Influence of Delayed Elimination Communication and Related Disposable Diapers Usage on the Prevalence of Bladder and Bowel Dysfunction in Children at 4 to 10 Years of Age in Mainland China

Xu P1, Wen J1, Wen Y1, Wang Q1, Sihoe J1, Franco I2

Research Type


Abstract Category


Abstract 388
ePoster 6
Scientific Open Discussion Session 25
Pediatrics Incontinence Bowel Evacuation Dysfunction Voiding Dysfunction Constipation
1. Pediatric Urodynamic Center and Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China., 2. Department of Urology and Children’s Bladder and Continence Program,Yale-Newhaven children’s hospital,USA

Peng Chao Xu



Hypothesis / aims of study
To determine the prevalence of bladder and bowel dysfunction( BBD )and its relationship with delayed elimination communication(EC) and related disposable diaper(DD )usage in children in mainland China.
Study design, materials and methods
A cross-sectional study was carried out in 19 kindergartens and 18 primary schools in 12 cities distributed throughout the four main regions of mainland China with an anonymous, self-administered questionnaire that addressed non-neuropathic paediatric BBD. A total of 10166 children with ages ranging from 4 to 10 years old were included in the nationally representative sample.
A total of 10166 valid questionnaires were collected, and 409 children were diagnosed with BBD. ①The overall prevalence was 4.02% (409/10166) and decreased with age, from 6.19% at age 4 to 1.96% at 10. ②With the prolonged use of DDs, the onset time of EC was significantly delayed and the prevalence of BBD increased (P <0.001). The prevalence of BBD in children who stopped using DDs within the first 12 months and at more than 24 months was 2.79% and 4.38%, respectively, which were higher than that in those who had never used DDs (1.05%). ③The prevalence of BBD in children who started EC within 12 months after birth and those who never engaged in EC was 1.36% and 15.71%, respectively.④ In addition, the all-day use of DDs increased the risk of BBD (P<0.001). ⑤Logistic regression and the multi-factor analysis showed that the prolonged use of DDs for years and continuous use for the whole day increased the prevalence of BBD (OR>1). Starting EC before 2 years old (especially within one year) was an obvious protective factor for BBD (OR<1).
Interpretation of results
Bladder and bowel dysfunction (BBD) is highly prevalent worldwide and is thought to result from the interplay of multiple factors that vary regionally. The coexistence of voiding dysfunction symptoms and functional constipation and/or faecal incontinence (FI) in children was previously termed ‘dysfunctional elimination syndrome’ (DES). However, there was no standardized definition of DES for children until 2013 when the International Children’s Continence Society (ICCS) suggested the term ‘bladder and bowel dysfunction’ (BBD) instead of DES to describe children with a combination of functional bladder and bowel incoordination or disease, including bladder overactivity (urge), voiding frequency, bladder underactivity, constipation, etc. [1]

The prevalence of BBD gradually decreases with age, however,the time to initiate EC or toilet training is delayed with the popular use of DD, resulting in the actual practice of missing children’s early learning self-controlled urination and feces as soon as possible, as well as an increase in the prevalence of BBD.

EC, also known as natural infant hygiene, is the practice of using the infant s natural timing and cues to recognize when they need to defecate or urinate. By identifying the cues, caregivers can coordinate elimination in the toilet rather than in DDs. Contrary to the notion that infants relieve themselves randomly and constantly throughout the day, infants naturally eliminate at predictable times, such as on waking or after feeding. Caregivers can incorporate audio cues (soft whistle or hum) to associate with the act of eliminating. With practice, many children learn to eliminate when they are in proper position and hear the cue EC is not a new concept. Humans have been doing this for millennia and still do in most resource-limited regions like being absent from DDs. However,in the recent decades,DDs are widely used in most countries worldwide due to their strong water absorption capacity, which has become a necessity for solving voiding and defecation problems during childcare.
Concluding message
BBD prevalence has increased significantly over recent decades in mainland China. Early EC and the decreased use of DDs may be effective in preventing the occurrence of BBD in children to some extent.
Figure 1
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  1. Austin PF, Bauer SB, Bower W,et al. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children’s Continence Society[J].Neurourol Urodyn. 2016 ;35:471-481. DOI: 10.1002/nau.22751.
  2. Jeffrey M.Bender, Rosemary C.She.Elimination Communication: Diaper-Free in America[J].PEDIATRICS PERSPECTIVES, 2017, 140(1): 1-3.DOI:http://doi.ort/10.1542/peds.2017-0398.
  3. Wang X Z , Wang XZ, Wen YB, Shang XP, et al. The influence of delay elimination communication on the prevalence of primary nocturnal enuresis—a survey from Mainland China. Neurourology and Urodynamics. 2019;1-7.
Funding National Natural Science Foundation of China (No.81670689/H0515) ;Henan International Cooperative Project (No:182102410002) Clinical Trial No Subjects Human Ethics Committee Henan medical ethics committee,China Helsinki Yes Informed Consent Yes
27/02/2024 18:18:50