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Is cloth diapering hygienic in a daycare setting?
Cloth
Diapered Children and Day Care Providers
by Heather L. Sanders
At
some point or another a good portion of parents are faced with the
issue of finding and placing their infant or toddler in a day care
setting. According to Frank E. Young, M.D., PhD,
Commissioner of Food and Drugs for the U.S. Food and Drug
Administration, “Day-care centers have become a way of life in
America. More than half of all mothers of children too young
to care for themselves hold jobs outside the home. For them –
indeed for millions of American families – day-care centers provide a
service that is a necessity. If both parents work, a solo
parent caring for a child must work, or other family support systems
are inadequate, child day care answers a critical need.” (1) As if the
issue of choosing a Day Care facility is not problematic enough, there
is the added dilemma that some facilities do not/will not accept cloth
diapers. To be fair, there are many reasons parents decide to cloth
diaper their children – health being one of those possible reasons …
and that same reasoning, yet from a different viewpoint, is what shapes
the somewhat misdirected/misinformed policies of some Day Care
facilities to refuse cloth diapers at their place of
business. On the brim of the ongoing debate regarding whether
cloth or disposables are better overall for children, there is the less
discussed concern regarding whether the use of either system is
healthiest for all concerned (the children attending the day care and
its workers). Based on the same precautions and respecting
the same concerns of advocates for disposable diaper usage in day care
systems, some of today’s modern cloth diapering systems can easily be
incorporated right alongside disposable diapers without deviating from
a routine or compromising the health of any involved.
Today’s
Diapering Systems. Just as all things of necessity
seem to evolve to meet the growing demand for ease and convenience in
our fast-paced world, so have cloth diapers. So, to better
understand the efficacy of blending both disposable and cloth diapers
under the same system in a day care facility, it need be recognized
that cloth diapers are no longer defined by simple flat fold cotton
squares and plastic pull-on pants. Modern cloth diapering
encompasses a variety of designs – some of which closely resemble the
fit and convenience of a disposable diaper, yet in a reusable form.
- Fitted
Diapers
are designed in fit/style to secure with tabs like a disposable, yet
require a waterproof diaper cover.
- Wrap-Style
Covers secure a regular flat fold or prefolded diaper to baby
with wrap around tab closures – again, much like a
disposable.
- All-In-One
Diapers are most comparable to the disposable
diapers. They are comprised of a multiple-layered cotton
inner lining attached to an outer waterproof covering. All-In-One
diapers, like disposables, have tabs that wrap around baby to secure
the diaper. The difference being that All-In-Ones secure with
Velcro/aplix or snap closures instead of diaper tape.
Personal
Preference Aside. Setting aside personal preference and
preconceived notions, the basic root of the concerns that shape day
care policies, county compliance, state licensing requirements,
national organization recommendations and the local municipalities,
seems to have little to do with the actual type of diaper being
used. It is the desire to minimize illnesses within the day
care system – especially enteric (small intestine) infections – that
prompts the policies being enforced.
So
what do we know of enteric infections as it relates to
diapers? According to the FDA, enteric infections
are usually attributed to food poisoning. However, in the day
care system they are more commonly linked to fecal
contamination. “In these cases, infections are transmitted
directly from the feces to the mouth usually by way of the hands … or
other objects which go into the mouth.”(3) According to Young, “The
cause of these infections is usually some well-known pathogen such as
the hepatitis A virus, rotavirus, Giardia, E.coli, Cryptosporidium,
Shigella, or Campytobacter.” (1)
Disposable
and cloth both meet the national standard. Both
disposable diapers and two of today’s cloth diapers (primarily the
All-In-Ones, but also the Wrap-Style Covers that hold in a flatfold or
prefolded diaper) meet the physical requirements of the nationally
recognized standards by being “able to contain urine and stool and
minimize fecal contamination of the children, caregivers, environmental
surfaces, and objects in the child care setting.,” (5) With both types
of diapers meeting the same requirements, it would stand to reason that
the possibility for fecal contamination would not lie within the choice
of diapering system, but rather, the person responsible for changing
the diaper. The logical area of concern in a day care
setting, regardless of diaper type, should be less concentrated on the
disposable –v– cloth issue and more concentrated on the actual
diapering procedure as carried out by an informed and properly trained
day care worker.
Regardless
of the choice in diapering systems, the same preventive
measures should be taken to minimize risks of infection from fecal
contamination both during, and directly after, diaper
changes. “Changing diapers in a sanitary way may be one of
the most important things day care staff can do to prevent the spread
of infectious organisms present in fecal material.” (4) Hygienic diaper
changing procedures have been published by a plethora of organizations:
The Food and Drug Administration (FDA), U.S. Center for Disease Control
(CDC), each State’s Department of Health Services, the American Public
Health Association (APHA), the American Academy of Pediatrics (AAP) to
name a few, not to mention countless local governing agencies and child
care organizations. It would be nice to assume that most day
care workers are educated by their employers and versed in minimizing
the spread of infections at the diaper changing area before
tending to any child in a day care environment. Do not take
for granted that this is the case. In fact, as an educated
‘consumer,’ a question you would want to pose in interviewing any day
care center prior to placement of your child is not whether or not they
accept cloth diapers, but instead, “What type of initial and on-going
education or direction is given your day care workers regarding
minimizing the spreading of infections?” The American Public
Health Association found this worth further
attention. In one of the APHA’s Public Policy
Statements they supported, “… research on the health, safety, and
handling of various types of diapers (home-laundered, cloth diaper
services, and disposable diapers) in day care settings in order to
guide the development of standards for these settings.” (2)
To
date there is biased research like The Personal Absorbent Products
Council (PAPC) which reported that disposable diapers offer superior
health benefits and that there is “… clear evidence that disposable
diapers are significantly more effective than double cloth diapers and
plastic overpants in reducing the risk of spread of gastrointestinal
illnesses.” (9) Even by reading this it can be recognized that the PAPC
does not take into account the newer styles of All-In-One Cloth Diapers
that mimic style and function of the disposable diaper, but with the
added benefit of being reusable. Why would they?
Cloth is not their market.
The
minimal requirements for reducing the spread of illness should
be the same whether a day care worker is changing a
disposable diaper or a cloth diaper of comparable style.
First and foremost being good hand hygiene. In October 2002,
the Center for Disease Control’s Healthcare Infection Control Practices
Advisory Committee (HICPAC), in collaboration with the Society for
Healthcare Epidemiology of America (SHEA), the Association of
Professionals in Infection Control and Epidemiology (APIC) and the
Infectious Disease Society of America (IDSA) released updated hand
hygiene guidelines for health care settings emphasizing that “Clean
hands are the single most important factor in preventing the spread of
dangerous germs” and that hand hygiene prevents infections and saves
lives. (6) Day care workers are as active in caring for children as the
health care professionals in this study are in caring for their
patients. Both deal with the possibilities of spreading
dangerous germs, which could lead to infection, if good hand hygiene is
not adhered to with uncompromised consistency.
The
disposal of diaper ‘waste’ in day care settings. Actual
contact with fecal matter remains the longest standing argument in
favor of the sole usage of disposable diapers in day care
settings. Fecal contamination “can be a prime source of
disease in centers that care for children under 3 – those still in
diapers and still being toilet trained.” (1) The truth is that whether
cloth or disposables are being used, according to The American Public
Health Association (APHA), the fecal matter should be handled the same
with either diapering system. The APHA’s Public Policy
Statement #8910,Health and Environmental Hazards of Disposable
Diapers states: Acknowledging that the World Health
Organization advocates adequate disposal of human excreta, and knowing
that more than 100 different enteric viruses, including polio and
hepatitis are known to be excreted in human feces and that these
viruses can live for months after the stool has passed from the body;
and realizing that the product labels instructing consumers to empty
the feces into the toilet before disposing of the diaper are not
commonly followed by consumers; and knowing that human excreta entering
the waste stream via disposable diapers pose potential health risks to
sanitation workers and threaten to contaminate groundwater if landfills
are not properly constructed; therefore
1.
Supports public education to educate consumers about diapering choices
and their potential environmental consequences so that they can make an
informed choice; 2. Supports consumer education so that if
disposable diapers are used, the users dispose of them in a prudent
manner so as to minimize the risk of disease transmission . .
. (2)
Day
Care Facilities that allow for/accept cloth diapers are often given
state or local requirements and recommendations regarding the disposal
of feces, for example, “Soiled cloth diapers shall be emptied of feces
in the toilet and placed in a securely covered container which is not
accessible to children. The container shall be emptied and
sanitized daily.”(7) Yet, it is surprising that in spite of the APHA’s
public stance on proper disposal of fecal matter, their recommendation
is only recognized in day care facilities as related to
cloth. There are no directives with what is required of the
feces when changing a child in a disposable diaper. It is
simply understood that the feces will remain in the disposable diaper
to be tossed in with the trash headed for a landfill. The
concern should not be over the problem of discovering how to best
handle fecal matter concerning changing cloth diapers, but rather, why
we are not ‘handling’ fecal matter with regards to disposable
diapers.
Disillusionment
of Diaper Changes. The supposition is that
disposable diapers require less handling or possible fecal
contamination than do cloth diapers – therefore, possibly reducing the
contamination of other items in the nearby environment. The
rationale that is contaminating our landfills and disallowing some day
care facilities to accept cloth diapers says that –
“Containing and minimizing the handling of soiled diapers so they do
not contaminate other surfaces is essential to prevent the spread of
infectious disease. Putting stool into a toilet in the child
care facility increases the likelihood that other surfaces will be
contaminated during the disposal. There is no reason to use
the toilet for stool if disposable diapers are being used.” (8) Yet, if
attention is being paid to the recommendations of the APHA and the
World Health Organization (WHO) and sanitary diaper
changing measures are being followed, the diaper changing system of an
All-In-One Cloth Diaper (or similar style) should not differ from a
disposable diapering system. All feces should be deposited in
the toilet for the safe management of waste.
Hygienic
diaper changes. Because proper hygiene seems to be
the determining factor in the spread of infection through fecal
contamination, diaper changing areas in day care facilities should be
washed and disinfected after every diaper change – disposable or
cloth. The diaper changing area should be located in close
proximity with a faucet for the ease of immediate hand-washing – and to
decrease the ‘spreading’ of germs en route to the hand-washing
area. Day care facilities often use disposable pads between
the infant’s bare bottom and the diaper changing surface – with wax
paper being the most effective as it does not have absorbent properties
– and dispose of these pads after each diaper change.
Surfaces used for diapering should be used for the sole purpose of
diapering for that very same reason … again, decreasing the possibility
of contaminating surfaces used for other duties. Finally,
if there are fecal contents in either cloth or disposable, it should be
emptied into the toilet. After emptying any fecal
contents that will fall out of the diaper, dunking is unnecessary, and
the diapers can be disposed of accordingly: cloth diaper can be placed
in a waterproof bag that is taken home daily with the child for
laundering and disposable diapers can be discarded in a plastic lined
garbage can.
The
BANANAS Child Care Information & Referral service states that
“Regardless of the type of diapers used, the steps to reducing the
spread of illness are the same” (3) and suggest the following steps in
their handout for ‘Promoting Health and Hygiene in a Child
Care Setting’:
1.
Proper
hand-washing by adults and children (this if the children are toilet
training).
2.
Surface
sanitizing
3.
Proper
diaper disposal
4.
Minimizing
the handling of diaper wastes with latex gloves being made available
for ‘messy’ diaper changes – or in the case where visible blood is
present in feces or urine.
5.
Having
the children wear clothes over diapers.
A
Healthy Conclusion. The health of children and day
care providers is not tied-up in the types of diapers allowed if proper
hygiene is consistently monitored and followed. Just as a
disposable diaper improperly handled could result in fecal
contamination and disease, so might a cloth diaper. Both systems paired
under the same health and hygiene guidelines can be equally as
infectious if handled poorly or equally as safe when handled
knowledgeably. Cloth diapering parents should continue to
present their diapering systems to prospective day care providers with
the expectation that acceptance is not an issue. Day care
facilities and communities, on the other hand, should educate
themselves regarding today’s choices for cloth diapering towards a
developed awareness that cloth diapering can be as convenient and
hygienic as its paper alternative for diapering babies.
For
more ideas on how you can make an impact within your community refer to
the City Council’s report in Sunnyvale. Subject:
Encouraging Use of Cloth Diapers to Reduce Solid Waste Management
Expenses – RTC #99-246. This origin of this study
was prompted following one woman’s question, “What can the City do to
encourage the use of cloth diapers as an alternative to using and
throwing away disposable diapers.” (10)
Sources:
(1)
Young, Frank E., M.d., Ph.D, Commissioner of Food and Drugs, U.S. Food
and Drug Administration, June 2002, In Day-Care Centers,
Cleanliness Is a Must.
(2)
American Public Health Association (APHA) Public Policy Statement 8910:
Health and Environmental Hazards
of Disposable Diapers.
(3)
BANANAS Northern Alameda County's Child Care Information and Referral
Service. BANANAS Handout: Promoting Health & Hygiene
in a Child Care Setting, www.bananasinc.org
(4)
Alaska Dept. of Environmental Conservation Food Safety and
Sanitation. Diapering Guidelines for Day Care
Providers.
(5)
National Resource Center for Health and Safety in Child Care, Caring
for Our Children: National Health and Safety Performance Standards,
2nd Edition, 2002. STANDARD 3.012-Type of Diapers.
(6)
Department of Health and Human Services, Hand Hygiene in
Healthcare Settings, CDC releases new hand-hygiene
guidelines. October 25, 2002.
(7)
Child Care Standards,
65C-22, Florida Administrative Code, March 18, 1999, www.orchd.state.fl.us
(8)
National Resource Center for Health and Safety in Child Care, Caring
for Our Children: National Health and Safety Performance Standards,
2nd Edition, 2002. STANDARD 3.018-Handling Cloth Diapers.
(9)
The Benefits and Safety of
Disposable Diapers. PAPC, Personal Absorbent
Products Council.
(10)
SUBJECT: Encouraging Use of Cloth Diapers to Reduce Solid
Waste Management Expenses-RTC #99-246, June 8, 1999, City of
Sunnyvale, CA www.ci.sunnyvale.ca.us/199906/rtcs/99-246.asp
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