Abstract
Safe sleep practices, including use of sleep-appropriate clothing, are crucial for reducing sleep-related deaths. Diapers are part of infant sleepwear, but many caregivers cannot afford them. This study explored diaper insecurity and safe sleep practices, with secondary assessment of social health factors. A 34-question survey examined infant sleep practices, diaper insecurity, and social determinants of health among birthing persons in Kansas who received safe sleep education. Of respondents, 69% (n = 78/113) experienced diaper insecurity, with affected infants being older (6.8 vs 5.3 months, P = .026), non-Hispanic (P = .049), and on Medicaid (P = .018). No significant difference in sleep practices was found. Diaper-insecure participants were more likely to report housing insecurity (P = .029), food insecurity (P < .001), childcare difficulties (P = .007) and financial insecurity (P < .001). These findings showcase the need for screening and interventional support for diaper insecurity, especially for families experiencing challenges related to social health factors, receiving Medicaid, and/or with infants over 6 months old.
Introduction
An important part of infant sleepwear involves the use of diapers. Disposable diapers are highly absorbent and keep the infant dry. However, many caregivers are unable to afford disposable diapers. The National Diaper Bank Network, partially funded through donations from the diaper industry, reports 66% of families who experience a lack of diaper availability, often referred to as diaper insecurity, are low-income. 1 This network indicates diaper insecurity is a growing problem, rising from 33% of families in 2010 to 47% in 2023. 1 For those who rely on The Supplemental Nutrition Assistance Program (SNAP) or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for the purchase of groceries, these aids do not cover diaper costs, leaving some without the means to obtain diapers for their infants. 2 These caregivers may make infant diapers out of rags or clothes, reuse diapers, decrease the frequency of diaper changes, or simply do not place a diaper on the infant. 3
An epidemiological research study of diaper insecurity in under-resourced families with neurodivergent children suggested a link between diaper insecurity and decreased quality of infant sleep (disrupted, shorter infant sleep periods) while controlling for child age, total household income, food security, child disability, and parent behavior scores. 2 However, research has not fully explored potential impacts of diaper insecurity on sleep-related issues.
Sleep-associated incidents cause the deaths of nearly 3400 infants (birth to 1 year of age) in the United States (U.S.) each year. 4 These deaths, often termed sudden unexpected infant deaths (SUID), are caused by suffocation, strangulation, entrapment, and sudden infant death syndrome. 5 SUID is the third leading cause of death among U.S. infants and the second leading cause of infant death in Kansas.6,7
Safe sleep practices are one of the most effective ways to reduce the risk of SUID. 4 Safe sleep practices focus primarily on modifying the conditions surrounding infants during sleep. In 1994, the American Academy of Pediatrics (AAP) introduced safe sleep recommendations for birth through 1 year of age with the intent to reduce the risk of sleep-related infant mortality. 5 These recommendations include having babies sleep alone on their backs in a flat, firm-bedded crib, with a clean fitted sheet over the mattress; having no other objects near the infant; making sure the environment is tobacco-free; and placing the infant in sleep-appropriate clothing that prevents overheating. 5
Practices of those facing diaper insecurity may impact an infant’s risk of SUID by leading to unsafe sleep practices. For example, the use of extra clothing during sleep may contribute to an infant overheating or the use of an ill-fitted diaper may become a loose object in the infant’s sleeping space, resulting in a suffocation hazard. Further, poor infant sleep due to less-than-optimal diaper change frequency may result in unsafe sleep practices (eg, bedsharing, prone position) by parents attempting to increase infant sleep time.
Therefore, the primary goal of this preliminary investigation was to explore whether an association between diaper insecurity and infant sleep practices may exist. Due to previous studies linking diaper insecurity and social health factors, a secondary goal of the research was to explore diaper insecurity and social determinants of health.3,8,9
Methods
Participants
A survey was conducted with birthing persons who were 18 years of age or older, English-speaking, had an infant 1 month to 1 year old at the time of the study, and participated in Baby Talk, a free group prenatal education program, 10 and/or LYFTE, a free perinatal home visitation program. Both programs are well established (7+ years), open to anyone who is pregnant or postpartum, and engage in broad recruitment practices, including referrals from physician’s offices, health departments, maternal and child programs, community organizations and self-referral. Both also provide education on the AAP Safe Sleep recommendations and connect families to resources for a crib if they do not have one. Participants were excluded if they reported having an infant with congenital anomalies (eg, heart defects, neural tube defects) as these might have impacted infant care practices.
Instrument
The survey was composed of 34 questions. As no validated measure of diaper insecurity exists, 4, forced-choice questions informed by previous studies were used to broadly assess diaper insecurity1 -3,11:
Do you ever feel that you do not have enough diapers to change your baby’s diaper as often as you would like? (No-0; Yes-1)
Have you ever cut back on household or personal expenses to afford diapers? (No-0; Yes, but only occasionally-1; Yes, often-2)
How many diapers do you currently have at home? (2 weeks or more-0; 1 week or less-1)
Have you had to get diapers (or money for them) from family, friends, a diaper bank or other resources? (No-0; Yes-1)
Infant sleep practices were assessed using previously developed questions10,12,13 including position, surface and items in the sleep environment. One question evaluated clothing worn for infant sleep. The survey also included questions on tobacco avoidance, infant feeding practices, demographics, and social determinants of health. An open-ended question allowed additional feedback on infant care practices.
Procedures
Eligible participants received an email invitation to complete the Research Electronic Data Capture (REDCap)14,15 survey on May 7, 2024, with 2 reminders. Response time was approximately 15 minutes and participants received a $10 incentive.
Statistical Procedures and Analysis
Investigators coded diaper insecurity as diaper secure (score of 0) versus diaper insecure (score of 1-5 indicating at least one affirmative response).1 -3,11 Sleep practices were coded as safe versus unsafe. Overall safe sleep practice score was computed based on only safe responses (infant sleeping on their back in a non-inclined, crib, bassinet, or portable crib with only safe items [firm mattress, fitted sheet, wearable blanket, and/or pacifier]) compared to at least one unsafe practice.
Data were summarized using descriptive statistics or central tendencies according to diaper insecurity (diaper secure vs diaper insecure). Chi-square tests or Fisher’s exact tests assessed associations between infant sleep practices and diaper insecurity. Additional analyses assessed demographic differences between groups, using independent t-tests or equivalent nonparametric statistics for non-normal data. SPSS for Windows, Version 29.0 (Armonk, NY) was used for data analysis.
Ethical Approval and Informed Consent
This study was approved by the University of Kansas Medical Center Institution Review Board (STUDY00160544). All participants provided informed consent in REDCap prior to completing the survey.
Results
Of 289 potential participants, 117 (40%) completed the survey. Four surveys were incomplete and removed from analysis. One respondent did not complete demographics but was included in the analysis of other variables. The final study sample was 113 participants.
Participant and Infant Characteristics
Diaper insecurity was experienced by 78 (69%) participants versus 35 (31%) who were diaper secure. Full demographics by diaper insecurity are in Table 1. Diaper insecure infants were significantly older, with an average age of 6.8 months (SD = 3.1 months) compared to 5.3 months (SD = 3.0 months; P = .026) for infants without diaper insecurity. One participant’s comment highlighted this finding, “It became much harder to care for our baby as she got older. Most programs [that provide diapers] go from 0-3 months. A lot of challenges occurred after 4 months especially with changing needs. Larger diapers were needed, but baby showers and diaper banks mostly only provide small sizes.” In addition, non-Hispanic birthing persons (P = .049) and those receiving Medicaid were most likely (P = .018) to report diaper insecurity.
Characteristics of Birthing Persons and Infants by Diaper Insecurity.
Missing data: age (n = 17); race/ethnicity (n = 3); relationship status (n = 1); employment (n = 2); insurance (n = 1). Race/Ethnicity other: multiracial and other.
Relationship status Single: single, widowed, separated, divorced.
Insurance other: Tricare and other.
Employment: Unemployed: unemployed, unemployed-looking, students; infant age (n = 9); baby weight at birth (n = 2).
Determined by the independent t test(age) and the chi-square test for independence.
Diaper Insecurity
Diaper secure participants reported using only correctly sized disposable diapers (n = 33; 94%) and/or purchased cloth diapers (n = 3; 9%). Those with diaper insecurity reported using only correctly sized disposable diapers (n = 77; 99%), incorrectly sized disposable diapers (n = 2; 3%), and/or purchased cloth diapers (n = 1; 1%). In addition, those with diaper insecurity reported not having enough diapers to change infant as often as they would have liked (n = 30; 39%); having to cut back on household or personal expenses to afford diapers often (n = 23; 30%) or occasionally (n = 40; 52%); only having diapers for a week or less (n = 47; 61%); and having to get diapers (or money for them) from family, friend, diaper bank or other resource (n = 52; 67%).
Diaper Insecurity and Safe Sleep Practices
No difference was observed in safe sleep practices based on diaper insecurity (Table 2). In addition, no differences were observed regarding tobacco use (P = .307), breastfeeding initiation (P = .177), or current infant feeding practices (P = .229).
Infant Care Practices by Diaper Insecurity.
Missing data: sleep position (n = 1); sleep surface (n = 2); crib items (n = 2); sleep surface incline (n = 1); tobacco use inside home (n = 1); current infant feeding practice (n = 1).
Practice safe sleep is a comprehensive score based on responses to sleep position, sleep surface, crib items and inclined sleep surface.
Determined by the Chi-square test for independence.
Diaper Insecurity and Social Determinants of Health
Compared to those who were diaper secure, participants who reported diaper insecurity were more likely to report housing insecurity (P = .029); food insecurity (P < .001); difficulties with childcare (P = .007); and struggling to keep up with the cost of living (P < .001). No differences were observed regarding transportation limitations in accessing infant healthcare (Table 3).
Social Determinants of Health and Diaper Insecurity.
Missing data: housing (n = 1); food (n = 2); childcare (n = 1); financial situation (n = 1).
Determined by the Chi-square test for independence.
Discussion
Diapers are a fundamental necessity for infants and are crucial for their health and well-being. 1 Infants of birthing persons facing diaper insecurity are more likely to be seen for diaper dermatitis and urinary tract infections compared to those who were diaper secure. 16 Caregiver health may also be impacted as The National Diaper Bank Network reported 28% of those who experienced diaper insecurity admitted to skipping meals to afford more diapers. 1 These health issues associated with diaper insecurity may be of increasing concern as this study reported 69% of participants experienced some level of diaper need. This is less than the 76% of neurodivergent children observed by Shaffer et al, but more than the 41% Reinoso et al reported at a large safety-net health system.3,9 Variance between study findings may reflect the populations assessed. However, findings may also reflect differences in measurement, which highlights the need for a validated diaper insecurity screening tool, as there is none currently available. Reinoso et al 9 used a single-item screener asking whether caregivers have enough diapers to change their baby as often as needed, but were able to follow up with families to better assess needs. The current study incorporates this item along with additional questions informed by prior research to capture a broader range of diaper-related challenges due to the use of a survey at a single timepoint. 9 Despite methodological differences, this study and previous studies collectively acknowledge the burden of diaper insecurity among birthing persons.
Diaper insecurity is often driven by underlying social health factors. The current study suggests diaper insecurity is closely related to difficulties with childcare, housing insecurity, financial struggles, and food insecurity. These findings can help raise awareness and encourage more interventional support or the development of programs similar to SNAP or WIC to supply diapers to those in need. The results of this study are consistent with previous research suggesting food insecure families are 4 times more likely to experience diaper insecurity compared to food-secure families. 3 Further, households earning less than $50 000 per year demonstrate higher diaper insecurity than those earning over $100 000. 8 The 2025 study conducted by Reinoso et al further emphasizes the connection between diaper insecurity and social determinants of health with a large portion of diaper insecure participants reporting food, transportation, housing, and financial insecurities. 9
In this study, diaper insecurity was also associated with participants who were non-Hispanic (P = .049) and enrolled in Medicaid (P = .018). Echoing these results, earlier studies have found that Medicaid recipients are disproportionately affected by diaper insecurity. 9 The increased diaper insecurity observed among non-Hispanic caregivers may reflect clinic and community level resource differences, as well as potential differences in survey participation or reporting. This highlights that diaper insecurity is not experienced uniformly across the population and additional studies with varying demographics are needed.
This study also found the average age of infants experiencing diaper insecurity is higher (6.8 months) than those not experiencing insecurity (5.3 months). This disparity may reflect that birthing persons often receive diapers through family, community baby showers or prenatal programs, which may temporarily alleviate diaper need in the early months. Another contributing factor may be that many community-based support programs (eg, prenatal education, home visitation) primarily focus on the prenatal period, or the immediate postpartum period (birth to 6 months).
While this study does indicate associations between diaper insecurity and social determinants of health, as well as demographic factors, its primary aim was to explore the relationship between diaper insecurity and infant sleep practices. The results suggest there is no association between diaper insecurity and safe sleep practices. As the first study to examine the relationship, there is no previous research for comparison. However, findings regarding adherence to the AAP’s Safe Sleep Recommendations of placing infant to sleep only on the back (80%, n = 89) are consistent with previous research (78%). 17
All birthing persons included within this study received prior education on the AAP’s Safe Sleep Recommendations, 5 which may not be representative of the general population. However, consistent education across participants and access to a safe sleep surface (eg, crib) if needed strengthens this study by ensuring all participants had similar knowledge of safe sleep practices, decreasing the chances that insufficient knowledge or tools are contributing factors. This suggests that diaper insecurity is not associated with safe sleep practices of birthing persons who have received education on the AAP’s Safe Sleep Recommendations, which are crucial for reducing infant deaths from SUIDs. 4
Given the effectiveness of the AAP’s Safe Sleep Recommendations in reducing infant deaths from SUID, the lack of relationship suggests that diaper insecurity might not contribute to SUID risk. 4 However, this study does not directly examine the incidence of SUID among infants experiencing diaper insecurity. Future research should explore the potential relationship between diaper insecurity and the incidence of SUIDs using a cohort study to enhance understanding of SUID risk factors.
The current study’s findings differ from Shaffer et al’s 3 research regarding alternative diapering methods, where previous research suggested a higher likelihood of using disposable diaper alternatives among those experiencing diaper insecurity. As such, it is crucial to investigate the methods birthing persons use to obtain disposable diapers despite experiencing insecurity. This is important to further evaluate as this study suggests that most of those with diaper insecurity used new, well-fitting, disposable diapers (99%, n = 77). Most childcare providers do not allow cloth diapers and most shared laundry facilities (commonly used by households living in poverty) do not allow the laundering of cloth diapers which may have impacted use. Further investigation into this topic may aid in understanding the strategies used by those with diaper insecurity to cope with their need. It may also indicate further possible reasons, such as more resources in the area, which may explain the discrepancy in coping strategies between the population studied by Shaffer et al 3 and this study.
Limitations
Limitations of this initial exploratory study include a small sample size from a limited cohort. Specifically, participants were English-speaking, had access to the internet to receive the electronic survey, and participated in at least one perinatal education program. Further, due to program enrollment guidelines and the AAP Safe Sleep Recommendations being limited to those from birth to 1 year, no data was collected on older children (≥1 year), who often wear diapers up to the age of 3 or 4. This research was a cross-sectional study and cannot establish causation. The self-report nature of this survey may have introduced potential biases, such as response bias, recall bias, or social desirability bias. For example, respondents might have chosen not to report socially unacceptable choices, such as reusing dirty diapers. Measurement bias due to question wording is also possible as no standardized measure of diaper security exists, however this was minimized by using validated questions from previous studies when possible.
Conclusion
This study suggests there is no association between diaper insecurity and safe sleep practices. However, limitations of the study population may indicate that additional studies with a larger, more diverse sample are needed. Demographic differences were observed based on race/ethnicity, insurance type and infant age. This research also identified that birthing persons with financial challenges, food insecurity, housing insecurity, and difficulties accessing childcare are more likely to experience diaper insecurity. These results highlight the importance of developing a validated diaper insecurity screening tool to identify families in need and provide direct support or referral to available resources.
Footnotes
Ethical Considerations
The University of Kansas Medical Center Institution Review Board approved the study (IRB ID: STUDY00160544) on 05/01/2024.
Consent to Participate
All participants gave informed consent prior to participating in survey.
Author Contributions
All authors (Segura, Hervey, and Ahlers-Schmidt) made significant contributions to the concept, design, acquisition, and analysis or interpretation of the data; drafted the article or revised it critical for important intellectual content; approved the final version for publication; and agree to be accountable for all aspects of the work and resolved any issues related to its accuracy or integrity.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project was provided in part by The Kansas Department of Health and Environment Maternal Child Health funds and The University of Kansas School of Medicine-Wichita Center for Research for Infant Birth and Survival.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statements
Share upon reasonable request.*