Articles
Volume 48 Number 1
Association Between the Frequency of
Disposable Diaper Changing and
Urinary Tract Infection in Infants
Tetsu Sugimura, MD, Yoshifumi Tananari, MD, Yukiko Ozaki, MD,
Yasuki Maeno, MD, Seiji Tanaka, MD, Shinichi Ito, MD,
Keiko Kawano, MD, and Kumiko Masunaga, MD
Background Often diapers are not changed after
infants pass urine.
Aim To define the association between the frequency of
changing diapers and urinary tract infection (UTI) in infants.
Methods Urine samples were tested in 131 infants
(aged from 2 months to 2.5 years) who had a temperature
≥38°C. The authors investigated the number of times dia-
pers were changed daily. A total of 128 infants, excluding
3 cases, were divided into 2 groups: group A, without UTI
(n = 96); group B, with UTI (n = 32). The number of times
diapers were changed was compared between the groups.
Introduction
Along with upper respiratory tract infection and oti-
tis media, urinary tract infection (UTI) is an impor-
tant underlying cause of fever in young children. In
addition, UTI is the most common serious bacterial
infection in infants and children.1,2
In recent years, disposable diapers have come
into widespread use, and products with high water
absorption and increased air permeability have been
developed to reduce the need for troublesome diaper
changing. On the other hand, infants whose diapers
are not changed after they pass urine are often seen
in the ambulatory setting.
From Sugimura Children’s Medical Clinic, Ghikugo (TS);
Department of Pediatric Cardiology, St Mary’s Hospital, Fukuoka
(YT, SI); Department of Pediatrics, Kurume University School of
Medicine, Fukuoka (YO, YM, KK); and Department of Pediatrics,
Kurume University Medical Center, Fukuoka (ST, KM), Japan.
Address correspondence to: Tetsu Sugimura, MD, Sugimura
Children’s Medical Clinic, 991-2 Mizuta, Chikugo 833-0027,
Japan; e-mail: sugimura@kurume.ktarn.or.jp.
18
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Clinical Pediatrics
January 2009 18-20
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Results In group A and group B, the number of times
diapers were changed daily were 7.5 ± 1.4 and 4.7 ± 1.4,
respectively. The number of times diapers were changed
was significantly lower (P < .0001) in group B than in
group A.
Conclusions Among infants wearing disposable dia-
pers, there is an increased risk of UTI as the frequency of
changing diapers decreases.
Keywords: urinary tract infection (UTI); infant; dis-
posable diapers; children
The purpose of this study was to define the asso-
ciation between the frequency of changing dispos-
able diapers and UTI in infants.
Methods
Infants who were outpatients of Sugimura Children’s
Clinic and wore disposable diapers because they had
not undergone toilet training were studied. Infants
who had congenital urinary tract malformation or
pubic region deformity were considered ineligible
for the study.
Urine samples were testing for all 131 infants
(aged from 2 months to 2.5 years) who presented to
the clinic with a temperature ≥38°C and no symp-
toms of upper respiratory tract infection such as
cough or nasal discharge. In addition, the numbers
of daily bowel movements and diaper changes dur-
ing the previous 1-week period were investigated. A
nurse interviewed a patroness of the infants in
examination at the clinic during May 1999 to April
2004. The nurse did not know whether the infants
were positive for UTI.
 Frequency of Disposable Diaper in Infants With UTI / Sugimura et al 19

Table 1. Bacterial Pathogens Isolated From the Urine

Samples of Infants With UTI 12
P <.0001
Organism Number Percentage 10 Group A

Number of times
8 Group B
Escherichia coli 15 47.9
Klebsiella pneumoniae 6 18.8
6
Entrococcus faecalis 4 12.5
Staphylococcus epidermidis 3 9.4 4
NS
Citrobacter freunidii 2 6.3
Pseudomonas aeruginosa 2 6.3 2

Note: UTI = urinary tract infection. 0

1.6 ± 1.1 1.4 ± 1.0 7.5 ± 1.4 4.7 ± 1.4
Bowel movements Diaper changes

A urine collection bag was used to obtain the

urine specimen. Two infants with watery diarrhea and
1 infant with severe genital eczema at the time of
urine collection were excluded. Perineums of the
infants were cleansed with 0.02% Hibitane (chlorexi-
dine gluconate) before the bag was attached. If void-
ing did not occur within 20 minutes after attaching
the bag, the bag must was removed and reattached
following the same cleaning routine. Urine samples
were tested by using the dipstick method (N-multi-
sticks SG-L; Miles Sankyo, Tokyo, Japan), and a
Clinitek 50 (Bayer Medical, Tokyo, Japan) was used
for measurement. Bacterial culture and assays were
done for all the samples, with white blood cell (≥1+)
and nitrites positive. A bacterial count ≥105/mL was
considered to be positive for UTI.
A total of 128 infants, excluding 3 cases, were
divided into 2 groups: group A, without UTI (n = 96,
aged 1.1 ± 0.6 years); group B, with UTI (n = 32,
aged 1.2 ± 0.6 years). The number of daily diaper
changes was compared between the groups.
Statistical Analysis
Tests were performed with StatView for PC (Abacus
Concepts; Cary, NC). Quantitative variables were
compared using unpaired Student’s t test, and the
level of significance was set at P < .05.
Results
Frequency of Changing Diapers
In group A (52 boys and 44 girls), the daily number
of bowel movements and the number of diaper
changes was 0.5 to 5.0 (1.6 ± 1.1) and 5.0 to 11.0
(7.5 ± 1.4), respectively. In group B (14 boys and 18
girls), the daily number of bowel movements and the
Figure 1. Number of bowel movements and diaper changes in
groups A and B. Group A, infants with no urinary tract infection;
Group B, infants with urinary tract infection; NS, nonsignifi-
cant. Sticks show the mean, error bars show the standard error.
Data are shown as mean ± standard deviation.
number of diaper changes was 0.5 to 5.0 (1.4 ± 1.0)
and 3.0 to 8.0 (4.7 ± 1.4), respectively. The number
of diaper changes was significantly lower (P < .0001)
in group B (infants with UTI) than in group A
(infants without UTI; Figure 1). Bacterial culture
detected Escherichia coli most often followed by
Klebsiella pneumoniae (Table 1).
Clinical Course
Serum biochemical analysis and hematological
analysis were performed in 20 infants with UTI and
10 infants without UTI.
C-reactive protein was moderately positive
(>5.0) in 5 infants with UIT and in 2 infants with-
out UTI. These infants were introduced to a second
medical institution for exact examination and treat-
ment. The other 27 infants with UTI were treated
with oral antibiotics (cephem antibiotics or sul-
famethoxazole/trimethoprim) for 7 to 10 days. The
infants’ fever came down after 1 to 3 days, with
excellent progress. On the other hand, 18 infants
given antibiotics and 28 infants not given antibiotics
showed good progress in group A. Ultrasonography
was performed in the 27 infants with UTI. Using
echography, mild center expansions of a pelvis of the
kidney were detected in 3 infants with UTI. These
infants were followed-up in our clinic and a second
medical institution.

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20 Clinical Pediatrics / Vol. 48, No. 1, January 2009
Discussion
UTIs are often encountered in infants and young chil-
dren. Although older children with UTI occasionally
complain of fever, abdominal pain, or dysuria, there
are few infants with characteristic symptoms. In
many cases, fever is the main symptom, and there
may also be atypical symptoms such as bad temper,
vomiting, diarrhea, and anorexia. The diagnosis and
management of UTI in infants has not yet been suffi-
ciently well defined.3 In addition, it is unusual to
identify risk factors for UTI, other than anatomic or
neurogenic abnormalities, in young children before
having of some degree of daytime urinary control.
The present study was conducted to investigate the
actual status of UTI in infants who presented with fever
as the main symptom and to clarify the association
between UTI and the frequency of changing diapers.
The main result that we obtained was that the frequency
of changing diapers was significantly lower in the group
of infants with UTI when compared with the group of
infants without UTI. Less frequent changing of diapers
is thus suggested to be a potential risk factor for UTI. It
is unlikely that the diaper itself is a risk factor for UTI;
failure to change the diaper after urination and the con-
tinued wearing of wet diapers, which remain in contact
with the genitals for a long period, may be conducive to
bacterial infection of the urinary tract. Considering the
large number of times that healthy infants pass urine
(14-16 times) every day,2 the average daily number of
times diapers were changed in the group of infants with
UTI (4.7 times) was considered to be too low.
There are 2 main ways through which UTI could
occur: ascending infection and hematogenous infection.
This disease is considered to involve nonspecific inflam-
mation of the urinary tract caused by bacterial invasion.
The route of access for bacteria is generally the ascending
route through the urinary tract.4,5 The UTIs are caused by
bacteria that have colonized the periurethral area.6
In infants, genital contamination by bacteria from
feces and urine is likely to be the cause. The present study
also suggested the possibility of ascending infection.
Diagnosis of a UTI is based on culture of a prop-
erly collected specimen of urine. Methods to obtain
a urine specimen include suprapubic aspiration,
transurethral catheterization, midstream collection,
and bagged collection. In the present study, diagno-
sis and classification of UTI were based on the
investigation of a limited age group of infants in the
ambulatory setting, so urine specimens were col-
lected in bags and the dipstick test was used for pri-
mary screening. Collection of a midstream specimen
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of urine and microscopic confirmation were not per-
formed. McGillivray et al7 calculated that the urine
dipstick method on bag-obtained urine specimens
had a sensitivity of 85% for detecting UTI when
compared with 71% for catheterized specimens. In
our study, we used the dipstick test for leukocyte
esterase and nitrites and obtained a urine specimen.
With regard to gender difference in the incidence
of UTI in infants, male infants are reported to be more
often affected by UTI due to congenital anomalies,
reduced local immunity, or residual urine.8-10 However,
our current study showed that more female infants
had urinary tract infection. With regard to our results,
the influence of the method of urine collection may
need to be considered.
Conclusions
The present findings suggest that among infants wear-
ing disposable diapers, there is increased risk of UTI
as the frequency of changing diapers decreases. It is
important not to overestimate the performance of dis-
posable diapers, and it is important to change diapers
soon after it is noticed that an infant has urinated.
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