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Supporting the infant during hygiene procedures

Authors

Hankes Drielsma I, Oude-Reimer M, Frauenfelder O, Camba F, Ceccatelli M, Kalbér A, Kühn T, Silva E

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

All infants receive appropriate activities of daily living (ADL), commencing with low-stress cleaning and moving to methods that support self-regulation once the infant is stable, alert and interactive.

Rationale

Activities of daily living (ADL) are described as tasks that every human being participates in for personal care such as eating, bathing, dressing, toileting and repositioning themselves. All infants depend on others (parents) for these daily activities in which they experience trust, empathy and bonding. (1,2)

All caregivers have to be aware that infants’ skin is particularly sensitive (3) and cleaning can negatively affect skin integrity (4,5); therefore, early and frequent washing and bathing should be avoided. Furthermore, these procedures can lead to distress and physiological, as well as thermal, instability. (6–8)

Choosing an appropriate ADL includes a washing method that leads to the least distress and disruption of sleep in the infant. (7,9,10)

There are different washing methods like cleaning the minimum of body parts, sponge bathing, or immersion bathing. Washing an infant should never be a scheduled task but should always be cue based and individualised. (3,4,6,9,11–13)

The bio-behavioural cues of the infant should be the leading factor to decide the correct washing method.

Benefits

Short-term benefits

  • Appropriately supported activities of daily living (ADL’s) in the infants (6,9,10)
  • Reduced risk of infections (4,5,14) (see TEG Care procedures)
  • Minimised energy expenditure (1,2,7–10,12)
  • Improved self-regulation of the infant and ensuring bathing is a pleasant experience (9–13,15)
  • Supports the parental role with improved confidence and competence in supporting their child’s ADL’s (2,6,13,15,16)

Long-term benefits

  • Improved weight gain and development of the infant (1,2,10,14,15)
  • Improved parent-infant bonding (2,9,13,15,16)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family
1. Parents and family are informed by healthcare professionals about hygiene and bathing procedures. (6,13,16) (see TEG Patient safety & hygiene practice) A (High quality)
B (High quality)
Patient information sheet
2. Parents are involved in interpreting cues in their infant. (1,2,13,14,16) A (High quality)
B (High quality)
Clinical records, parent feedback, patient information sheet
3. Parents are supported by healthcare professionals to carry out bathing and feel confident. (6,10,13,15,16) A (High quality)
B (High quality)
Guideline, patient information sheet
4. Parents get opportunities to practice bathing with a doll during parent education groups. B (Moderate quality) Training documentation
For healthcare professionals
5. A unit guideline on hygiene and bathing procedures for infants in an individualised manner is adhered to by all healthcare professionals. (6,9,10,13) A (High quality)
B (High quality)
Guideline
6. Training on hygiene and bathing procedures is attended by all responsible healthcare professionals. B (High quality) Training documentation
7. All healthcare professionals see bathing as an important parental procedure which is only done with or by parents. (2,10,13,16) A (High quality)
B (High quality)
Guideline
For neonatal unit
8. A unit guideline for hygiene and bathing procedures for infants in an individualised manner is available. (6,13,16,17) A (High quality)
B (High quality)
Guideline
9. Continuous education about bathing and interpreting cues in the infant is available. (6,13) A (High quality)
B (High quality)
Training documentation
For hospital
10. Training on hygiene and bathing procedures is ensured. B (High quality) Training documentation
11. Quiet spaces where parents can bathe their infants are available. (see TEG NICU design) B (Moderate quality) Guideline
For health service
N/A

Where to go

Further development Grading of evidence
For parents and family
N/A
For healthcare professionals
N/A
For neonatal unit
N/A
For hospital
N/A
For health service
N/A

Getting started

Initial steps
For parents and family
  • Parents and family are verbally informed by healthcare professionals about hygiene and bathing procedures.
  • Hygiene of the infant is performed by or with parents.
For healthcare professionals
  • Attend training on hygiene and bathing procedures.
For neonatal unit
  • Develop and implement a unit guideline for hygiene and bathing procedures.
  • Develop information material about hygiene and bathing procedures for parents.
For hospital
  • Support healthcare professionals to participate in training on hygiene and bathing procedures.
For health service
N/A

Description

Coughlin (9) describes how age-appropriate activities of daily living (ADL’s) in the NICU include postural support, feeding and skin management. She underlines the importance for healthcare professionals to partner with parents in the provision of ADL’s. This partnership not only creates parental confidence and competence but also validates the parental role while meeting the fundamental age appropriate needs of their infant. (18)

All infants, and especially ill and preterm infants, are exposed to many stressors due to medical and nursing care procedures needed to support physiological needs that are often painful. (3,5,9,18) Other stressors infants in the NICU are exposed to are interrupted sleep, excessive noise and light levels and daily care procedures in an unfamiliar extra-uterine environment without the protection of their mother. (6)

When deciding the appropriate washing method for an individual infant it’s not only important to take the age of the infant into consideration but more so to observe the infant’s cues through different subsystems. These include autonomic integrity, motor activity the infant state, attention capacity and self regulation based on the Synactive Theory of Development. (1,2) Bathing should be delayed until an infant shows competence across the five subsystems.

After birth infants should not be washed. Inspection of the scalp is indicated if the newborn infant was invasively monitored during labour to identify skin damage and prevent infections. When the hair of a newborn infant is full of blood or green amniotic fluid the hair and body may be gently washed. There are no other reasons to give a full term infant a bath after birth.

Very preterm infants in the NICU who show signs of instability should never be bathed or sponge bathed fully in order to avoid distress. (11) Places where the skin can become irritated and may require cleansing are face (eyes), behind the ears, neck/throat, armpits, hands between the fingers and feet between toes. This can be carried out with warm sterile water or breast milk. (see TEG Care procedures) Cleansing a body part should be done gently while responding to the newborn infant’s cues and letting parents support their newborn infant. A “4-hands-manoever” is recommended for such possible stress related procedures”: two carers, ideally one healthcare professional and one parent perform body cleansing procedures: one providing care, the other supporting the infant to remain stable and calm in a potential stressful situation.

Once the infant is in a step down unit or in the NICU shows competence across the 5 subsystems the infant may be ready to experience being bathed while swaddled. (6,7,11,13) Swaddled bathing helps the infants feel secure and gives them support to self-regulate. This way they can be an active participant. Every healthcare professional should see bathing as a social event that promotes the wellbeing of the infant and includes the parents. Parental participation helps them feel confident and competent. During this process healthcare professionals can support the parents by helping them to move slowly, watch, interpret and respond to their infant’s cues. A calmed bathing experience is an ideal situation to bring parents and their child into interaction, communicating to each other. This will increase self-confidence and resilience of the parents and is a perfect tool to establish secure parent-child bonding.

Sources

  1. Als H. Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Ment Health J. 1982 Dec;3(4):229–43.
  2. Als H. A Synactive Model of Neonatal Behavioral Organization: Phys Occup Ther Pediatr. 1986 Jan 1;6(3–4):3–53.
  3. Montagu A. Touching: The Human Significance of the Skin. HarperCollins; 1986. 516 p.
  4. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs JOGNN. 2001 Feb;30(1):41–51.
  5. Maguire DP. Skin protection and breakdown in the ELBW infant. A national survey. Clin Nurs Res. 1999 Aug;8(3):222–34.
  6. Coughlin M, Gibbins S, Hoath S. Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. J Adv Nurs. 2009 Oct;65(10):2239–48.
  7. Edraki M, Paran M, Montaseri S, Razavi Nejad M, Montaseri Z. Comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration in premature infants: a randomized clinical trial. J Caring Sci. 2014 Jun;3(2):83–91.
  8. Peters K. Bathing premature infants: physiological and behavioral consequences. Am J Crit Care. 1998;7(2):90–100.
  9. Coughlin M. Transformative Nursing in the NICU [Internet]. Springer Publishing. [cited 2018 Jun 20]. Available from: http://www.springerpub.com/transformative-nursing-in-the-nicu.html/
  10. Coughlin M. Trauma-Informed Care in the NICU [Internet]. Springer Publishing. [cited 2018 Jun 20]. Available from: http://www.springerpub.com/trauma-informed-care-in-the-nicu.html/
  11. Liaw J-J, Yang L, Chou H-L, Yang M-H, Chao S-C. Relationships between nurse care-giving behaviours and preterm infant responses during bathing: a preliminary study. J Clin Nurs. 2010 Jan;19(1–2):89–99.
  12. Liaw J-J, Yang L, Yuh Y-S, Yin T. Effects of tub bathing procedures on preterm infants’ behavior. J Nurs Res JNR. 2006 Dec;14(4):297–305.
  13. Milette I, Martel M-J, da Silva MR, Coughlin McNeil M. Guidelines for the Institutional Implementation of Developmental Neuroprotective Care in the NICU. Part B: Recommendations and Justification. A Joint Position Statement From the CANN, CAPWHN, NANN, and COINN. Can J Nurs Res Rev Can Rech En Sci Infirm. 2017 Jun;49(2):63–74.
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  16. Bracht M, OʼLeary L, Lee SK, OʼBrien K. Implementing family-integrated care in the NICU: a parent education and support program. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2013 Apr;13(2):115–26.
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  18. Castiello U, Becchio C, Zoia S, Nelini C, Sartori L, Blason L, et al. Wired to be social: the ontogeny of human interaction. PloS One. 2010 Oct 7;5(10):e13199.

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Hankes Drielsma I, Oude-Reimer M et al., European Standards of Care for Newborn Health: Supporting the infant during hygiene procedures. 2018.

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