Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 3: Health Promotion and Protection

3.2 Hygiene

3.2.1 Diapering and Changing Soiled Clothing

3.2.1.4: 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.