Chapter 3: Health Promotion and Protection
3.2.1 Diapering and Changing Soiled Clothing
220.127.116.11: Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
The following changing procedure for soiled pull-ups or underwear and clothing should be posted in the changing area, should be followed for all changes, and should be used as part of staff evaluation of caregivers/teachers who change pull-ups or underwear and clothing. The signage should be simple and should be in multiple languages if caregivers/teachers who speak multiple languages are involved in changing pull-ups or underwear. All employees who will change pull-ups or 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 are a good idea. This would help reduce the risk of back injury for the adults that 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 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 (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, and gather and bring supplies to the changing area.
- Non-absorbent paper liner large enough to cover the changing surface;
- Unused pull-up or underwear, 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, including underwear, or pull-ups;
- Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or pull-ups) and remove them before handling clean pull-ups or underwear and clothing.
Step 2: Avoid contact with soiled items.
- 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;
- To avoid contaminating the child’s clothes, have the child hold their shirt, sweater, etc. up above their 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 clothes pins that can be washed and sanitized to keep the clothing out of the way;
- If disposable pull-ups 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;
- 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;
- 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.
- 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. 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 or paper towels into the soiled pull-up 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;
- Check for spills under the child. If there are any, use 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;
- 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;
Step 4: Put on a clean pull-up or underwear and clothing, if necessary.
- Assist the child, as needed, in putting on a clean disposable pull-up or underwear, then in re-dressing (1);
- Note and plan to report any skin problems such as redness, skin cracks, or bleeding;
- 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, 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 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 7: Perform hand hygiene according to the procedure in Standard 18.104.22.168 and record the change in the child’s daily log.
- In the daily log, record what was in the pull-up or underwear and any problems (such as a loose stool, an unusual odor, blood in the stool, or any skin irritation), and report as necessary (3).
RATIONALEChildren who are learning to use the toilet may still wet/soil their pull-ups or 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 (4,5). 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 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 resoiled.
Children’s hands often stray into the changing area (the area of the child’s body covered by the soiled pull-ups or underwear) during the changing process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number or organisms carried into the environment in this way. Infectious organisms are present on the skin and pull-ups 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 pull-up or 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 pull-up 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 upon 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) (6).
Changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils.
COMMENTSChildren 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 age 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 normal 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 normally 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 regarding 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 FACILITYCenter, Large Family Child Care Home
RELATED STANDARDS22.214.171.124 Toilet Learning/Training
126.96.36.199 Type of Diapers Worn
188.8.131.52 Handling Cloth Diapers
184.108.40.206 Checking For the Need to Change Diapers
220.127.116.11 Situations that Require Hand Hygiene
18.104.22.168 Handwashing Procedure
22.214.171.124 Routine Cleaning, Sanitizing, and Disinfecting
126.96.36.199 Containment of Soiled Diapers
188.8.131.52 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
- Early Childhood Education Linkage Systems. Healthy Child Care Pennsylvania. 2016. Changing soiled underwear. http://www.ecels-healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled-underwear?highlight=WyJzb2lsZWQiXQ.
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.
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.
Early Childhood Education Linkage System. Healthy Child Care Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster.
Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, and 8/23/2016.