Chapter 3: Health Promotion and Protection
3.2.1 Diapering and Changing Soiled Clothing
126.96.36.199: Diaper Changing Procedure
The following diaper changing procedure should be posted in the changing area, should be followed for all diaper changes, and should be used as part of staff evaluation of caregivers/teachers who diaper. The signage should be simple and should be in multiple languages if caregivers/teachers who speak multiple languages are involved in diapering. All employees who will diaper 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 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, gather and bring supplies to the diaper changing area:
- Non-absorbent paper liner large enough to cover the changing surface from the child’s shoulders to beyond the child’s feet;
- Unused diaper, clean clothes (if you need them);
- Wipes, dampened cloths or wet paper towels for cleaning the child’s genitalia and buttocks readily available;
- A plastic bag for any soiled clothes or cloth diapers;
- Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers) and remove them before handling clean diapers and clothing;
- 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.
- Always keep a hand on the child;
- 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.
- Place the child on the diaper change surface and unfasten the diaper, but leave the soiled diaper under the child;
- 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);
- Lift the child’s legs as needed to use disposable wipes, or a dampened cloth or 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, or a dampened cloth or wet paper towel each time you swipe. Put the soiled wipes 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.
- Fold the soiled surface of the diaper inward;
- 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;
- Put soiled clothes in a plastic-lined, hands-free plastic bag;
- Check for spills under the child. If there are any, use the corner of the paper to fold the paper that extends under the child's feet over the soiled area so a fresh, unsoiled paper surface is now under the child's buttocks;
- If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can;
- 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.
- Slide a fresh diaper under the child;
- Use a facial or toilet tissue or wear clean disposable glove to apply any necessary diaper creams, discarding the tissue or glove in a covered, plastic-lined, hands-free covered can;
- Note and plan to report any skin problems such as redness, skin cracks, or bleeding;
- 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.
- Use soap and warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can.
Step 7: Clean and disinfect the diaper-changing surface.
- Dispose of the disposable paper liner used on the diaper 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 home;
- Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, 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 change table surface with fresh water afterwards.
Step 8: Perform hand hygiene according to the procedure in Standard 188.8.131.52 and record the diaper change in the child’s daily log.
- In the daily log, record what was in the diaper and any problems (such as a loose stool, an unusual odor, blood in the stool, or any skin irritation), and report as necessary (2).
RATIONALEThe 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 (3). Posting the multi-step 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 resoiled.
Children’s hands often stray into the diaper area (the area of the child’s body covered by 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, or, if no gloves were used, before proceeding to handle the clean diaper and the 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 upon 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) (5).
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.
TYPE OF FACILITYCenter, Large Family Child Care Home
RELATED STANDARDS184.108.40.206 Type of Diapers Worn
220.127.116.11 Handling Cloth Diapers
18.104.22.168 Checking For the Need to Change Diapers
22.214.171.124 Situations that Require Hand Hygiene
126.96.36.199 Handwashing Procedure
188.8.131.52 Routine Cleaning, Sanitizing, and Disinfecting
184.108.40.206 Containment of Soiled Diapers
220.127.116.11 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
Children’s Environmental Health Network. 2016. Household chemicals. http://www.cehn.org/wp-content/uploads/Household_chemicals_1_16.pdf.
- National Association for the Education of Young Children. 2012. Healthy Young Children, A Manual for Programs. Fifth edition. Editor. Susan Aronson Washington, DC.
Red Book: 2015 Report of the Committee on Infectious Diseases, 30th Edition American Academy of Pediatrics Committee on Infectious Diseases; Editor: David W. Kimberlin, MD, FAAP; Associate Editors: Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; and Sarah S. Long, MD, FAAP.
Early Childhood Education Linkage System. Healthy Child Care Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster.
University of California, San Francisco School of Nursing’s Institute for Health & Aging, University of California, Berkeley’s Center for Environmental Research and Children's Health, and Informed Green Solutions, California Department of Pesticide Regulation. 2013. 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.
Content in the STANDARD was modified on 1/2012, 7/2012, 5/13/2013 and on 8/23/2016.