Do disposable diapers reduce urination elimination signals in non-toilet-trained children?

Elimination signals play a key role in facilitating toilet training. This pilot study assessed whether disposable diapers affect urination elimination signals in typically developing children aged 18 to 36 months who are not yet toilet trained. A prospective observational pilot study with a within-subject design was conducted under two conditions, presented in a fixed order: first diaper-free, then with a diaper. Three trained researchers conducted real-time and video-recorded observations, using a urination elimination signals checklist. Of the 28 children enrolled, complete data was available for 23 (10 boys, 13 girls, mean age 24 months, SD 3.1 months, range 19-30 months). Descriptive statistics and logistic regression were used to assess the effect of wearing a diaper on the display of urination elimination signals. More children showed elimination signals when diaper-free. Significant differences were found in the proportion of children who verbally expressed the need to void (43% vs. 13%, p = 0.029), sought caregiver contact (52% vs. 13%, p = 0.008), showed lower limb movement (87% vs. 35%, p = 0.0009), ceased activity (87% vs. 35%, p = 0.0009), and touched or looked at the genital area both before (74% vs. 30%, p = 0.004) and during urination (78% vs. 13%, p = 0.00007). When grouped by urination phase, significant differences were found before (p = 0.045), during (p = 0.0009), and after urination (p = 0.0008).

This is the first prospective study to show that disposable diaper use is associated with a reduced display of urination elimination signals. Further research is needed to explore how this reduction might impact toilet training initiation timing and, in turn, continence outcomes.

• Elimination signals are cues exhibited by children before, during, or after urination and play a key role in facilitating toilet training. • A trend toward later toilet training initiation has been observed in Western countries in parallel with the widespread use of highly absorbent disposable diapers.

• This is the first prospective study to assess the effect of disposable diapers on the display of urination elimination signals in non-toilet-trained children. • In our study, children were more likely to show elimination signals in the diaper-free condition compared to the disposable diaper condition.