Diaper-Free Before 3: The Healthier Way to Toilet Train and Help Your Child Out of Diapers Sooner by Jill Lekovic, MD

Review by Shannon Jones

Written by a pediatrician and grounded in research, this book had me convinced within a few chapters that infant toilet training (also known as elimination communication) was the most normal thing in the world. Though I read the book for practical reasons, my interest was piqued by the history and social context of toilet training and diaper use in the US.  I was fascinated to learn that the age of initiation of toilet training gradually changed from one month in the early 20th century, to six months in the 1950s, to 18 months in the 1970s, to 24-30 months today. In non-Western cultures, the process for infants often begins within the first few weeks of life.  Though the author recommends starting at six months, it is because she sees it at more practical in our modern society and not because younger infants are not capable. But the clear message is that beginning toilet training at age two or three, which is the norm in Western countries today, is actually only a very recent societal trend and it's possible to start at a much younger age.

It's important to clarify that the "training" referred to is not accomplished through any type of coercion or rewards system.  In a nutshell, it is more of developing an association for the child between voiding and actually sitting on the toilet.  When the child is young the caregiver pays attention to the baby's patterns (for instance usually babies urinate soon after eating or waking up from sleep) and simply puts them on the toilet at those times, starting with just once or twice a day and gradually increasing.  The caregiver makes it a positive experience by reading books with the child or giving them a favorite toy to play with while sitting on the toilet and makes it a built-in, matter-of-fact part of daily life just like getting dressed and eating breakfast.  As the association builds the child will naturally wet her diaper less and less often.  

The author effectively dispels the myths and articulates the benefits of early toilet training, and then goes on to provide very practical and straightforward instructions for how to actually accomplish it.  She also provides helpful information about how children's bodies work and related medical issues such as urinary tract infections and constipation that all parents would benefit from, regardless of choice of toilet training method.  As a reader I felt motivated and eager to start as soon as I could.  

While the sections on the history of toilet training and the practical tips to get started are very good, this book has some major weaknesses as well.  The first is what the book is missing.  The author focuses on timing as the main method toilet training, namely after the baby wakes or feeds.  However, there are other important tools for success, such as paying attention to your baby's signals that they need to eliminate, and providing a cue for the baby to eliminate such as an "ssss" sound.  Second, the author offers no advice for parents who want to begin toilet training before the age of six months.  Thirdly, she doesn't provide any tools for nighttime potty training.  Her only solution to nighttime bed wetting is to not allow fluid intake in the evening, and for parents who nurse or bottle feed their children to sleep (let alone nurse/feed in the middle of the night) she offers no advice except "don't do it."  This is not only unhelpful but dismissive to parents who have a different parenting style to the author's.  

Lastly, I was put off at a few points when the author took advantage of her captive audience to dispense her personal parenting advice which was only tenuously related to the topic of the book.  A few examples are that she advocates cry-it-out sleep training, says that bottles and other comfort items should be cut off at age one, and devotes the entire epilogue to a critique of helicopter parenting.  This is not only out of place and irritating but in some ways it is detrimental to her message, as it does not acknowledge a diverse audience of parents.  For instance, she seems to assume that families bottle feed and only gives passing mention to breastfeeding.  She also does not differentiate clearly between breastmilk and cow's milk in her discussion of the role of milk in constipation.  She dismisses the use of cloth diapers as too much of an inconvenience, which not only perpetuates this cultural myth but is inconsistent with the rest of her philosophy about toilet training (as she states in many places how disposable diapers are unhelpful in toilet training because the child does not feel wet in them.)  While these views may appeal to a mainstream audience that formula feeds and uses disposable diapers, in the same breath she alienates (or at least fails to address the practical concerns of) parents who breastfeed, nurse to sleep, or use cloth diapers.  In short, while the core of this book is solid, there are important topics that are not addressed, and some parts of what she says or fails to say are too heavily influenced by her own personal parenting experiences and thus not broad enough for a diverse audience.  

Though I haven't had a chance to read it yet, from what I can glean I think the best book available on this topic, especially for parents practicing attachment parenting, is Diaper Free: The Gentle Wisdom of Natural Infant Hygiene by Ingrid Bauer.  Whatever you read, the take-home message is that infant toilet training is normal and healthy and requires only a few basic instructions and principles to get started.  I'm glad I am learning about this topic and am enjoying accompanying my baby in the process of learning to use the toilet!