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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 daycare setting. According to Frank E. Young, M.D., Ph.D., Commissioner of Food and Drugs for the U.S. Food and Drug Administration, “Daycare 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 – daycare 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 daycare answers a critical need.”
(1) As if the issue of choosing a Daycare 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 Daycare 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 daycare and its workers). Based on the same precautions and respecting the same concerns of advocates for disposable diaper usage in daycare 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 daycare 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 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 the 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 daycare 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 daycare 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 daycare 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 Campylobacter.” (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 daycare 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 daycare worker.
Regardless of 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 daycare 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 daycare 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 daycare 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 daycare 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 daycare 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 daycare settings 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 daycare worker is changing a disposable diaper or a cloth diaper of comparable style. First and foremost is 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) Daycare 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 daycare settings.
Actual contact with fecal matter remains the longest standing argument in favor of the sole usage of disposable diapers in daycare 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)
Daycare 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 daycare 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 daycare 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) 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 daycare 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. Daycare facilities often use disposable pads between the infant’s bare bottom and the diaper changing surface – with the 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’:
- Proper hand-washing by adults and children (this if the children are toilet training).
- Surface sanitizing
- Proper diaper disposal
- 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.
- Having children wear clothes over diapers.
A Healthy Conclusion.
The health of children and daycare 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 daycare providers with the expectation that acceptance is not an issue. Daycare 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)
(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 DayCare 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