Diaper
Rash
Two Main Factors
Diarrhea has been found to be the cause of diaper rash in 70-80%
of cases.(1,2) Liquid stool spreads over a wide area and is very
irritating to the skin.
Infrequent diaper changes make it difficult for the skin to protect
itself from many causes of irritation in the diaper area, including
diarrhea and others listed below. Frequent changes will minimize
the effects of all irritants.(3)
Other Factors
& Types of Rash
Prolonged and/or frequent exposure to feces can cause rash. The
mixture of urine and feces produces ammonia (high pH), which increases
fecal enzyme activity, making the skin more susceptible to damage.(4)
Hydration of
skin - Urine alone does not generally damage skin, but if skin
is allowed to become hydrated (filled with liquid), it is more
easily damaged by irritants such as friction, chemicals or microbes
(i.e., bacteria or yeast).(5)
Friction - When
baby is mobile and the diaper rubs on wet skin, it will sometimes
result in a rash. (Redness will be seen where chafing is greatest,
but not in the baby's skin folds.)
Yeast or fungus
infection - The main cause of severe diaper rash is infection
of the skin with Candida,(2) an organism found in feces of infants
(this is more likely to happen if the child is taking antibiotics).
This rash is bright red and tender, with distinct edges, and appears
in the creases between the abdomen and thighs, with small red
spots or pustules close to the large patches.
Heat inside the
diaper may cause heat rash and may increase the growth of microbes
such as yeast or bacteria. Some types of rash (e.g., impetigo)
are most common in warm conditions.(6)
Allergens and
irritants - Some possible allergens and irritants are: baby wipes,
plastic, chemicals, perfumes, chlorine bleach, residues/ingredients
in some detergents, fabric softeners, and paraben (a preservative
in some creams and ointments).
Diet and age
- Some studies have found less rash with breastfed babies than
with formula-fed babies.(3) Also, introduction of new foods can
sometimes give feces higher pH and cause a rash (3) (usually around
the anus), which is possibly the reason diaper rash peaks at 7-15
months.(1)
Susceptibility
- Some babies are simply more prone to rash than others.(2,3)
Teething (6)
and the common cold (7) have been reported to cause diaper rash.
Aggressive and/or
frequent cleansing of the diaper area with soap (3) or disposable
baby wipes can damage skin. Insufficient cleaning can also contribute
to rash.
Other forms of
rash in the diaper area are: seborrheic dematitis (may be accompanied
by "cradle cap" on the scalp), intertrigo (from skin
rubbing on skin, in the creases), impetigo (caused by bacteria),
psoriasis and scabies.
Diaper Type
Disposable diaper manufacturer, Procter & Gamble, Inc. (P&G)
has funded a number of studies to determine the causes of diaper
rash and to compare the effectiveness of cloth versus disposable
diapers in maintaining skin dryness, normal pH, and healthy skin.(8)
Findings include the following:
Disposables
If a baby is left in a diaper containing feces, disposable diapers
with Absorbent Gelling Material (AGM) have been shown to reduce
the mixture of urine and feces and the resulting fecal enzyme
activity and rising pH levels.(9)
If a baby is left in a wet diaper, disposable diapers with AGM
have been shown to provide reduced skin hydration compared to
cloth.(9)
A 1985 survey of pediatric practices reported diaper rash for
3% fewer disposable-diapered babies than cloth-diapered babies
(wearing pull-on plastic pants).(1)
One study showed lower rash grades for disposable-diapered babies
with atopic (allergic) skin in 5 out of 8 visits. However, the
control group of infants with normal skin showed no difference
in rash grades between those diapered in cloth and those diapered
in AGM disposables.(10)
Three studies showed less rash with AGM diapers during a product
test period.(9)
For prevention of moderate or severe rash, no significant advantage
was shown for disposable diapers.(1)
Cloth
There have been a number of developments in cloth diapers and
accessories for the purpose of improving comfort and maintaining
skin health. However, to date, no studies have been done comparing
AGM disposable diapers to cloth diapers used with breathable waterproof
diaper covers and/or non-absorbent inner liners.
No studies have been done comparing full-time use of AGM disposable
diapers to full-time use of cloth diapers rented from a diaper
service, which treat their diapers with a bacteriostat and lowered
pH. (Home-laundered diapers can also be treated in this way with
the use of vinegar in the last rinse followed by dipping the diapers
in a solution of DIAPER PURE bacteriostat.)
Generally, the times when a baby's diaper cannot easily be changed
and skin may become more hydrated with cloth, are times when baby
is immobile (sleeping or travelling), and friction on his skin
is minimal.
Conclusion
Diaper rash may relate directly to diaper type if baby is sensitive
to something in the disposable or cloth diaper. However, it seems
in most cases, incidence and seriousness of diaper rash depend
more on diapering practices, and on other factors such as diarrhea
and yeast infection, than on diaper type. The one Procter &
Gamble study that monitored diaper changes observed that:
if a baby's diapers were changed often (average 8 times/day),
diaper rash seldom occurred with either cloth or disposable diaper
use.(3,11)
The Canadian Paediatric Society concludes: "To prevent diaper
rashes, infants should be changed frequently. For most healthy
infants, cloth diapers are as effective as disposable ones. However,
some disposable diapers absorb more water than cloth diapers,
offering an advantage in situations where regular changing is
hard to organize, or for infants with very sensitive skin."(12)
To Keep Baby's
Skin Healthy
On average, a baby's diaper should be checked for wetness every
hour. Newborn babies urinate 8-20 times a day (average 10-12).
This gradually decreases to 7-10 times a day at 12 months of age,
and 5-8 times a day as they reach toilet-training age.
Gentle wiping
of baby's bottom with a clean, warm wet cloth is recommended at
ever diaper change for newborns, several times a day for older
babies. Let baby's skin dry before applying a clean diaper.
Creams and moisture
barriers (e.g., petroleum jelly) need not be used with every diaper
change. Generally, after the bath and/or before bed is sufficient.
It is good to let the skin "breathe." Skin must be clean
before applying a moisture barrier. Powders and cornstarch can
be accidentally inhaled by baby and probably should not be used.
Diapers containing
feces: Gently wipe most of the feces off baby with the inside
front of the diaper ( or liner). Use toilet paper as well if necessary.
Wipe girls from front to back to avoid vaginal infection. Wash
baby's bottom throughly with warm water and a soft cloth (fold
and use a clean part of the cloth for each wipe). If you use soap,
use a mild one and rinse it completely off.
If baby has diarrhea
or a cold or is teething a moisture barrier (e.g., petroleum jelly)
should be applied to his skin after cleaning and drying it well.
If using cloth
diapers, diaper liners made of non-absorbent fabric, such as polyurethane
or rayon, will help keep wetness away from baby's skin, and may
reduce mixture of urine and feces.
Less Moisture
More Air
Air baby's bottom in a warm place after bathtime (or any convenient
time).
The use of plastic on the outside of the diaper (disposable or
cloth) tends to hide the evidence that a change is needed, and
tends to prevent evaporation and raise the temperature of baby's
skin. This can cause general discomfort in warm conditions, and
may increase growth of bacteria, fungi or yeast if present. The
use of breathable waterproof diaper covers over cloth, at least
part time, may help prevent diaper rash, and is especially recommended
if baby develops a yeast infection.
Breathable waterproof
pants do not necessarily reduce wetness on baby's skin while the
diaper is wet, but they do help prevent the build up of heat inside
the diaper, and tend to encourage more frequent diaper changing
during the day, as evaporation or dampness is often felt on the
outside of the pant if the diaper is wet.
Night Diapering
For night diapering, ensure the diaper has adequate absorbency
capacity. Disposable diapers with AGM are generally more than
adequate for night time.
Cloth diapers
usually require the addition of an absorbent insert or two (or
double diapering if using traditional diapers). Use of a non-absorbent
inner liner next to baby's skin is especially recommended for
night.
Apply a moisture
barrier (e.g., petroleum jelly) to reduce hydration of skin with
urine during the night, and to protect skin from irritants.
If baby's skin
is healthy, changing a wet diaper in the middle of the night is
not generally necessary if the diaper is absorbent enough, as
most of the moisture will be drawn away from the baby's skin.
Also, as the baby is relatively immobile, there is not much friction
on the skin.
If baby has a persistent rash, a 3 a.m. diaper check may be advisable.
If a Rash Develops
If diaper rash develops, let baby go without a diaper for one
to three hours a day. For young babies, put them on the diaper
instead of in the diaper (make sure the room is warm). For older,
mobile babies, try to keep them in a non-carpeted area, or wait
until nap time. (If urine gets in the carpet, baking soda or rug
cleaning foam can be used to treat odors and stains.)
The next most
airy option is to put baby in a cloth diaper alone (without a
diaper cover). Using a breathable waterproof cover over a cloth
diaper is also an option that will allow some air in, and some
moisture out, which may encourage more frequent diaper changes.
It is important
to air baby's bottom when a mild rash appears, to allow healing.
Once skin becomes irritated, it is more susceptible to further
irriation. Organisms that cause severe rash (e.g., yeast) do not
generally infect healthy skin; however, if present in the feces,
they can infect damaged skin.
Avoid use of
disposable baby wipes if baby has a rash. If allergies are suspected,
eliminate possible allergens until the rash clears. Then reintroduce
one possible allergen each week, so allergies can be detected.
If in doubt, discuss this with your doctor.
Often a diaper
rash cream or ointment will help clear up a rash within a day
or two (consult your pharmacist or health nurse for a recommended
brand). If ointment is difficult to remove, use olive oil or baby
oil on a cotton ball.
If a Rash Persists
Consult a physician if a rash worsens or persists for more than
three or four days, or if skin is broken or develps pimples, pustules
or blisters. Prescription creams or medicine may be required to
clear some types of rash (e.g., yeast infection).
If a rash persists,
or keeps coming back, you may consider other things besides wet
diapers. If using cloth, change to a different detergent, and/or
add 175ml (3/4 cup) of vinegar to an added final rinse (to lower
pH and help remove detergent residues if present). Switching to
disposables for a while may help remove detergent residues if
present. Switching to disposables for a while may help in some
cases. If using disposables, try changing brands or switching
to cloth (diaper service or home-laundered) for a while. Baby
may be reacting to the plastic, chemicals, or some other irritant.
Footnotes
1. Austin, A.P., et.al., A Survey of Factors Associated with Diaper
Dermatitis in 36 Pediatric Practices, J. Ped. Health Care 2, 295-299,
1988. (P&G funded)
2. Benjamin,
L., Clinical Correlates with Diaper Dermatitis, Pediatrician,
Suppl. 1 14:21-26, 1987. (P&G funded)
3. Jordan, W.E.,
et. al., Diapering Dermatitis: Frequency & Severity Among
a General Infant Population, Pediatric Dermatology, 3:198-207,
1986. (P&G funded)
4. Buckingham,
et. al, Etiologic Factors in Diaper Dermatitis, The Role of Feces,
Pediatric Dermatology, Vol. 3, No. 2 107-112, 1986. (P&G funded)
5. Berg, R.W.,
et. al., Etiolgic Factors in Diaper Dermatitis: The Role of Urine,
Pediatric Dermatology, 3:102-106, 1986. (P&G funded)
6. Rassmussen,
James E., Classification of Diaper Dermatitis: An Overview, Proceedings
of an International Symposium, Diapering and Infant Skin Care,
Hakone Japan, June 12, 1986, Pediatrician, 14 S1, 1987.
7. Hayakawa,
Risuko, et. al., Common Conditions and Factors Associated with
Diaper Dermatitis, An Overview, Proceedings of an International
Symposium, Diapering and Infant Skin Care, Hakone Japan, June
12, 1986, Pediatrician, 14S1, 1987.
8. Most of these studies have been published in peer reviewed
journals (i.e., an independent panel has attested to their technical
validity).
9. Campbell,
R.L., et al., Clinical Studies with Disposable Diapers Containing
Absorbent Gelling Materials: Evaluation of Effects on Infant Skin
Condition, J. Amer. Acad. Dermatology, 17:978-989, 1987. (P&G
funded)
10. Seymour,
Jon L., Ph.D., et. al., Clinical Effects of Diaper Types on the
Skin of Normal Infants and Infants with Atopic Dermatitis, J.
Amer. Acad. Dermatology, 17:988-997, 1987. (P&G funded)
11. Kellen, Philippa
E., Diaper Dermatitis: Differential Diagnosis and Management,
Can. Fam. Physician, 36:1569-1572, 1990.
12. Canadian
Paediatric Society, Well Beings - A Guide to Promote the Physical
Health, Safety and Emotional Well-Being of Children in Child Care
Centres and Family Day Care Homes, 1992, page 384.