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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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