MM: Can you give us an idea of what Elimination Communication is, and how caregivers might practice it?
GJ: Elimination Communication refers to the gentle, nurturing response of a caregiver to a baby’s needs to eliminate (that is, pee and poo). You might also hear of Elimination Communication as EC, Natural Infant Hygiene, infant-potty training, baby-led potty training and assisted infant toilet training. However, really, while we think of toilet training as a sort of skill taught to a child, in the context of infants, it is not training at all, but a kind of communicating. I have read that in China, EC is known as baniao, and in some places of the world, there is apparently no word for EC, because it is simply what you do with babies.
So, how do you “do” EC? EC practice involves the baby using cues or signals to tell the caregiver about toileting needs. Research by Dr. Simone Rugolotto and others shows that babies provide cues that they need to eliminate: such as grunting, flushed face, passing gas, intent look, fussing and crying. The baby’s caregiver then responds by gently holding the baby in a secure and supported posture to help the baby eliminate. This position can be with the baby’s back against the caregiver’s chest, and with the caregiver gently and securely holding the baby’s legs, while the baby’s bottom is undiapered. The caregiver holds the baby over an appropriate receptacle, such as a bowl, potty, sink (or, really, anywhere appropriate for elimination). There are other ways of holding the baby also, but it is always in a gentle and secure way, so that the baby is kind of in a cradled squatting position, and all elimination wastes are expelled away from the baby’s body, keeping the baby’s bottom very clean indeed.
In addition to looking for cues, the caregiver also uses timing to help the baby eliminate at certain times, like waking up from sleep, or after feeding when the gastrocolic reflex has been stimulated. Some authors who write about EC, like Ms. Laurie Boucke and Ms. Ingrid Bauer, discuss the fact that intuition is also used in knowing when to give your baby an opportunity to eliminate. (I should mention here that intuition, in this context, is probably a form of caregiver awareness.) So cues, and timing, along with caregivers’ instinctive awareness about their baby, are all part of what guides EC practitioners to respond the baby’s elimination needs.
MM: Many parents I deal with in practice have never heard of EC or natural infant hygiene, could you give us an idea of what this is and why it's important?
GJ: I think the reason that many parents in your practice may never have heard about EC is largely due to cultural influences. We can maybe start with defining the idea that today’s western world is really a minority world because the majority of the world’s human population is not aptly defined by “Western” characteristics. In fact, Dr. Kelly Dombroski’s research on water, sanitation and hygiene (WASH) indicates that the private household toilet is the exception, rather than the norm, and that EC forms part of successful hygiene practices in the majority world. We can say that our (that is, the minority world’s) current lack of knowledge about EC is a result of some critical turning points in history, including events in the Industrial Revolution, the invention of plastic, and mid-20th century changes in child toilet training approaches.
With respect to the history of diapering, Dr. Bernice Krafchik indicates that, around the mid-20th century, plastic disposable diapers became widely available in infant caregiving in the minority world. Around this same time, caregiving toileting practices were revised upon recommendations based on the research by reknowned pediatrician Dr. Berry Brazelton in 1962. Rejecting some early toilet training methods from previous decades which were supposedly coercive (and rightly so, that is, to reject any coercive methods), Dr. Brazelton championed a child-oriented approach. Dr. Brazelton’s approach, which advised that caregivers wait until the child shows signs of toilet training readiness in all aspects, has been adopted by the present-day minority world medical community, and has consequently resulted in caregiving methods in which children are exclusively diapered until about two years of age, or longer.
In some ways, EC compared to current toilet training methods, is probably very much like breastfeeding compared to bottle-feeding, 50 years ago. We now know that breast-is-best when at all possible. The same may indeed be true of EC, a traditional knowledge which has sustained humans through the millennia, by hygienically managing infant waste without plastic diapers. I know that, to our minority world, it seems incredible that we could raise infants without diapers, and by this I mean, without full time reliance on commercial diapers, or even full time reliance on cloth diapers. However, bombarded with their advertising, disposable diaper companies would certainly make us think otherwise. Reporters Raju Narisetti and Jonathan Friedland from the Wall Street Journal reported in the 1990’s about the huge commercialization of diapers at that time, creating (perceived) dependence through affordable products which have been aggressively marketed in places around the world, such as Brazil, where reliance on cloth, or nothing at all, had been the norm. This aggressive marketing continues today, as seen in advertising everywhere, to carve out markets for multinational companies, throughout the world, and to new niches: older children.
From a money-making perspective, it’s really motivating for multinational companies to create a cultural dependence on something disposable, especially over something that babies do every day. However, this is only contrived dependence, with many negatives. These negatives include environmental damage in the manufacturing of diapers, energy use, transit, disposal, etc. Negatives also include the high financial cost of diapers to households, especially to low-income households. So, when you think of becoming less reliant on diapers, there are huge environmental, and household financial, benefits. But, these benefits are really small when you think about tangible and intangible relational benefits, such as human attachment through the communication between baby and caregiver. In fact, Dr. Dombroski studies these in her research, that of attachment. When we are in tune with our babies, we are very able, and confident, to meet their basic human needs. EC is one of the most amazing ways of tuning into our babies that we can have. We might even be able to say that it is the back-end of feeding. It is so important, and in fact, transformational.
MM: In your 2014 publication you speak about EC possibly having a role to play in reducing colic symptoms. Could you give some insight into the physiology and neurology that would be involved in it helping to reduce excessive crying?
GJ: Yes. It’s common knowledge that needing to go to the bathroom is uncomfortable. Needing to go to the bathroom, but not being able to, is even more uncomfortable! Researchers Dr. Vildan Tunc and others, in a 2008 paper, evaluated stooling patterns in infants under two years of age. Dr. Tunc and others stated that “[t]o our knowledge, the relation of infantile colic to stool frequency has not been previously demonstrated. Less defecation due to slow transit time may result in distention of the gut and pain and crying in the infant, and this may be an associated reason of infantile colic” (Tunc. et al 2008, 1361). We can explore this hypothesis of infant crying being related to elimination needs in two ways: physiologically, and culturally.
Physiologically, it has been shown, in adults, that squatting is a more beneficial posture for defecating. But, infants in the minority world are rarely in this position, rather they are lying down in a crib, semi-prone in a bucket carseat, and so on. However, the squatting position straightens the anorectal angle, easing defecation. In fact, Dr. Ryuji Sakakibara and others studied the influence of body position on defecation in adults, finding that squatting provides greater hip flexion while straightening the anorectal canal and resulting in less strain during defecation, compared to upright sitting positions on a toilet. Also, Dr. Dov Sikirov studied the amount of time and straining required for defecation in healthy adult volunteers in three positions: squatting, a low-sitting toilet and a standard height toilet. The results of the research showed that the time spent emptying the bowel in a squatting position was half that for the standard height toilet, and that squatting was easier than sitting on a standard height toilet. Studies, like these, indicate that squatting is a more physiologically beneficial approach to defecation.
Infants less than approximately half a year cannot sit up on their own, let alone squat independently. As a result, defecation often will occur in a lying or reclining position for minority world infants. Lying down is probably the worst, because, actually, Dr. Satish Rao and others studied how hard it might be for adults to defecate lying down. (If you wonder why this study was done, it was due to the fact that people who have bowel problems often have to have their defecation examined by doctors while lying down, so it is important to know just how difficult this might be, in comparison, for healthy people.) The results of Dr. Rao and others’ study of healthy volunteers showed that a horizontal position is the most difficult one in which to defecate. So, we wonder, how could this not be true of infants also? Do infants find it really hard to eliminate in uncomfortable body positions? Does it slow down their elimination time? Does slow elimination time cause gut distension, as Dr. Tunc and others suggested? Will the infants respond to gut discomfort by crying?
We know from existing studies that the gut and the brain are linked. Studies show that rectal discomfort triggers activation in the brain, such as a study on adults by Dr. David Hobday and others. A study done by Dr. Paul Dunckley and others showed that rectal discomfort can result in adult study participants reporting anxiety. Again, we wonder, could this be true for infants also?
So, from a physiological standpoint, there is evidence which helps to support the hypothesis that not being able to comfortably and freely eliminate might be creating discomfort in infants. This discomfort might lead to crying, in some cases, perhaps excessive crying.
From a cultural standpoint, we turn to studies of the hunter-gatherer culture of the Koi San people in central Africa. A really important study by Dr. Ronald Barr and others in 1991, showed that infants of Koi San people cry less than their ‘Western’ counterparts. However, Koi San infant caregiving practices differ substantially (e.g., demand feeding, increased carrying), but trying to replicate these practices to reduce infant crying has proved elusive. One aspect of Koi San caregiving that has never been replicated in a crying context includes how caregivers respond to, and attend to, an infant’s need to eliminate. Author Joseph Pearce stated that Koi San caregivers assist the infant by allowing the infant an opportunity to eliminate freely, rather than restricted in diapers. This response to elimination may be why anthropologist Dr. Melvin Konner, in 1972 stated that, among the Koi San infants, elimination is never a source of crying.
We can also look at the link between elimination and crying from a somewhat different cultural standpoint: if infant crying can be somehow considered ‘normal,’ than the stimulus for crying can be dismissed. I think one of the reasons excessive infant crying has been normalized, is through the research done in minority world settings in the mid-20th century on infant crying. In fact, in the same year (1962) that Dr. Brazelton published the paper on child-oriented toileting, Dr. Brazelton also published a paper stating that infants have a natural increase in unexplained crying in early infancy. This paper on “normal infant crying” has become influential in infant caregiving, that is, in the infant crying literature, in the same way that child-oriented toilet training became a salient paper in the toilet training literature. Never, in any journal article that I have read, have these two papers both been cited together. By delaying toilet training, and by accepting ‘unexplained’ crying as normal, have we been enabled to think that there is no relationship between an infant’s elimination needs and the infant’s crying?
In my 2014 paper, I hypothesized that, in contrast to Dr. Brazelton, and later Dr. Barr (2006), excessive inconsolable crying in the otherwise healthy infant is not necessarily normal, nor necessarily part of normal developmental stages; rather, crying perhaps signals an unmet basic human need, that of eliminating. Specifically, if infant disregulation is caused by lack of gut motility of the fecal bolus, which the infant cannot easily expel independently, or is caused by the infant’s aversion to soiling its own environment (i.e., diaper), then assistance is required by the caregiver. The hypothesis is that the caregiver is signaled through the infant’s crying. Then, using EC, a caregiver can gently hold the infant in a calm, cradled, safe, secure squatting position for the infant to eliminate.
MM: You have just released a pilot study regarding EC and unexplained crying, would you mind going through the results?
GJ: Yes, so we put these ideas to the test in a pilot study. One of the ideas in the infant crying literature is the concept of the Normal Crying Curve. The Normal Crying Curve refers to infants’ unexplained crying from birth to a peak at about 6 to 8 weeks, and self-resolving by three months. The Normal Crying Curve is really useful for caregivers, especially for caregivers whose infants cry excessively. It helps caregivers know that this period of excessive crying won’t last forever (as it typically resolves around the 3 month mark). The literature surrounding the Normal Crying Curve helps caregivers to become informed with soothing methods (such as feeding, holding, changing soiled diapers, etc.), and, perhaps most essentially, with the advice that if you are frustrated as a caregiver with your baby’s crying, to gently put the baby down in a safe place and make sure you calm yourself. Above all, a baby’s safety is the top priority. So, the Normal Crying Curve literature provides really essential caregiving information on how to keep babies safe.
But, here’s a question, what if some of that unexplained crying was ‘just' because a baby had to eliminate, and didn’t want to soil their diaper, and/or was maybe anxious about the feeling of a full colon? What if babies are wired to not soil themselves? What if, through the use of full-time diapering, we are actually training the babies to eliminate in their diapers, and what if babies were wired to not want to do that? (It may explain why humans have gotten along so well, for so long, throughout the millennia, without disposable diapers.) What if we could reintroduce EC in the minority world, as another aspect of infant care, that is, another way to address basic human needs? Here’s the key thought: What if EC could help flatten the Normal Crying Curve?
To look at this question, my research team developed a study to track crying in the first three months of infancy, like other infant crying studies, with the addition that the caregivers would practice EC with their infant. Caregivers were asked to practice EC as best they could, without the practice of EC becoming a stress. (In fact, that is one of the amazing aspects of EC: that of communicating gently and non-coercively, and is not at all intended to be a source of stress, neither for the caregiver, nor the infant, but a source of relief!)
We had ten mother-infant pairs participate in our pilot study. As researchers, we provided EC support for the mothers, mentoring them on how to practice EC if they didn’t yet know how to do so. Mothers (as the primary caregiver, but sometimes with the help of others), tracked their baby’s crying in a 24-hour journal, over seven days in Weeks 4, 6, 8 and 12 of infancy, just like other infant crying studies. We assessed the mothers’ journal data for a statistical peak of crying at Week 6, that is, the “peak” of the Normal Crying Curve, but found none.
We also found that, in addition to there being no significant peak in crying, the babies in our study, compared with babies in two other studies, cried significantly less. In fact, our babies cried, on average, about 50% less, and up to 70% less in Week 6, compared to literature studies.
Now, we know we only had ten babies in our study, so that is definitely a small sample. So one of the things we did was to look at how many times our babies were given an opportunity to eliminate over the course of each day, in each week, in those four weeks, and we looked at how many crying episodes our babies had over the course of each day, in each week, in those four weeks. That’s a lot of data! Using a type of modeling, we found that the more times the babies cried (episodes of crying) predicted more daily elimination opportunities. This means that the more times a baby cried, the more EC opportunities a baby was given. So, that was interesting, because it suggests that caregivers are responding to an infant crying episode with an opportunity to eliminate.
However, what was really interesting was when we compared the length of crying (that is, the duration of crying) with the number of times the babies were given an opportunity to eliminate. What we found was the more times the babies were given an opportunity to eliminate, the shorter the crying duration, no matter if the babies had high baseline or low baseline crying tendencies.
For babies with low baseline colic symptoms (which is different from crying tendencies), we also found that the more times the babies were given an opportunity to eliminate, the shorter the crying episodes. (But, not for babies with high baseline colic symptoms, and we need to investigate this association further. It may be that the mothers may have moved on to other options for soothing the baby, or indeed, there may have been another cause for crying, or something yet unstudied.)
On the whole, when we look at our pilot study, it’s really amazing to find these results which indicate that practicing EC reduces unexplained infant crying, even though we know that there are so many other factors to investigate. For example, many of our participants were recruited from midwifery practice, so it may be that the care that mothers receive in those early weeks contributes to infant crying reduction.
If indeed there are other factors which are contributing to this significant decrease in crying, then they too should be investigated. But, our study was extremely successful as a pilot study to test the methods used, as well as derive preliminary results on the impact of EC on unexplained crying. In fact, the results point to the fact that a larger, controlled study should be done.
If, in a larger study, the practice of EC actually flattens the Normal Crying Curve, then such results will have a significant impact on our understanding of unexplained infant crying. That will mean that practicing EC will have a noteworthy impact on how we care for infants. It may also have a significant impact on our attachment with our babies.
EC, as an infant caregiving practice, is transformational in the sense that it connects caregivers to their babies (and vice versa) in a very tangible, basic, and easy way. In addition to all the ways in which caregivers provide for babies, EC is one more way to meet our infants’ basic human needs, lovingly and gently.
EC Interview (transcript) with Dr. Geraldine Jordan