Response to Dr. Hodges’ criticism of infant potty training

On 04/17/12, the Huffington Post ran an article written by Dr. Steve Hodges sharply criticizing early potty training.

Dr. Hodges claims in his article that early toilet training leads to chronic holding of the bowels, which according to his research  can lead to a whole host of problems, including urinary tract infections and bedwetting. We AGREE that holding your bladder and bowels does not sound like a good idea. Where we DISAGREE with Dr. Hodges is with the assertion that infant potty training (“IPT”) results in  chronic holding.

Dr. Hodges’ recent publication in the Urology, on which his attack on IPT was based, was a retrospective study of patients that came into his clinic with the complaint of nighttime bedwetting.  In a retrospective study, a researcher (in this case, Dr. Hodges) gathers information from patients in order to establish a relationship between a current condition and something that has already occurred in the past.  In Dr. Hodges study, he was trying to show a relationship between nighttime bedwetting and constipation.  The problem with retrospective studies is that they are subject to error and bias, and cannot with any accuracy claim cause and effect.  Dr. Hodges knows this, and in his research, acknowledges that the retrospective nature of his research was a key limitation.  Dr. Hodges did NOT establish cause and effect between bedwetting and constipation, although his conclusion is certainly persuasive.

At larger issue, Dr. Hodges uses this research to extrapolate that IPT leads to chronic holding, which presumably leads to constipation and then nighttime bedwetting. Subjects for his study ranged in age from 5 to 15 years of age, with an average age of 9 years.  A huge oversight on Dr. Hodges’ part is that he never collects information on the age at which these children were potty trained!  So how can he assert that IPT is responsible for chronic holding?  He could not establish cause and effect for bedwetting and constipation, and yet he tries to establish a link between IPT and constipation without collecting the data.  In fact, we’re not sure what information Dr. Hodges collected from the patients other than their ages.  We know nothing of their weight, diet or physical activity level, all of which may play a role in their constipation.

He presents a compelling argument for bedwetting-constipation link, but he has no proof nor does his research even analyze toilet training habits of his patients.  Additionally, a review by Oliveira da Fonseca et al in the April 2011 issue of the Journal of Pediatric Urology found no association between IPT (defined in this study as < 24 months) and dysfunctional elimination syndrome (symptoms include urinary tract dysfunction and constipation).  These researchers had 80 patients between the ages of 3 and 17 years.  Given that this investigation a larger sample size (Dr. Hodges study had a sample size of 30, all patients at his urology clinic)and specifically looked at the impact of IPT and constipation, it seems clear that the relationship established is that there is no relationship between IPT and constipation.

Moreover, we disagree with his claim that early potty training is the causation behind the “holding epidemic” he discusses in his article.

Infant potty training/ elimination communication

Let’s talk about the basics of infant potty training (“IPT”), also known as elimination communication (“EC”). IPT is about encouraging children to listen to their bodies. It is natural and instinctual for all animals, including human beings, not to soil themselves and their habitat. Human beings are the only animals to diaper their young. By diapering our children, we teach them to use their diaper as a toilet. Conversely, IPT fosters baby’s natural instinct and introduces the potty at birth (or generally within the first few months).

This type of potty philosophy has existed throughout time and throughout many different cultures, where children have potty “trained” significantly sooner than what is typically seen in this country. In Dr. Hodges’ own words “holding [bladders and bowels] is epidemic in contemporary Western culture and on the rise.” If IPT were the cause of these holding problems, wouldn’t holding be epidemic in cultures, like China and India, where IPT is commonly practiced?  Conversely, “holding” is a problem that is growing in Western culture where the norm is to diaper children until around the third birthday, the average age of when children become potty trained in the US.

We believe that people develop very strong attachments to their bathroom habits. Even adults are known to exhibit extreme resistance to breaking their own bathroom customs and habits. It is very common for people to find it difficult to use bathrooms outside of their own home, particularly when it comes to bowel movements. A common response for adults would be to hold it. Even though adults may realize that this is not a healthy response, it can be very difficult shaking the psychological discomfort of going in a public bathroom.

Now, imagine the predicament of a child who has been taught to use her diaper for her entire life, and years later, is told to now go in a toilet. Naturally, many children have a very difficult time letting go of the security of their diaper, as it has been their bathroom habit for so long. A common child’s response is no different than any other human being- holding it.

Dr. Hodges believes that early potty training results in children not being able to freely eliminate when the need arises. We believe that diapering forces children to be so dependent on their diapers for their toileting needs that they are rendered unable to go otherwise.

Let’s look at Dr. Hodges claims:

“For most babies, wearing diapers facilitates unconstrained elimination.”

IPT believes that babies have a natural instinct to not soil themselves and are amazingly primed to learn at birth. A child’s brain is like a sponge, and they learn at an extraordinary pace, especially during the first few years of their life. Diapering may have the unintended consequence of having the child ignore their bodies’ elimination signals. In fact, disposable diapers are so “good” that they often strip away the child’s ability to even be aware of what their body is doing, making it ever more challenging for our children to become potty trained.

IPT believes that babies should be encouraged to listen, rather than ignore, to what their bodies are telling them. And IPT believes this learning begins at birth, not three years down the road, after diapering training has already taken place.

“It takes an evolutionarily advanced brain to realize that by holding in their poop, you can play Rapunzel for a few more uninterrupted minutes (or hours).”

Yes, every parent can appreciate how enraptured a child can be during play. Children are so busy learning, that they often don’t have the time to be bothered with things like using the bathroom. This is true at 6 months of age, 2 years, 3 years, even 5 years old. We don’t believe this to be a good reason to hold off potty learning since playing with Rapunzel will generally win out for years to come. Families practicing IPT understand that misses are common during these times. But we believe that we should encourage our children to listen to what’s happening to their bodies, rather than teaching them to ignore it completely.

Moreover, we think IPT/EC makes babies MORE aware of their eliminations, and if they’re smarter about what’s going on with their bodies, then they are MORE likely to eliminate when they need to go, since they know how to get rid of that uncomfortable feeling! Furthermore, we’ve talked with parents that do NOT EC their kids (kids that use diapers, no potty training whatsoever), and they’ve commonly noted that they don’t poop in their diaper at daycare/ with caregiver/out of the house, or only poop in their diaper when they are with them. Our conclusion- we think kids are just like adults, they poop when they feel comfortable doing so. And so “holding it” is not a problem limited to potty training grads or infant potty training/ elimination communication babies.

“Chronically holding poop, a problem exacerbated by Western kids’ low-fiber diets, compounds the damage.”

Here is where we absolutely agree with Dr. Hodges.  No matter what your bathroom habits may be, diet will no doubt play a role.

“Chronically holding pee and poop also causes urinary tract infections.”

Peeing and pooping in a diaper also increases your risk of getting a urinary tract infection. The vast majority of urinary tract infections (UTI) are caused by the bacteria Escherichia coli (“e. coli”) which originates from the intestines. Females are at higher risk for urinary tract infections, which is believed to be partially attributed to a shorter uretha as well as the close distance between the anus and uretha. Anyone who has ever cleaned up a poopy diaper understands how easily fecal matter can get into the uretha, increasing the risk for a urinary tract infection.


After reading his research, it’s evident that Dr. Hodges did not definitively establish cause and effect between nighttime bedwetting and constipation because of the nature of the study (retrospective).  We assume he thinks chronically holding your bowels leads to constipation.  This makes perfect sense to us, and we agree.  You shouldn’t hold it when you need to go.  However, there is NO proof that IPT results in chronic holding!  Dr. Hodges did not establish it.  In fact, he did not even try because his data collection did not include toilet training age, and other research has affirmatively shown a lack of relation between IPT and constipation.  Therefore, his attack on IPT is truly without merit.



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