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2From the rationale developed for this standard: "Gastrointestinal disease caused by bacteria, viruses, and parasites and hepatitis A virus infection of the liver are spread from infected persons through fecal contamination of objects in the environment and hands of caregivers and children.... Diapering practices that require increased manipulation of the diaper and waterproof covering, particularly reuse of the covering before it is cleaned and disinfected, provide increased opportunities for fecal contamination of the caregivers' hands, the child, and, consequently, objects and surfaces in the environment. Therefore, reusable cloth diapers worn alone or worn with a separate, nonattached waterproof covering are not acceptable in facilities. One study demonstrated that fecal contamination in the center environment was less when paper diapers were used than when cloth diapers were used; contamination was also reduced when clothes were worn over either cloth or paper diaper.
"Whereas reusable diaper systems consisting of an outer waterproof covering and an attached inner cotton lining that are changed together meet the physical criteria of this standard; they have not been evaluated for their ability to reduce fecal contamination. Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. If these reusable diapers are used in child care, considerable care should be taken to minimize diaper handling and to determine the waterproof characteristics of the covering material at frequent intervals.
"Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both. The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin. Damaged skin is more susceptible to other biological, chemical and physical results that can cause or aggravate diaper dermatitis. Theoretically, diapering practices that reduce the frequency and severity of diaper dermatitis will result in reduced application of skin creams, ointments, and drug treatments, which increase the likelihood for fecal contamination of caregivers' hands."