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Diaper Rash: Comparing Diaper Choices by Angelique Mullen

Articles from the Real Diaper Association Quarterly Newsletter
August 2005

Most new parents have experienced changing their baby’s diaper to find their skin covered in a red, splotchy rash. When my daughter was two weeks old, she had her first diaper rash. At the time, we had only used cloth diapers a handful of times. Not knowing what other options we had, we were also using disposable baby wipes when we changed her. My daughter’s rash developed slowly, and eventually became bleeding red. Every time we changed her diaper, she let out blood-curdling screams. I sometimes cried with her, frustrated because I did not know what to do for my sweet baby.

It was at this time that I started going to a new-parent support group. Another mother looked at my daughter’s rash and suggested I use cotton and warm water to clean her diaper area. She was convinced it was the wipes that were causing my baby’s rash.
At the same meeting, a father in the group told me about the flannel squares that he and his wife used on their daughter. It gave me an idea. I went home and cut up an old flannel sheet. I made about a hundred squares of plain flannel wipes. Wetting our new homemade wipes with warm water only, we used them and her rash cleared up in a matter of days.

Diaper rash, also known as diaper dermatitis, is the most common type of rash in infancy, with most children experiencing it at least once by the time they learn to use the toilet.

Why do babies get diaper rash? While there are a variety of factors that contribute to rash, the most common reason is excessive moisture against the skin (Boiko, 1997). Usually, a baby will feel a wet cloth diaper
because it can be hard to avoid the wetness. Cloth diapers are usually changed more often. Many parents leave disposable diapers on their baby too long. There is urine in the diaper and bacteria in the urine. When the ammonia in urine mixes with the plastic, the baby’s skin does not get a chance to breathe and the bacteria can grow. Babies who urinate frequently or have diarrhea and frequent bowel movements can often be more prone to rash. The frequency of diaper dermatitis decreases as the number of diaper changes increases. It is not known how much exposure to urine or feces is necessary to generate irritation, but one study recommended changing newborns every hour and older babies every 3-4 hours, no matter what kind of diaper they are wearing (Shin, 2005).

There are other reasons for rash, such as food allergies, yeast infection, skin sensitivity, chafing, and chemical irritation. For older babies who have started eating solids, diaper rash can result from the introduction of new foods. Food sensitivities can develop and change the content of a baby’s stool, increasing the likelihood of dermatitis. Also, some foods can raise the frequency of bowel movements, adding another source of irritation. Changes in a breastfeeding mother’s diet may alter the baby’s stool, causing rash (Boiko, 1979).

Yeast infection rashes or candidal dermatitis can easily grow in the diaper area, especially if a baby has been taking antibiotics for a bacterial infection. Antibiotics kill the bacteria causing the infection, but they can also kill the bacteria that prevent yeast from developing. Without these bacteria, the warm, moist environment of the diaper area makes an ideal breeding ground for yeast infections (Kazzi).

Babies with sensitive skin are also more prone to diaper rash. Those with atopic dermatitis or eczema may be more likely to develop diaper rashes, although they will usually get a rash on other parts of their bodies, too (Wong, 1992).

Another type of diaper rash is tidemark dermatitis. Tight diapers or bindings that rub against the baby’s skin can cause painful chafing (Kazzi).

Some diaper rash may be caused by chemical irritation. Disposable diapering products, including wipes, are composed of many chemicals that are likely skin irritants. Residual detergent, bleach or fabric softener used to launder cloth diapers and lotions or creams used in diapering can also be bothersome. (Kazzi). In my daughter’s case, we concluded that the chemicals in the commercial wipes we were using were probably causing her newborn rash.

As common as it is today, diaper dermatitis is a relatively new phenomenon. Fred Weiner, a Montreal doctor who studied rash in the 1970’s, reported that diaper rash was almost unheard of before the use of rubber or plastic pants in the 1940’s (Weiner, 1979). In an article published in the Journal of Pediatrics in 1959, before the introduction of disposable diapers, only 7.1% of 1,505 babies in a one-time clinical study had diaper rash (Tanino, 1959). In a study of diaper rash in the 1980’s, some twenty years after the invention of disposable diapers, 63% of 1,050 babies had diaper rash at least once in an 8-week period (Gaunder and Plummer, 1987). The most recent study I reviewed reported that at least half of all babies will exhibit rash at least once during their diapering years (Shin, 2005).

Why would wearing disposable diapers lead to higher incidence of dermatitis? Weiner believed the lack of airflow in a tight-fitting plastic cover to be one of the main factors for rash. He noted that babies also developed rash from plastic or rubber pants (Weiner, 1979).

Disposable diapers are made using a large variety of in chemicals and the manufacturers are not required to disclose these chemical ingredients. Consumers should be aware of what chemicals are present in disposable diapers. Ingredients include polyethylene film, polypropylene plastic, bleached paper pulp, petrolatum, stearyl alcohol, hot melts (glue), elastic, cellulose tissue, and perfume. There are also super absorbent polymers (SAP), sometimes called absorbent gelling material, that keep the diaper from leaking. SAP has been known to cause skin irritations and severe allergic reactions including vomiting, staph infections and fever. The use of super-absorbent polymers was banned from tampons in 1985 due to links to toxic shock syndrome. When wet, this gel can escape through the liner and end up in direct contact with a child’s skin (Landbank, 1991).

In disposable diapers, there are also traces of dioxin and tributyl-tin (TBT), two highly toxic chemicals. TBT is known to cause hormonal problems in humans and animals (Greenpeace, 2000). Dioxin is a by-product of the bleaching process. Dioxin is a carcinogenic chemical, listed by the EPA as the most toxic of all cancer-linked chemicals. It is banned in most countries but not in the U.S (Greenpeace, 1994).

Considering this list of ingredients, it might be expected that research would show a higher incidence of rash and allergic reactions in babies wearing disposable diapers. How do researchers view the connection between diapers and dermatitis? What type of diapers cause more rash?

The dozens of studies I surveyed appear to favor the use of disposable diapers for rash prevention. Also, most pediatricians seem to believe that disposable diapers are superior to cloth when it comes to keeping babies dry and rash-free. In fact, studies and medical professionals in favor of cloth diapers are hard to find. Why? If disposable diapers put harmful chemicals next to babies’ skin, it would make sense that throwaway diapers would cause more rash. The reasons may be economic and political.

Fred Weiner was an early exception to the tendency to favor disposable diapers. Dr. Weiner, the Montreal doctor previously mentioned, studied 146 infants who appeared for their one-month checkup. He reported that babies wearing disposables had 20% more incidences of diaper rash than babies wearing cloth diapers with plastic pants, and three times more than babies wearing cloth alone. He did not, however, gather information on the frequency of diaper changes or the overall health of the babies, which could have been a factor in the development of the rashes. He also did not blind his study, which means that he knew which parents used cloth and which ones used throwaway diapers. Regardless, he came to the conclusion that disposable diapers were not allowing the babies’ skin to breathe, and airtight fitting diapers should be avoided (Weiner, 1997).

Another study (supported by a grant from Johnson and Johnson) in 1982 also failed to demonstrate superiority of disposable diapers. Unlike previous studies, this was “double-blinded,” which means that not only were the examiners of the rash unaware of what kind of diapers the participants were using, the mothers of the infants studied were not aware they were participating in a study about diaper rash. This eliminated any bias by parents or the examiners toward a particular diapering system. The study was also controlled to some extent by standardizing skin care. No specific recommendations were given with respect to laundry practices or the frequency of diaper changes. The results showed that there was no significant difference between cloth and disposables when it came to diaper rash (Stein, 1982).

During the first 20 years that disposable diapers were on the market, they were composed of cellulose fluff as an absorbent. In the mid-1980s, sodium polyacrylate (SAP) gel began to replace cellulose fluff. SAP is able to absorb liquid in excess of 80 times its weight. For a few years after SAP diapers were introduced, they were sold alongside the old cellulose disposables without SAP. Eventually, throwaway diaper manufacturers stopped making “non-SAP” disposable (Shin, 2005). Today, unless you buy eco-friendly disposables in a natural food store, all disposable diapers contain SAP.

The pro-disposable studies claim that super-absorbent polymers themselves are the reason fewer babies get rash with this type of diaper. Most pediatricians seem to believe it also. They claim that diaper rash is due to excess skin moisture, and the SAP in disposables wick the moisture away from the baby’s skin (Boiko, 1997). On closer inspection, it appears that many of the studies favoring disposable diapers are influenced by the manufacturers, who either sponsor the research or adjust the way in which the results are presented.

For example, two studies conducted in 1987 found that babies wearing diapers with absorbent gelling material had significantly less rash than babies wearing home-laundered cotton diapers. One study compared three different diapering systems -- two types of disposable diapers as well as home-laundered cloth. However, the study did not control how the cotton diapers were used or laundered. No mention is made of the type of cotton diaper or the type of cover used (plastic or wool). Detergent was not standardized or measured, and there is no note of how often diapers were washed. The authors even admit, “No attempt was made to control or change the diaper care or the skin care habits of the participating families.” (Campbell et al, 1987).

There are other problems with this study. The participants using the two types of disposables were blinded, meaning that those who were grading the rash and taking measurements did not know what diapering product was used on that particular baby. However, the cloth-diapered group was not blinded. If researchers had biases against cloth diapering, this could easily have influenced their conclusions. A leading disposable diaper company sponsored the study.

Another study done on diaper maintenance in 1989 compared seven brands of reusable diapers of various types (cotton, birdseye, terry, flannel among others), four types of “conventional” disposable diapers (the kind without SAP), and five types of disposables with SAP. Again, the diapers with SAP were found to be better at keeping the skin dry. There was no difference found between cloth diapers and conventional disposables when it came to dryness (Wilson, 1990).

This study, however, was not conducted on babies. They used college-age volunteers who did not wear diapers, but instead wore, on their arms, square patch samples cut from the diapers. Each diaper patch was loaded with synthetic urine made from distilled water, sodium, chloride and a nonionic surfactant. Participants had to wear the patches of fake urine for two hours. The moisture absorbed by the patch was recorded. How relevant can this be if it is not measured on a baby’s skin? The laundry practices were not.

I do not find that the question of rash and diaper systems has been adequately addressed by the research. I am not satisfied with the generalizations of researchers and pediatricians. Although many doctors might disagree, it seems risky for babies to spend years with throwaway diapers papered to their bottoms. While there are a variety of factors that contribute to rash, the most common reason is excessive moisture against the skin. Usually, a baby will feel a wet cloth diaper because it can be hard to avoid the wetness. Cloth diapers are usually changed more often. Many parents leave disposable diapers on their baby too long. There is urine in the diaper and bacteria in the urine. When the ammonia in urine mixes with the plastic, the baby’s skin does not get a chance to breathe and the bacteria can grow.

It may be that previous studies don’t provide satisfactory answers because they don’t consider advances in design of both cloth and disposable diapers. The old studies comparing conventional, cellulose disposable diapers and “old-style” cloth diapers are worth learning from, but they are not relevant to today’s diapers. Disposable diaper manufacturers have significant financial resources to spend on research and development, and are constantly trying to prove with science that their products are superior to cloth diapers. As a result, their diapers have changed. Cloth diapers, also, have changed dramatically since the days of plastic or rubber pants that did not let babies’ skin breathe. Today, parents use a wide variety of cloth products, including all-in-one and pocket diapers. Some parents do not use plastic of any kind to diaper their child, preferring to use only wool covers over cotton diapers.

It seems clear that now is the time for new research on diaper rash. In order to ever find an adequate answer to this issue, we need a new study on diaper rash that is independent of disposable diaper manufacturers. It needs to be blinded and controlled with standardized laundry practices, a variety of cloth diapers and covers used, and an equal number of diaper changes performed. Independent research also needs to be done on the health effect of SAP on infants and other chemicals that are present in throwaway disposable diapers. We need unbiased research that examines all angles of rash and the role of diapers. Until then, change your babies frequently and keep their bottoms clean. Diaper rash is ultimately under the control of the primary caregivers.

Allsopp, Michelle. Achieving Zero Dioxin: An emergency strategy for dioxin elimination. September 1994. Greenpeace.

Boiko, S. (1997). Diapers and diaper rashes. Dermatology Nursing. 2/1/1997.

Borkowski, S. (2004). Diaper rash care and management. Pediatric Nursing, 11/1/2004.

Campbell, R. et al. (1987). Clinical studies with disposable diapers. Journal of the American Academy of Dermatology, 17: 978-987.

Gaunder, B. and E. Plummer. (1987). Diaper rash: managing and controlling a common problem in infants and toddlers. Journal of Pediatric Health Care. 1: 26-34.

Greenpeace. New Tests Confirm TBT Poison in Procter & Gamble's Pampers: Greenpeace Demands World-Wide Ban of Organotins in All Products. 15 May 2000.

Kazzi, A.A. Pediatrics, Diaper Rash. eMedicine,

The Landbank Consultancy Limited. A Review of Procter & Gamble's Environmental Balances for Disposable and Re-useable Nappies. July 1991.

Seymour, J.L. et al (1987). Clinical effects of diaper types on the skin of normal infants and infants with atopic dermatitis. Journal of the American Academy of Dermatology, 17: 988-997.

Shin, H.T. (2005). Diaper dermatitis that does not quit. Dermatologic Therapy, 18: 124-135.

Stein, H. (1982). Incidence of diaper rash when using cloth and disposable diapers. The Journal of Pediatrics, 101: 721-723.

Tanino, J. et al. (1959). The relationship of perinatal dermatitis to fecal pH. The Journal of Pediatrics, 54: 793-800.

Weiner, F. (1979). The relationship of diapers to diaper rashes in the one-month-old infant. The Journal of Pediatrics, 95: 422-424.

Wilson, P.A. et al. (1990). Diaper Performance: Maintenance of Healthy Skin. Pediatric Dermatology, 7: 179-184.

Wong, D.L. et al. (1992). Diapering Choices: A Critical Review of the Issues. Pediatric Nursing, 18: 41-54.

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