Babies or toddlers who are still on breast milk or who are not eating mostly solids are much less likely to have constipation which is one of the huge benefits of starting potty early. Older toddlers often can become more picky over time and will choose white fiber-less foods and dairy products. Younger babies have softer poo and that makes toilet learning easier.

URINE WITHHOLDING AND UTI

When a parent decides it is time to start potty learning based on perceived cues of the child as in the readiness method, it is still the parent who decides to buy a little potty and encourage going. By 2.5 years or so, even the gentlest parent is personally invested in making potty happen and this can translate into unspoken anxiety children are very perceptive about (E.C. parents are actually often less concerned with a certain age to be trained by because they are starting plenty early). Toddlers this age of 2 or so are also very playful, funny, tricky, defiant, busy, fast, independence-minded and not exactly prone to doing those things which you are most hoping for – like cleaning up his toys. This is why they are so darned cute and also why potty learning after 2 is so talked-about and challenging! Pediatricians know that many toddlers simply hold pee because they do not want to take time out from activities. Early potty learning while the child is still looking to the parent for entertainment and constant connection is a much better time/way to teach the healthy habit of visiting the potty often to relieve oneself.

And if you want to talk about urinary tract infections, you absolutely must not leave out Diaper Rash! Pee stings diaper rash and so babies and toddlers withhold pee – causing infection. So away with the diapers and onto the potty. Earlier Potty is how I cured my daughter’s recurrent UTIs, at the suggestion of her doctor, and why I am such a fervent early potty advocate. I believe the reason Dr. Hodges says he sees many newly potty learning toddlers (2-3 years) with UTIs in his clinic is because the children are at a cognitive age of development where they don’t want to pee in the pull-ups because they don’t want to disappoint a parent or because they are so busy in their play. So we don’t want to go to the restroom but we don’t want to have an accident and upset our parents, so we hold it – unless we’ve learned to potty regularly throughout the day before we arrived at this busy, sensitive and defiant 2 years. 

It is not because children in diapers don’t get UTIs as Hodges suggests. A regular Pediatrician doesn’t send a diapered non-pottying patient to a Pediatric Urologist like Dr. Hodges, she simply medicates the diaper rash and treats the UTI with antibiotics. Just because Dr. Hodges hasn’t seen diapered children with UTIs, doesn’t mean they don’t exist. I hear about them every week. They are a very common pediatric issue that does not usually require a urologist. This is a simple example of a specialist using his tiny frame of reference to make a generalization. As a specialist, you must realize that the insights gained come from your specific practice don’t always hold true for most healthy children. Hodges sees the worst medical cases. But for most children, diet and method of toileting must have much more to do with common withholding and constipation than age of potty learning. 

Dr. Hodges’ article seems to suggest that the bathroom situations in this country and in schools being awful makes early-trained children ill-equipped to use the restroom.  But isn’t that true for all children, no matter what age they learned potty? Actually, the healthy, clean, sanitary and sane thing E.C. parents do (like many other, non-E.C. parents) is to bring a travel potty for your child (6 months or 6 years!) wherever you go! This shows how truly out of touch with actual parenting of typical healthy kids this doc is. 

How bull-headed and closed-minded is Dr. Hodges’ assertion that we don’t need to look cross culturally, historically or anthropologically when we are looking at a health practices issues?  Why would somebody say that we should ignore cross-cultural comparison with regards to keeping or changing health practices? And it is also so easy for him to poo-poo the effect on the environment and your pocketbook, but last I checked those were both very real concerns for many parents.

Another Place Hodges and I Disagree: Militant Potty

“Watch your child like a Secret Service agent once he is out of diapers. (This applies to all newly trained kids, regardless of when they trained). Have him on a peeing schedule so that he never goes more than about two hours without using the toilet. Have him sit on the potty to poop after breakfast and dinner. Never ask, “Do you need to go potty?” All kids will say no. It’s your job to instruct your child to go. Don’t lose track of the last time he pooped and what his poop looked like.” – Dr. Steve Hodges

Wow. That’s intense. That’s the sort of disrespectful militant parenting that causes potty problems like fear, shame and resistance in the first place. Oh well, more $$ for Dr. Hodges. Just because the small amount of children Hodges works with need specific medical interventions around timing, that does not mean all children should be treated like this. Not losing track of the last time your child pooped or what it looked like? Sounds like a recipe for parental frustration and anxiety that will rub off on the child, likely causing him to refuse toileting.

When we begin with pre-walkers, we don’t ever need to force them. They happily spend time with us while we hold them on their little pot, in much the way we hold them all day. Potty does not have to be scheduled or regimented, though I love to think about trying to get there about every hour at first and every two hours once pretty savvy, but not on a clock. And it is absolutely recommended to ask your older child if they need to go. How else will they learn to check in with their own bodies. We must give them this agency at some point. Most happily toileting children will say yes if they do. Many children will not want to interrupt their play. I suggest asking again 5 minutes later. Things change quickly with little ones.

Dr. Hodges didn’t include the many articles and studies from the U.S., Canada and Europe which he said not to post in his comments because he’d already read them and didn’t agree with any of them, but since they are highly regarded by other pediatricians and psychologists, I’ve included them below. I believe you deserve more than just my opinion. 

UPDATE: I came across a very important study. Oliveira da Fonseca et al in the April 2011  Journal of Pediatric Urology found no association between Infant Potty Training (defined in this study as < 24 months) and dysfunctional elimination syndrome (symptoms include urinary tract dysfunction and constipation). Here there were 80 patients between the ages of 3 and 17 years, looking back at age of potty learning.  Given that this study’s larger sample size (Dr. Hodges study had a sample size of 30, all patients at his urology clinic), the new study specifically looked at the impact of Infant Potty and constipation, it was clear that there is not a relationship between Infant Potty and constipation. (Since Hodge’s collection of data from his practice did not look at infant potty learning at all, and in fact, he may have himself had zero patients who learned as infants and his feelings about infant potty learning may be only a theory. A theory which had been proved wrong when looked at by these other researchers the year prior.) http://www.jpurol.com/article/S1477-5131(11)00080-5/abstract

For anyone who feels they “missed the boat” on infant elimination communication and doesn’t know where to start with potty, you can check out courses and consulting on my Potty Page.  — If you have a newborn or are expecting and want to go for EC, check out The Diaper-Free Baby or Infant Potty Training.

*Potty Articles and Studies:

American Academy of Pediatrics. 2006. Toilet training readiness American Academy of Pediatrics website. (visited November 24, 2006)

Bakker E; Wyndaele JJ. 2000. Changes in the toilet training of children during the last 60 years: the cause of an increase in lower urinary tract dysfunction? British journal of Urology, 86(3):248-52.

Bakker W. 2002. Research into the influence of potty training on lower urinary tract dysfunction. Unpublished MD dissertation, Department of urology, University of Antwerp, Belgium.

Bakker E, van Gool JD, van Sprundel M, van der Auwera JC, and Wyndaele JJ. 2002b. Results of a quaestionaire evaluating the effects of different methods of toilet training on achieving bladder control. British Journal of Urology, 90: 456-461.

Bakker, Els, and Jean Jaques Wyndaele.”Changes in the toilet training of children during the last 60 years: The cause of an increase in lower urinary tract dysfunction?” BJU International, 86 (2000) 248-252

Barone JG, Jasutkar N, Schneider D. 2009. Later toilet training is associated with urge incontinence in children. J Pediatr Urol. 5(6):458-61.

Blum NJ, Taubman B, and Nemeth N. 2003. Relationship between age at initiation of toilet training and duration of training: A prospective study. Pediatrics, 111: 810-814.

Blum, NJ and B. Taubman and M.L. Osborne. “Behavioral characteristics of children with stool toileting refusal.” Journal of Pediatrics, 99 (1) (1997)50-53

Brooks, Robert C, et al. “Revidw of treatment literature for encopresis, functional constipation and stool-toileting refusal.” Annals of Behavior Medicine, 22 (3) (2000) 260-267

Poole JM, Stadtler AC, Wright CL. 1999. Instruction, timeliness, and medical influences affecting toilet training. Pediatrics, 103: 1353-1358.

Canadian Pediatric Society. 2000. Toilet learning: Anticipatory guidances with a child-oriented approach. Paediatrics and Child Heath, 5: 333-5.

DeVries, Marten W.; and M. Rachel deVries.  “Cultural relativity of toilet training readiness: A perspective from East Africa.” Pediatrics, 60 (2) (1997) 170-177

Gladh G, Persson D Mattsson S and Lindstrom S. 2000. Voiding pattern in healthy newborns. Neurourology and urodynamics, 19: 177-184.

Gorski PA. 1999. Toilet training guidelines: Parents—the role ofparents in toilet training. Pediatrics, 103: 362-363.

Hellstrom AL, and Sillen U. 2001. Early potty training advantageous in bladder dysfunction. Decreases the risk of urinary infection (in Swedish). Lakartidningen. 98: 3216-9. Ned Tijdschr Geneeskd., 147(1):27-31

Horstmanshoff BE, Regterschot GJ, Nieuwenhuis EE, Benninga MA, Verwijs W, and Waelkens JJ. 2003.[Bladder control in 1-4 year old children in the the Eindhoven and Kempen region (The Netherlands) in 1996 and 1966]

Jansson, U.-B et al. “voiding pattern in healthy children 0-3 years old: A longitudinal study.” Journal of Urology, 164 ) (2000) 2050-2054

Joinson C. et al. A prospective study of age at initiation of toilet training and subsequent daytime bladder control in school-age children. Journal of Developmental and Behavioral Pediatrics 2009 Oct;30(5):385-93.

Kiddoo, Darcie A. Toilet training children: when to start and how to train. CMAJ, August 8, 2011 DOI: 10.1503/cmaj.110830

Kinservik, Margo A., and Margaret M. Friedhoff. “Control issues in toilet training. Pediatruc Nursing, 26 (3) (2000) 267-272.

Largo RH, Molinari L, von Siebenthal K, and Wolfensberger U. 1996. Does a profound change in toilet-training affect development of bowel and bladder control? Dev Med Child Neurol. 38: 1106-16.

Luxem M and Christophersen E. 1994. Behavioral toilet training in early childhood: research, practice, and implications. J Dev Behav Pediatrics, 15(5):370-8.

Monsen, Rita B. “Giving children control and toilet training.” Journal of Pediatric Nursing, 16 (5)  (2001) 375-376

Rubin, Greg. “Constipation.” Clinical Evidence, 7 (2002) 292-296

Schum TR, Kolb TM, McAuliffe TL, Simms, MD, Underhill, RL and Lewis M. 2002. Sequential acquisition of toilet-training skills: A descriptive study of gender and age differences in normal children. Pediatrics 109: 48-54.

Sillen U and Hanson E. 2000 Control of voidings means better emptying of the bladder in children with congenital dilating VUR. British Journal of Urology, 58: 13.

Smeets PM, Lancioni GE, Ball, TS, and Oliva DS. 1985. Shaping self-initiated toileting in infants. Journal of applied behavior analysis, 18: 303-30.8

Taubman B. 1997. Toilet training and toileting refusal for stool only: A prospective study. Pediatrics, 99: 54-58.

Yang SS,  Zhao LL, Chang SJ. 2011. Early initiation of toilet training for urine was associated with early urinary continence and does not appear to be associated with bladder dysfunction. Neurological Urodynamics.  Sep;30(7):1253-7. doi: 10.1002/nau.20982. Epub 2011 Mar 10.

Yeung, 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 Urology, 76:235-40.

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