It is generally believed that children's daytime urination control function gradually develops and matures when they are 2–3 years old. The association between toilet training and this physical development remains unproven. Toilet training involves not only complex nerve, muscle's participation and control, at the same time, its concept and practice are restricted by social culture custom and environmental material condition.5−7 Some conventional wisdom holds that bladder control development is an ongoing process of maturation, and that it is not possible to promote bladder development through toilet training.8 Brazelton9 described a toilet training for children in her 1962 study and emphasized the age of toilet training. They believe that the theory of children's toilet training focuses on the development of children's voluntary control of excretory function (that is, after the excretory function is fully developed), emphasizes flexibility and reduces the conflict and anxiety in training, so it is not necessary to start toilet training prematurely. It continues to influence parenting and toilet practices in contemporary American families. But that doesn't tell us that we have to train at about age 2 in accordance with their philosophy. Studies have confirmed the existence of synaptic neural pathways associated with bladder control development after birth in mammals.10 Dr. JG Wen et al.11−13 using dynamic bladder pressure monitoring techniques combined with polysomnography also showed that the mechanism of awakening reflex during bladder expansion has been established in neonatal period. Recent studies in Belgium have shown that toilet training after the age of two or more can increase the risk of daytime urinary incontinence and infectious diseases and delay the ability to control urine.5 Yang SS' study found that early toilet training can acquire the ability to control urine during the day and at night earlier, and toilet training can not affect the normal bladder function, and can reduce the incidence of enuresis.2 All of these provide a theoretical basis for early toilet training.
In traditional Chinese (Asian) customs and concepts, parents in the past often began to EC(toilet training) after the baby was born. EC refers to the use of a special posture to help infants urinate:When parents read bodily cues and body language, they hold the baby’s legs up over a baby’s toilet or bucket and make a cuing sound like “so-” or “en-,” to help the child release their waste away from their body. When able to walk, the child is helped or guided by parents to void in a toilet or in a place to mimic toilet voiding.
The present study points towards the fact that lack of early EC is associated with decreased daytime urination control meaning that early EC enables children to become diaper-free all-day much earlier than their peers who are only using diapers without early voiding training. EC helps infants move quite easily into traditional toilet training when they are old enough. In the study, it was found that the urinary control rate of children who started urinary training within 12 months after birth was 72.31% and 69.43% in the sub-group at the age of 2, which was significantly higher than that after 12 months. The urinary control rates of infants who started EC after 12 months at 2 years of age were 59.97% and 54.1%, respectively. The urinary control rate of each subgroup was similar at 0.5 years, 1 year, 1.5 years, and 2 years old, that is, the urinary control rate of the subgroups with EC before 12 months was significantly higher than the subgroup of ECs after 12 months and the group without EC. In other words, the earlier and longer the EC is, the more favorable it is to obtain urination control.
This study shows that infants and young children who use diapers begin to exercise EC(toilet training) before the age of 1 to facilitate the development of daytime urination control. The reason for this is that there are anatomical and pathophysiological foundations. The micturition reflex system initiates in the brainstem while bladder emptying is a spinal reflex that is not controlled by the brain in newborns and young infants; with maturation of the central nervous system (CNS), the cerebral cortex gradually assumes conscious control of micturition, so in theory early toilet training should help in children's urination control.14 Additionally, many studies have shown that the newborn’s brain has joint or partially joint control of voiding.11,15 The connections between brain and bladder are already established in newborns. Babies are aware of their elimination needs from birth and communicate those needs through various vocal and bodily signals, the relationship between voiding patterns and brain activity in healthy preterm neonates using video-electroencephalo-graph (video-EEG) has been established.13 This connection between the CNS and bladder or voiding control, forms the basis of voiding training. By taking babies to appropriate elimination places during infancy, we enable them to maintain a connection with their bodily sensations and learn from an early age what to do when they experience those sensations.16 In fact, the basis of Chinese-style toilet training (i.e. EC) is that the baby can sense the meaning of urination, and will send a defecation signal to correlate the urinary movements, sounds and urination, form a conditional reflex, and practice continuously. Over time, the ability of infants to control urination will be synchronized with physical development and language development. The present study provided some evidence supporting that EC may be helpful for infants to acquire voiding control by establishing a reflex between the brain and the bladder.
Furthermore,Joinson comparing children who started toilet training (i.e. EC) between 15 and 24 months to children starting toilet training after 24 months and found that late training was associated with higher odds of persistent daytime wetting.17 Children may become used to the feeling of wearing DD and may develop manifestations of dependence, making them resistant to toilet training. Thus, to establish a reflex between brain and bladder, starting EC earlier seems to be important. It can be practiced by stay-at-home or working parents. EC can be undertaken by people of all income levels and physical abilities.18 China has a history of early EC lasting thousands of years, and until at least ten years ago, Chinese parents continued this traditional way of toilet training. In 2006, we published a cross-sectional survey showing the prevalence of attaining urinary control rate was 52% in one-year old children and 70% in two-year-olds after EC, indicating that by using EC most Chinese infants developed voiding control by two years. Most children begin kindergarten at 2–3 years of age in Mainland China. It is very beneficial for children to become dry by the time they enter kindergarten. Although it would be easier for parents to commence toilet training when their children have developed an increased ability to act and behavior, this would not be acceptable for children of primary school age (5–7 years old). Therefore, guidelines for starting EC after 18 months would not be acceptable for most Chinese children and parents.
In addition, it is well known that the infant's physical development is incomplete within 3 months, especially the spine and neck are still fragile. If EC is performed at this time, it may increase the risk of various accidents of the infant and is not conducive to the growth and development of the infant. However, since infants can complete their head-up behavior after 3 months, this indicates that they are eligible for EC. Therefore, it is more suitable for EC after 3 months. We also found in the survey that children who are taking EC also start three months after birth, while children without EC did not carry out other toilet training.Parents of these children without EC may only use DD for reasons such as busy work.
Finally, considering the huge Chinese population in Mainland China with varying climates, different living habits, and unbalanced regional economic development, the samples and area investigated in the present study cannot represent all children and territory throughout China. An international multi-center project involving more countries is recommended to provide stronger documentation to update present guidelines using DD and EC, not only in Mainland China but worldwide.