Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 3: Health Promotion and Protection

3.2 Hygiene

3.2.1 Diapering and Changing Soiled Clothing

3.2.1.1: Type of Diapers Worn

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.1

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.1: Type of Diapers Worn

Question:
Does this standard allow for use of the newer cloth diapers (with either a removable or connected absorbent inner liner and waterproof Velcro closure cover)? 

Answer:
Yes, (for children who require cloth diapers for a medical reason), but only if the cloth diaper and cover are removed simultaneously as one unit and not removed as two separate pieces (see page 105). Please review the Comments section of this Standard for more information.

Content in the STANDARD was modified on 8/9/2017.


Facilities should adhere to the procedures outlined in 3.2.1.2: Handling Cloth Diapers and 3.2.1.4: Diaper Changing Procedure to prevent and control infections caused by fecal contact:
 
Diapers worn by children should be able to contain urine and stool and minimize exposure to human waste in the child care setting. Children should use disposable diapers with absorbent material (e.g., polymers) or cloth diapers. Cloth diapers should have an absorbent inner layer that is completely covered with an outer waterproof layer that has a waist closure (i.e., not pull-on waterproof pants). The cloth diaper and waterproof later should be changed at the same time (1). Whichever diapering system is used in the facility, clothes should be worn over diapers while the child is in the facility.

No rinsing or dumping of the contents of cloth diapers should be performed at the child care facility. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family, stored in a location inaccessible to children, and given directly to the parent/guardian daily upon discharge of the child. Children of all ages who are incontinent of urine or stool should wear a barrier method, such as a disposable diaper or a cloth diaper that is completely covered with an outer waterproof layer and a waist closure.

While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and reusable cloth diapers, worn with a front closure waterproof cover, meet the physical criteria of this standard (if used as described), they have not been evaluated for their ability to reduce fecal contamination, or for their association with diaper dermatitis (rash). Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. Therefore, single-use disposable diapers should be encouraged for use in child care facilities.


RATIONALE

Procedures that reduce fecal contamination help control the spread of disease. Fecal contamination has been associated with increased diarrheal rates in child care facilities (1). Gastrointestinal tract disease, or diarrhea (caused by bacteria, viruses, and parasites) and hepatitis A virus infection are spread from infected persons through fecal contamination of hands and objects. Protective procedures includes minimal handling of soiled diapers and clothing, thorough hand hygiene, and containment of fecal matter.  Fecal contamination in child care settings may be reduced when single-use, disposable diapers are used compared to cloth diapers worn with pull-on waterproof pants (3). When clothes are worn over either disposable or cloth diapers with pull-on waterproof pants, there is a reduction in contamination of the environment (1, 3).

Diaper Rash
Diaper dermatitis (rash) occurs frequently in diapered children. Diapering practices that reduce the frequency and severity of diaper dermatitis will require less application of skin creams and ointments, thereby decreasing the likelihood for fecal contamination of caregivers/teachers’ hands. Most common diaper dermatitis is caused by prolonged contact of the skin with urine, feces, or both (1). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (1). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (1). The use of disposable diapers with absorbent material has been associated with less frequent and less severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (2, 3).

COMMENTS
Reusable cloth diapers worn either without a covering or with pull-on waterproof pants do not meet the physical requirements of the standard.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
5.2.7.4 Containment of Soiled Diapers
5.4.1.10 Handwashing Sinks
REFERENCES
  1. American Academy of Pediatrics. Infections Spread by the Fecal-Oral Route In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 143
  2. American Academy of Pediatrics. Healthychildren.org. 2015. Diaper rash. https://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/Diaper-Rash.aspx
  3. Counts, J.L., Helmes, C.T., Kenneally, D., Otts, D.R. Modern disposable diaper constructions: Innovations in performance help maintain healthy diapered skin. 2014. Clinical Pediatrics. 53(9S):10S-13S. 
NOTES

Content in the STANDARD was modified on 8/9/2017.

3.2.1.2: Handling Cloth Diapers


If cloth diapers are used, soiled cloth diapers and/or soiled training pants should never be rinsed or carried through the child care area to place the fecal contents in a toilet. Reusable diapers should be laundered by a commercial diaper service. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family. The sealed plastic bag should be sent home with the child at the end of the day. The containers or sealed diaper bags of soiled cloth diapers should not be accessible to any child (1).
RATIONALE
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 (2). There is no reason to use the toilet for stool if disposable diapers are being used. Commercial diaper laundries use a procedure that separates solid components from the diapers and does not require prior dumping of feces into the toilet.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.1 Type of Diapers Worn
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

3.2.1.3: Checking For the Need to Change Diapers


Diapers should be checked for wetness and feces at least hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers should be changed when they are found to be wet or soiled.
RATIONALE
Frequency and severity of diaper dermatitis is lower when diapers are changed more often, regardless of the type of diaper used (1). Diaper dermatitis occurs frequently in diapered children. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (2). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1,2). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (2).

Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by odor. Nonetheless, since these methods of checking may be inaccurate, the diaper should be opened and checked visually at least every two hours. Even though modern disposable diapers can continue to absorb moisture for an extended period of time when they are wet, they should be changed after two hours of wearing if they are found to be wet. This prevents rubbing of wet surfaces against the skin, a major cause of diaper dermatitis.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
REFERENCES
  1. Healthy Children. 2010. Ages and stages: When diaper rash strikes. http://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/When-Diaper-Rash-Strikes.aspx.
  2. Shelov, S. P., T. R. Altmann, eds. 2009. Caring for your baby and young child: Birth to age 5. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3.2.1.4: Diaper Changing Procedure

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Is the recommendation for an Environmental Protection Agency (EPA)-registered disinfectant different from the previous cleaning and sanitizing definitions?  What’s the difference between a disinfectant and sanitizing agent?

Answer:

For some surfaces it is important to disinfect to be healthy and safe (this is the deepest “clean”). For some surfaces sanitizing is enough to be healthy and safe, and for some surfaces cleaning is adequate. Remember that before some surfaces are disinfected or sanitized, the visible “dirt” must first be cleaned off.

Please see Appendix J, Selecting an Appropriate Sanitizer or Disinfectant for more information.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 11/22/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
What is the rationale for requiring hand washing before diaper changing?

Answer:
The diaper changing process may require many interactions with the child before the process, for example evaluating whether the diaper contains stool.  Because of the potential for contamination of hands during this process, hand hygiene should be performed before collection of diaper supplies and further handling of the child to avoid contaminating the remaining diaper supplies.  However, activities in child care do not occur in isolation.  If hand hygiene has been done for another reason prior to a diaper changing event, the process does not have to be repeated if no contamination of hands has occurred.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 7/21/2014

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Step 6 of Standard 3.2.1.4: Diaper Changing Procedure states to "Use soap and warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can." If the child is too heavy to hold at the sink, or has a special health care need that prevents him/her from standing at the sink, it is OK to use several wipes (one after the other) to clean the child's hands?

Answer:
Wipes that have chemicals should not be used as a replacement for washing an infant's/toddler's hands.

However, Managing Infectious Diseases in Child Care and Schools, 4th Edition and Model Child Care Health Policies, 5th Edition offers an alternative method to washing the hands of an infant/toddler at the sink if they are too heavy to hold or have a special need that prevents standing at the sink. This ”three paper towel” method is as follows:

1. Wipe the child’s hands with a damp paper towel moistened with a drop of liquid soap.
2. Wipe the child’s hands with a 2nd paper towel wet with clear water.
3. Dry the child’s hands with a 3rd paper towel.

Additionally, as stated in CFOC3 Standard 3.2.2.5: Hand Sanitizers, the use of hand sanitizers by children over twenty-four months of age and adults in child care programs is an appropriate alternative to the use of traditional handwashing with soap and water if the hands are not visibly soiled.

Last, please remember to check your local and/or state regulations before implementing this strategy.

Content in the STANDARD was modified on 10/16/2018.


The following diaper-changing procedure should be posted in the changing area, followed for all diaper changes, and used as part of staff evaluation of caregivers/teachers who diaper. The signage should be simple and in multiple languages if caregivers/teachers who speak multiple languages are involved in diapering. All employees who will change diapers should undergo training and periodic assessment of diapering practices. Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the diaper-changing table. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.
Use a fragrance-free bleach that is US Environmental Protection Agency (EPA) registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA registered (1).

All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

Step 1: Get organized. Before bringing the child to the diaper changing area, perform hand hygiene if hands have been contaminated since the last time hand hygiene was performed (2), gather, and bring supplies to the diaper changing area.

  1. Nonabsorbent paper liner large enough to cover the changing surface from the child’s shoulders to beyond the child’s feet
  2. Unused diaper, clean clothes (if you need them)
  3. Readily available wipes, dampened cloths, or wet paper towels for cleaning the child’s genitalia and buttocks
  4. A plastic bag for any soiled clothes or cloth diapers
  5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers; remove them before handling clean diapers and clothing)
  6. A thick application of any diaper cream (e.g., zinc oxide ointment), when appropriate, removed from the container to a piece of disposable material such as facial or toilet tissue

Step 2: Carry the child to the changing table, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change.

  1. Always keep a hand on the child.
  2. If the child’s feet cannot be kept out of the diaper or from contact with soiled skin during the changing process, remove the child’s shoes and socks so the child does not contaminate these surfaces with stool or urine during the diaper changing.

Step 3: Clean the child’s diaper area.

  1. Place the child on the diaper-changing surface and unfasten the diaper but leave the soiled diaper under the child.
  2. If safety pins are used, close each pin immediately once it is removed and keep pins out of the child’s reach (never hold pins in your mouth).
  3. Lift the child’s legs as needed to use disposable wipes, a dampened cloth, or a wet paper towel to clean the skin on the child’s genitalia and buttocks and prevent recontamination from a soiled diaper. Remove stool and urine from front to back and use a fresh wipe, dampened cloth, or wet paper towel each time you swipe. Put the soiled wipes, cloth, or paper towels into the soiled diaper or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm’s reach of diaper changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.

Step 4: Remove the soiled diaper and clothing without contaminating any surface not already in contact with stool or urine.

  1. Fold the soiled surface of the diaper inward.
  2. Put soiled disposable diapers in a covered, plastic-lined, hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without emptying or rinsing) in a plastic bag or into a plastic-lined, hands-free covered can to give to parents/guardians or laundry service.
  3. Put soiled clothes in a plastic-lined, hands-free plastic bag.
  4. Check for spills under the child. If there are any, use the corner of the paper that extends beyond or under the child’s feet to fold over the soiled area so a fresh, unsoiled paper surface is now under the child’s buttocks.
  5. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
  6. Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child’s hands. Put the wipes into the plastic-lined, hands-free covered can.

Step 5: Put on a clean diaper and dress the child.

  1. Slide a fresh diaper under the child.
  2. Use a facial or toilet tissue or wear clean disposable gloves to apply any necessary diaper creams, discarding the tissue or gloves in a covered, plastic-lined, hands-free covered can.
  3. Note and plan to report any skin problems such as redness, cracks, or bleeding.
  4. Fasten the diaper; if pins are used, place your hand between the child and the diaper when inserting the pin.

Step 6: Wash the child’s hands and return the child to a supervised area.

  1. Use soap and warm water, between 60°F and 120°F (16°C and 49°C), at a sink to wash the child’s hands, if you can.

Step 7: Clean and disinfect the diaper-changing surface.

  1. Dispose of the disposable paper liner used on the diaper-changing surface in a plastic-lined, hands-free covered can.
  2. If clothing was soiled, securely tie the plastic bag used to store the clothing and send the bag home.
  3. Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, and then rinse.
  4. Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer’s instructions for use.
  5. Put away the disinfectant. Some types of disinfectants may require rinsing the changing table surface with fresh water afterward.

Step 8: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the diaper change in the child’s daily log.

  1. In the daily log, record what was in the diaper and any problems (e.g., a loose stool, an unusual odor, blood in the stool, any skin irritation) and report as necessary (3).
RATIONALE

The procedure for diaper changing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (4). Posting the multistep procedure may help caregivers/teachers maintain the routine.

Assembling all necessary supplies before bringing the child to the changing area will ensure the child’s safety, make the change more efficient, and reduce opportunities for contamination. Taking the supplies out of their containers and leaving the containers in their storage places reduces the likelihood that the storage containers will become contaminated during diaper changing.

Commonly, caregivers/teachers do not use disposable paper that is large enough to cover the area likely to be contaminated during diaper changing. If the paper is large enough, there will be less need to remove visible soil from surfaces later and there will be enough paper to fold up so the soiled surface is not in contact with clean surfaces while dressing the child.

If the child’s foot coverings are not removed during diaper changing and the child kicks during the diaper changing procedure, the foot coverings can become contaminated and subsequently spread contamination throughout the child care area.

Some experts believe that commercial baby wipes may cause irritation of a baby’s sensitive tissues, such as inside the labia, but currently there is no scientific evidence available on this issue. Wet paper towels or a damp cloth may be used as an alternative to commercial baby wipes.

If the child’s clean buttocks are put down on a soiled surface, the child’s skin can be re-soiled.

Children’s hands often stray into the diaper area (the area of the child’s body covered by a diaper) during the diapering process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number of organisms carried into the environment in this way. Infectious organisms are present on the skin and diaper even though they are not seen. To reduce the contamination of clean surfaces, caregivers/teachers should use a fresh wipe to wipe their hands after removing the gloves (5) or, if no gloves were used, before proceeding to handle the clean diaper and clothing.

Some states and credentialing organizations may recommend wearing gloves for diaper changing. Although gloves may not be required, they may provide a barrier against surface contamination of a caregiver/teacher’s hands. This may reduce the presence of enteric pathogens under the fingernails and on hand surfaces. Even if gloves are used, caregivers/teachers must perform hand hygiene after each child’s diaper changing to prevent the spread of disease-causing agents. To achieve maximum benefit from use of gloves, the caregiver/teacher must remove the gloves properly after cleaning the child’s genitalia and buttocks and removing the soiled diaper. Otherwise, retained contaminated gloves could transfer organisms to clean surfaces. Note that sensitivity to latex is a growing problem. If caregivers/teachers or children who are sensitive to latex are present in the facility, non-latex gloves should be used. See Appendix D for proper technique for removing gloves.

A safety strap cannot be relied on to restrain the child and could become contaminated during diaper changing. Cleaning and disinfecting a strap would be required after every diaper change. Therefore, safety straps on diaper changing surfaces are not recommended.

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application, and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed (the last and essential part of every diaper change) (6).

Diaper changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils.

If parents/guardians use the diaper changing area, they should be required to follow the same diaper changing procedure to minimize contamination of the diaper changing area and child care center.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
5.2.7.4 Containment of Soiled Diapers
5.4.4.2 Location of Laundry Equipment and Water Temperature for Laundering
Appendix D: Gloving
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Children’s Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286.

  2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017

  3. National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
  4. American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018
  5. Early Childhood Education Linkage System, Healthy Child Care Pennsylvania. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster. Reaffirmed April 2018. Accessed June 26, 2018

  6. University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children’s Health; Informed Green Solutions. Green Cleaning, Sanitizing, and Disinfecting: A Checklist for Early Care and Education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf. Published 2013. Accessed June 26, 2018
NOTES

Content in the STANDARD was modified on 10/16/2018.

3.2.1.5: Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.5

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.5: Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing

Question:
Should a distinction be made between “wet” and “soiled” pull-up, clothing, and underwear? Or are these terms interchangeable in the Standard and Rationale? More specifically, are the steps required for changing a pull-up with a bowel movement the same for changing a pull-up that is only wet?

Answer:
The same changing procedure should be used regardless of the contents.

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, 8/23/2016 and 10/16/2018.


The following changing procedure for soiled disposable training pants, underwear and clothing should be posted in the changing area, followed for all changes, and used as part of staff evaluation of caregivers/teachers who change disposable training pants, underwear and clothing. The signage  should be simple and in multiple languages if caregivers/teachers who speak multiple languages are involved in changing disposable training pants or underwear. All employees who will change disposable training pants, underwear and clothing should undergo training and periodic assessment of these practices.

Changing a child from the floor level or on a chair puts the adult in an awkward position and increases the risk of contamination of the environment. Using a toddler changing table helps establish a well-organized changing area for both the child and the caregiver/teacher. Changing tables with steps that allow the child to climb with the caregiver/teacher’s help and supervision may also be used. Changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which may occur from lifting the child onto the table (1).

Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the changing surface. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.

Use a fragrance-free bleach that is US Environmental Protection Agency (EPA) registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA registered (2).

All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

 

Step 1: Get organized and determine whether to change the child lying down or standing up. Before bringing the child to the changing area, perform hand hygiene if hands have been contaminated since the last time hand hygiene was performed (3), gather, and bring supplies to the changing area.

  1. Nonabsorbent paper liner large enough to cover the changing surface
  2. Unused disposable training pants, underwear, clean clothes (if you need them)
  3. Readily available wipes, dampened cloths, or wet paper towels for cleaning the child’s genitalia and buttocks
  4. A plastic bag for any soiled clothes, including underwear, or disposable training pants
  5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or disposable training pants; remove them before handling clean disposable training pants, underwear and clothing)

Step 2: Avoid contact with soiled items.

    1. If the child is standing, it may cause the clothing, shoes, and socks to become soiled. The caregiver/teacher must remove these items before the change begins.
    2. To avoid contaminating the child’s clothes, have the child hold his or her shirt, sweater, etc., up above the waist during the change. This keeps the child’s hands busy and the caregiver/teacher knows where the child’s hands are during the changing process. Caregivers/teachers can also use plastic clothespins that can be washed and sanitized to keep the clothing out of the way.
    3. If disposable training pants were used, pull the sides apart, rather than sliding the garment down the child’s legs. If underwear is being changed, remove the soiled underwear and any soiled clothing, doing your best to avoid contamination of surfaces.
    4. To avoid contamination of the environment and/or the increased risk of spreading germs to the other children in the room, do not rinse the soiled clothing in the toilet or elsewhere. Place all soiled garments in a plastic-lined, hands-free plastic bag to be cleaned at the child’s home.
    5. If the child’s shoes are soiled, the caregiver/teacher must wash and sanitize them before putting them back on the child. It is a good idea for the child care facility to request a few extra pair of socks and shoes from the parent/caregiver to be kept at the facility in case these items become soiled (1).

Step 3: Clean the child’s skin and check for spills.

    1. Lift the child’s legs as needed to use disposable wipes, a dampened cloth, or a wet paper towel to clean the skin on the child’s genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe, dampened cloth, or wet paper towel each time you swipe. Put the soiled wipes, cloth, or paper towels into the soiled disposable training pants or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm’s reach of changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.
      1. Check for spills under the child. If there are any, use the corner of the paper that extends beyond or under the child’s feet to fold over the soiled area so a fresh, unsoiled paper surface is now under the child.
      2. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
      3. Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child’s hands. Put the wipes into the plastic-lined, hands-free covered can.

Step 4: Put on clean disposable training pants or clean underwear and clothing, if necessary.

      1. Assist the child, as needed, in putting on clean disposable training pants or underwear, and then in re-dressing (1).
        1. Note and plan to report any skin problems such as redness, cracks, or bleeding.
        2. Put the child’s socks and shoes back on if they were removed during the changing procedure (1).

Step 5: Wash the child’s hands and return the child to a supervised area.

Use soap and warm water, between 60°F and 120°F (16°C and 49°C), at a sink to wash the child’s hands, if you can.

Step 6: Clean and disinfect the changing surface.

Dispose of the disposable paper liner used on the changing surface in a plastic-lined, hands-free covered can.

If clothing was soiled, securely tie the plastic bag used to store the clothing and send the bag home.

Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, and then rinse.

Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer’s instructions for use.

Put away the disinfectant. Some types of disinfectants may require rinsing the changing table surface with fresh water afterward.

Step 7: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the change in the child’s daily log.

In the daily log, record what was in the disposable training pants or underwear and any problems (e.g., a loose stool, an unusual odor, blood in the stool, any skin irritation) and report as necessary (4).

RATIONALE

Children who are learning to use the toilet may still wet/soil their disposable training pants,  underwear and clothing. Changing these undergarments can lead to risk for spreading infection due to the contamination of surfaces from urine or feces (1). The procedure for changing a child’s soiled undergarment and clothing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (5, 6). Posting the multistep procedure may help caregivers/teachers maintain the routine.

Assembling all necessary supplies before bringing the child to the changing area will ensure the child’s safety, make the change more efficient, and reduce opportunities for contamination. Taking the supplies out of their containers and leaving the containers in their storage places reduces the likelihood that the storage containers will become contaminated during changing.

Commonly, caregivers/teachers do not use disposable paper that is large enough to cover the area likely to be contaminated during changing. If the paper is large enough, there will be less need to remove visible soil from surfaces later and there will be enough paper to fold up so the soiled surface is not in contact with clean surfaces while dressing the child.

If the child’s foot coverings are not removed during changing and the child kicks during the changing procedure, the foot coverings can become contaminated and subsequently spread contamination throughout the child care area.

If the child’s clean buttocks are put down on a soiled surface, the child’s skin can be re-soiled.

Children’s hands often stray into the changing area (the area of the child’s body covered by the soiled disposable training pants or underwear) during the changing process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number of organisms carried into the environment in this way. Infectious organisms are present on the skin and disposable training pants or underwear even though they are not seen. To reduce the contamination of clean surfaces, caregivers/teachers should use a fresh wipe to wipe their hands after removing the gloves or, if no gloves were used, before proceeding to handle the clean disposable training pants, underwear and the clothing.

Some states and credentialing organizations may recommend wearing gloves for changing. Although gloves may not be required, they may provide a barrier against surface contamination of a caregiver/teacher’s hands. This may reduce the presence of enteric pathogens under the fingernails and on hand surfaces. Even if gloves are used, caregivers/teachers must perform hand hygiene after each child’s changing to prevent the spread of disease-causing agents. To achieve maximum benefit from use of gloves, the caregiver/teacher must remove the gloves properly after cleaning the child’s genitalia and buttocks and removing the soiled disposable training pants or underwear. Otherwise, retained contaminated gloves could transfer organisms to clean surfaces. Note that sensitivity to latex is a growing problem. If caregivers/teachers or children who are sensitive to latex are present in the facility, non-latex gloves should be used. See Appendix D for proper technique for removing gloves.

A safety strap cannot be relied on to restrain the child and could become contaminated during changing. Cleaning and disinfecting a strap would be required after every change. Therefore, safety straps on changing surfaces are not recommended.

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application, and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed (the last and essential part of every change) (7).

Changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils. Additionally, changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which may occur from lifting the child onto the table (1).

COMMENTS

Children with disabilities may require diapering, and the method of diapering will vary according to their abilities. However, principles of hygiene should be consistent regardless of method. Toddlers and preschool-aged children without physical disabilities frequently have toileting issues as well. These soiling/wetting episodes can be due to rapid-onset gastroenteritis, distraction due to the intensity of their play, and emotional disruption secondary to new transition. These include new siblings, stress in the family, or anxiety about changing classrooms or programs, all of which are based on their inability to recognize and articulate their stress and to manage a variety of impulses.

Development is not a straight trajectory but, rather, a cycle of forward and backward steps as children gain mastery over their bodies in a wide variety of situations. It is typical and developmentally appropriate for children to revert to immature behaviors as they gain developmental milestones while simultaneously dealing with immediate struggles, which they are internalizing. Even for preschool- and kindergarten-aged children, these accidents happen, and these incidents are called “accidents” because of the frequency of these episodes among typically developing children. It is important for caregivers/teachers to recognize that the need to assist young children with toileting is a critical part of their work and that their attitude about the incident and their support of children as they work toward self-regulation of their bodies is a component of teaching young children.
TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.1.2.5 Toilet Learning/Training
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
5.2.7.4 Containment of Soiled Diapers
5.4.4.2 Location of Laundry Equipment and Water Temperature for Laundering
Appendix D: Gloving
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Early Childhood Education Linkage Systems, Healthy Child Care Pennsylvania. Changing soiled underwear. http://www.ecels-healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled-underwear?highlight=WyJzb2lsZWQiXQ. Published 2016. Accessed June 26, 2018

  2. Children’s Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286.

  3. American Academy of Pediatrics. Managing infectious diseases in child care and schools: A quick reference guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL; 2017.
  4. National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
  5. American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018
  6. University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children’s Health; Informed Green Solutions. Green Cleaning, Sanitizing, and Disinfecting: A Checklist for Early Care and Education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf. Published 2013. Accessed June 26, 2018

  7. Early Childhood Education Linkage System, Healthy Child Care Pennsylvania. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster. Reaffirmed April 2018. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, 8/23/2016 and 10/16/2018.