Diaper need linked to increased family stress and poor sleep in children, nurse’s doctoral research finds

August 5, 2021

diapers in background with coins in foreground
Emma Shaffer

Emma Shaffer’s experiences as a pediatric nurse practitioner introduced her to the effects of diaper need on families. She’s more closely investigating this important issue as a PhD in Nursing student at Rutgers School of Nursing, where she successfully defended her doctoral dissertation in July. Her research focuses on diaper need and family outcomes among a sample of under-resourced families with neurodiverse children. Below, she discusses the importance of addressing diaper need and her motivation for researching this issue. 

1) What drew you to this research topic, and how is diaper need categorized? 

 At the pediatric clinic where I worked, we had a store of diapers for the children who soiled a diaper during a visit. I started to notice that some families would ask for extra diapers and diapers would go missing from the supply drawer. Finally, the administration instituted a two diaper per family rule policy. But I never stopped to ask why, or if there was a different way to handle the situation. Years later, I learned that one in three U.S. mothers cannot afford diapers. Now I had an opportunity to ask these questions and look at the situation from another angle. In this effort, Dr. Sallie Porter, my adviser, was a great resource and guide.  

Diaper need is defined as an inability to obtain the supplies required to keep an infant dry, clean, and healthy without decreasing spending on food or other basic goods (Massengale et al., 2020; Porter & Steefel, 2015). It’s a lens through which we can measure and understand the manifestations of poverty among families with children. High diaper need is defined as not having enough diapers to last the month. Low diaper need is defined as occasionally (once a year or a few times a year) needing diapers, but typically having enough supplies to last the month. It’s important how you ask about diaper need, and that is something my work added to the body of research. In my study, the question, “Are you able to buy enough diapers for your baby all month long?” was better than the question from previous research, “How often have you needed diapers for your child but did not have them?” When I compared respondents’ answers to the questions, I found the first was better able at identifying families experiencing high diaper need and thus at greater risk for stress and sleep issues.   

2) From where was the sample drawn? 

This was an online survey open to United States caregivers who speak and read English or Spanish. Most of the participants were parents, but it was open to other caregivers such as grandparents or legal guardians. I used a purposeful sampling of families connected to early child support, home visiting, and disability programs. Families with a child with a developmental disability are more likely to be under-resourced but are often excluded from research.  

3) Does geography play a role in creating, increasing, or reducing diaper need? 

Geography plays a role in that some families live in areas where they do not have access to cost-saving strategies. While reusable diapers may be alternative for some, it is not a feasible option for many caregivers. Most commercial laundry facilities, which are utilized by many under-resourced families, do not allow cloth diapers to be washed in their equipment. Other cost-saving solutions, such as buying in bulk, are not universally accessible because of transportation or housing discrepancies. 

4) Your dissertation focuses on families. Why did you choose to look at the family as a whole? 

As a pediatric nurse practitioner, I have found that you cannot consider a child in isolation. So much of health and well-being is related to positive, nurturing relationships with the people (or lack thereof) around us. I entered the field because child development is remarkable, but I soon learned that equally notable is the growth, or development, of parents and other caregivers.   

5) One of the findings of your research suggests that the stress levels of parents are impacted by diaper need. What were some of the ways this stress manifested

On a biological level, stress activates the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system pathways. Over time, high levels of stress alter brain structure, disrupt neuroendocrine regulation, and negatively affect cognition and physiological function. The body’s stress response system recalibrates to favor a sustained ‘fight or flight’ mode rather than conditions conducive to health and learning to be a parent (McEwen, 2017National Scientific Council on the Developing Child). Emotional stress may even manifest into mental health symptoms. Mothers experiencing diaper need have significantly higher depressive symptoms than their peers (Austin & Smith, 2017).  

Stress can have repercussions for the parent-child relationship. Examples include hampering ‘serve and return’ interactions and the development of secure parent-child attachment. Conversely, having a sufficient supply of diapers can positively affect these interactions and the parent-child relationship. As a mother in one diaper study noted, “I think being happier and not stressed out (is the biggest impact of having diapers), it’s contagious so everyone is happier” (Messangale et al., 2017, p. 1990).

6) Your research focuses a bit on sleep. Why was this such a concern? 

Great question. Sleep is so important for infant and toddler health and parents often come to the pediatric office with sleep concerns. Sleep promotes brain development and solidifies learning and memory. It is associated with development, behavioral, and physical health including social-emotional wellbeing (Hysing, Sivertsen, et al., 2016) and childhood obesity (Na et al., 2020). 

7) What were some of the impacts of diaper need on the children themselves that were most surprising? 

My study was the first to link diaper need and poor sleep. The most exciting find was that diaper need was associated with poor sleep even after adjusting for parent’s behaviors/sleep environment (such as consistent bedtime routine and sleep location). These findings suggest the importance of both appropriate sleep hygiene education and sufficient supplies for child sleep. As nurses, we can educate about sleep or other health issues but we also need to ask questions. Is there an environment that is contributing to this health condition? Why is this family asking for extra diapers?  Are they able to buy enough diapers for their baby all month long? 

Diaper need continues to be a nationwide issue. For another discussion on this topic, see here.