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Practising developmentally supportive care during bathing: reducing stress through swaddle bathing

Although bathing is widely accepted within society to be stressful for the healthy newborn, there is minimal research into the physiological and behavioural impact it has on vulnerable preterm . Developmental care strategies encourage nursing staff to adapt the extra- uterine environment to reduce infant stress and promote overall stability. This article highlights the benefits of swaddle bathing in reducing stress and encourages considerations towards it becoming common practice for improving patient care.

Kerry Hall uring intra-uterine life the infant’s babies during bathing reduced stress. With RSCN, BSC (Hons) Dvital stages of growth and a lead role in developmental care the Developmental Care Nurse development are conducted in an ideal author was keen to implement the method Scunthorpe General Hospital environment, offering protection and of bathing onto the unit. Initially there was [email protected] security. However, when an infant is born staff resistance to the new concept and prematurely this becomes far from the with no evidence-based research to reality as continuing care is provided on support the procedure, a research proposal the neonatal intensive care. This was generated to provide the required environment in comparison to the womb information to take it forward. is full of noise, harsh lighting, touch as well Background knowledge was collected and as painful and stressful procedures, all of training of staff was carried out to record which have been found to cause distress in the comparisons between traditional tub preterm infants, disrupting their normal bathing and swaddle bathing, while growth and development1-3. awaiting ethical approval to conduct the Keywords It is with this understanding that study. During this time staff began to developmental care; infant stress cues; thought was given regarding the traditional recognise the benefits to both the baby and tub bathing; swaddle bathing routine care of tub bathing. Developmental the and were consequently Key points care has taught nursing staff to become reluctant to revert back to traditional more in-tune with infant behavioural cues baths, feeling it was morally and ethically Hall K. Practising developmentally in order to recognise and react to distress wrong. The research project was therefore supportive care during infant bathing: signs. Such distress signs are accepted as unable to be taken forward as this would reducing stress through swaddle bathing. normal during bathing of healthy infants, have meant infants were knowingly Infant 2008; 4(6): 198-201. generally with crying throughout the allocated to an inferior procedure, which 1. Tub bathing is a stressful experience for procedure4. However as neonatal nurses we poses ethical dilemmas in conducting healthy newborn babies and is even have a duty of care to recognise that this research5. Swaddle bathing became more stressful for vulnerable preterm infants with fragile physiological has potential dangers for the preterm common practice on the author’s unit for stability. infants in our care and act in an preterm babies, as well as any term baby 2. Sponge bathing premature infants appropriate manner. the staff felt would benefit. poses significant risks due to heat loss. The resolution to this problem was 3. The containment offered during introduced to the author’s unit through the History of bathing infants swaddle bathing mimics the compact practice of swaddle bathing. The concept Traditionally, sponge baths were carried environment of the womb. was brought to light when liasing with out on newborns until the umbilical cord 4. Swaddle bathing has been shown to developmental care medical representatives fell off, then tub baths where introduced6. reduce behavioural stress cues which regarding a Tiny Tub bathing system However, infants born prematurely normally occur during tub bathing, such (Children’s Medical Ventures). It seemed continued to have sponge baths as part of as crying, back arching and extended from observation and the decrease in noise their routine care (biweekly/daily) during limbs with splayed fingers. from the infant that swaddle wrapping of their prolonged hospitalisation on the

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NICU3. It was believed that this practice Benefits of weighing25. Fern et al18 discuss how a father reduced the risk of infection and bacterial With concerns still highlighted within the recognised the distress his child displayed colonisation, which can be life threatening literature surrounding the current method during a bath and how containment 7 for all preterm infants . However, in later of bathing preterm infants12, alternative relieved many of these stress cues. As research conducted comparing sponge approaches to the procedure need to be neonatal nurses we recognise such cues bathing to tub bathing it was found there considered. It is with this in mind that the including back arching, hyperextension, trusting, extended limbs with splayed was no significant difference in infection author decided to address tub bathing rates3,8,9. In actual fact, the research fingers, fussing, often crying and using swaddling techniques during the concluded that a sponge bath posed more expending large amounts of energy. The bath. This concept is promoted by of a risk due to significant heat loss, bath therefore becomes rushed and Children’s Medical Ventures15 with the physiological alterations, including changes unpleasurable for both the infant and the introduction of the developmental bathing in heart rate, oxygen requirements and bather, with the baby subsequently system the Tiny Tub. However there is saturation levels, and detrimental reluctant to feed and needing rest and minimal recognition of this technique behavioural cues, including crying, recovery time. Also, more importantly, all within the literature16-18 and no research wimpering and thrashing3,10-12. In addition, of such behaviours are recognised to be conducted to date into the benefits of the procedure of sponge bathing was not behavioural stress cues, which can impact swaddle bathing versus traditional supportive of family-centred care as neo- on other subsystems, most importantly the unswaddled tub bathing of preterm infants. natal nurses were reported to be carrying autonomic system12. With reference to swaddling preterm out the procedure in the middle of the The womb is a compact environment infants, historically research has indicated night when they had more time available, with clear boundaries offering security, that swaddled infants have improved sleep meaning the family were never involved3. which can be mimicked through the patterns19,20. However, this does raise the Bathing procedures therefore moved containment offered during swaddling. controversial issue of the possible assoc- away from sponge bathing as routine care Immersion into warm water also simulates iated risk of sudden infant death syndrome to the practices currently used today. the uterine environment14. Combining during swaddling of infants21. However, Critically ill infants are no longer bathed as immersion into water and containment 22- it is recognised to be detrimental to their mainly through research into infant pain may therefore offer a familiar feeling 24 well being, minimal handling is now , swaddling is recognised as improving and promote a calm and stress-free encouraged to reduce stress on suboptimal the stability of physiological parameters bathing experience. physiological ranges11. However through and reducing behavioural stress signs, the recognition that newborns appeared to including crying and fussing, which Swaddle bathing technique be comforted when immersed in warm continue to be of concern with infant All bathing should be carried out alongside water4,6,13, several studies have recommen- tub baths. or by the , to promote family- ded that once an infant is stable consid- An article by Neu and Brown compared centred care, with explanation and eration should be given to introducing tub swaddled versus unswaddled preterm education surrounding the bathing 25 bathing, with the involvement of the infants during weighing procedures . The technique. As hunger increases an infant’s family. It is believed that the tub simulates potential hazards to preterm infants during behavioural stress cues and alters the uterine environment, with the weighing were recognised and the data performance, baths should be carried out submersion of water being a familiar obtained indicated beneficial effects for while the baby is settled and before a feed feeling to the infant14. swaddled infants. These infants exhibited is due, with positive calming commun- Even though tub bathing was felt to be a less physiological distress, including ication promoted throughout the bath. more pleasurable experience for both paleness, duskiness, and reduced visceral The developmental bathing system Tiny infant and the family, it is still widely activity, such as hiccupping. Improved Tub offers a back support, temperature accepted within society that bathing motor organisation with reduced arousal guide and a triangular soft fabric with a continues to be a stressful experience for from conscious level was observed with less deep pocket for safe swaddling (FIGURE 1). healthy newborns, resulting in most babies motor activity in general, and any The water should reach the top of the tub crying throughout the procedure4. When movement that occurred was smoother, so that the infant’s shoulders are considering research on preterm infants, resulting in reduced general energy submerged, to assist with temperature Liaw et al acknowledged that papers on expenditure. Placing infants on the scales stability, and the infant’s feet positioned at bathing in the literature have unswaddled resulted in the babies the bottom corner for foot bracing. predominantly focused on traditional displaying either poor muscle tone, An additional bowl of warm water is sponge bathing techniques12. Regarding tub resulting in a flaccid uncontrolled posture, required to bath the eyes, using cotton bathing techniques, this highlighted that or rigid hyperextension tone. Also, self- wool balls. bathing routines in most NICUs are not regulatory infant behaviour was observed The limbs are cleaned using parental currently based on evidence and that during the swaddled procedure, whereas touch or cotton wool, only exposing one preterm infants tub-bathed continued to unswaddled infants could not, or made no extremity at a time. If the baby display alterations to heart rates and attempt to, self regulate. demonstrates any behavioural signs of oxygen saturation levels, with frequent Many of the difficulties preterm infants stress during this stage, pausing the behavioural distress cues. This, therefore, face during tub bathing mirror what was procedure and offering time out with raised further the question of the benefit of concluded in the research article by Neu containment holding, should resolve any tub bathing vulnerable preterm infants. and Brown when observing infants during distress. If the baby remains unsettled a infant VOLUME 4 ISSUE 6 2008 199 INFANT BATHING

Submerge infant to shoulder depth in Wipe eyes with fresh water, from the inner Supporting infant’s head, slowly unswaddle swaddling cloth, ensuring infant’s feet are corner to the outer corner. Clean face with one arm at a time to wash, using hand or a touching the bottom corner of the tub for additional clean water. wash cloth. foot bracing.

Slowly expose one leg at a time to wash and Rock the infant forward supporting under Top up with warm water if necessary. Wash clean genital area. If the infant demonstrates the neck. Wash the back through the wash the infant’s head. any signs of stress allow time for recovery. cloth, so as not to disorganise the infant.

Gently unswaddle the infant, remove from Quickly draw the infant to caregiver’s chest After bathing the infant should be alert and the tub leaving the cloth in the bath, main- and wrap in the fetal position in a towel, eager to feed orally. taining a contained, flexed position for ensuring that the head is covered. security.

FIGURE 1 Procedure for a swaddle bath. non-nutritive sucking tool (dummy) bather’s chest, where a towel is ready. After procedure – this helps the parents to feel should be offered. The infant’s back should the infant has been re-swaddled the comfortable in bathing their infant and be washed through the cloth, as priority is to dry the head, as this is where encourages a more pleasurable family unswaddling would disorganise the infant, infants lose most of their heat, through the event (FIGURE 2). Fern et al18 found parents and lastly the hair washed prior to large surface area26. The bath should take involved in swaddle bathing their infants finishing the bath, to reduce cold stress. To 7-10 minutes, with additional warm water had increased confidence in their complete the bath, the cloth is removed supplemented if required. skills, which helped with their attachment and the baby is quickly lifted onto the Infants should not cry during the and interaction with their baby and overall

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swaddle bathing observed have included tempurature in traditional newborn infants before Baby 1: born at 25 weeks’ gestation – I a reduction in temperature variation and after tub bathing. Applied Nursing Research bathed from 33 weeks 1995; 8: 123-28. I infants either remain in light sleep/semi My baby had a swaddle bath, I expected 14. Filho L.C. et al. The impact of different types of bath dozing or are awake, maintaining a quiet him to cry while having a bath but due to in the behaviour and physiology of ‘rooming in’ alert state the benefits of swaddle bathing he was newborn babies. Neuroendocrinol Lett 2004; I 25(suppl 1): 141-55. relaxed, calm and I definitely think that infants dislay reduced behavioural stress, 15. Children’s Medical Ventures – Tiny Tub™ swaddle bathing is very beneficial. ie absence of extended limbs, back arch- ing, splayed fingers saluting across the Developmental Bathing System. http://tinytub.respironics.com accessed 03/03/08. face, hiccupping, fussing and crying Baby 2: born at 26 weeks – bathed from 16. Lawhon G., Als H. Theoretic perspective for I after bathing the babies remain alert and developmentally supportive care. In: Kenner C., 32 weeks eager to feed orally. McGrath J.M. eds. Developmental Care of the We were introduced to swaddle bathing Swaddle bathing therefore has become Newborns and Infants: A guide for health by the NICU’s developmental care nurse. common practice on the author’s unit and professionals. St Louis: Mosby. 2004: 57. As he was lowered into the water he 17. Als H., Duffy F.H., McAnulty G.B. et al. Early is a method which the author believes all didn’t open his eyes and stayed asleep experience alters brain function and structure. throughout! He was so calm afterwards nurses caring for vulnerable infants should 2004; 113(4): 846-57. and went straight on the breast and had consider using as an alternative to the trad- 18. Fern D., Graves C., L’Huilier M. Swaddle bathing in the newborn intensive care unit. Newborn Infant a full breastfeed without tiring as I had itional bathing method commonly used. Nurs Rev 2002; 2(1): 3-4. expected he would. References 19. Giacoman S. Hunger and motor restraint on arousal and visual attention in the infant. Child FIGURE 2 Parental feedback regarding 1. Als H. Toward a synactive theory of development: Development 1971; 42: 605-14. swaddle bathing. Promise for the assessment and support of infant 20. Lipton E., Steinschneider A., Richmond J. Swaddling, individuality. Infant Mental Health J 1982; 3(4): 229- a practice: historical, cultural and improved their understanding of their 43. experimental observations. Pediatrics 1965; 35: 2. Als H. Manual for the Naturalistic Observation of baby’s needs. According to Children’s 521-67. Newborn Behaviour (preterm and fullterm) Boston, 21. Sleuwen B.E., Engelberts A.C., Boere-Boonekamp Medical Ventures15, infants exhibit positive MA. The Children’s Hospital. 1984. M.M. et al. Swaddling: a systematic review. feeding after bathing, as less energy has 3. Peters K.L. Bathing premature infants: physiological Pediatrics 2007; 120(4): 1097-106. been expended. Reviewing the and behavioural consequences. Am J Crit Care 1998; 22. Campos G.R. Soothing pain-elicited distress in independent literature surrounding 7(2): 90-100. infants with swaddling and pacifiers. Child research into tub bathing and generalised 4. Cole J.G., Brisstte N.J., Lundardi B. Tub baths or Development 1989; 60(4): 781-92. sponge baths for the newborn infants? Baby swaddling of infants, this theory appears 23. Walden M., Jorgensen K.M. Pain management. In: J 1999; 4(3): 39-43. Kenner C., McGrath M.J., eds. Developmental Care of plausible. 5. Hicks C. The randomised controlled trial: a critique. Newborns & Infants: A guide for health Nurse Researcher 1998; 6(1):19-31. professionals. St Louis: Mosby. 2004: 197-222. Changing practice 6. Bryanton J., Walsh D., Barrett M., Gaudet D. Tub 24. Hyesang I., Eunjung K., Eunsook P., Kyungsuk S., Nursing in today’s climate relies heavily on bathing versus traditional sponge bathing for the Wonoak O. Pain reduction of heel stick in neonates: newborn. JOGNN 2004; 33(6): 704-12. evidence-based practice and with such new yakson compared to non-nutritive sucking. Oxford 7. Boxwell G. Neonatal infection. In: Boxwell G., ed. Journals: J Tropical Pediatrics Advance Access concepts implementing change in practice Neonatal Intensive Care Nursing. Routledge: tropej.oxfordjournals.org/cgi/content/full/ 27 is by no means easy . Although, the initial London. 2001; 259-84. fmm083v1 accessed: 28/05/08. aim of the author was to begin the 8. Henningson A., Nystrom B., Tunnell R. Bathing or 25. Neu M., Browne J.V. Infant physiologic and collection of data to support this theory, washing after birth? Lancet 1981; 2: 1401-03. behavioral organization during swaddling versus whilst submitting a research design to the 9. Frank L.S., Quinn D., Zahr L. Effect of less frequent unswaddled weighing. J Perinatol 1997; 17(3): bathing of preterm infants on skin flora and ethical committee and organising staff 193-98. pathogen colonization. JOGNN 2000; 29(6): 584-89. 26. Stothers J.K. Head insulation and heat loss in the training, the overall consensus regarding 10. Peters K.L. Association between autonomic and newborn. Arch Dis Child 1981; 56: 530-34. swaddle bathing changed. motor systems in the preterm infant. Clin Nurs Crit 27. Turnage-Carrier C.S., Ward-Larson C., Gates L.V.S. Staff and parents expressed positive Care 2001; 7(2): 90-100. Organizational climate, implementation of change feedback related to swaddle bathing and 11. Lee H.K. Effects of sponge bathing on vagal tone and outcomes: Process for change. In: Kenner C., consequently felt it would be morally and and behavioural responses in preterm infants. J Clin McGarth J.M., eds. Developmental Care of ethically wrong to carry out a study, in Nurs 2002; 11(4): 510-19. Newborns and Infants: A guide for health 12. Liaw J-J., Yang L., Yuh Y-S., Yin T. Effects of tub professionals. St Louis: Mosby. 2004: 443. accordance with the NMC code of bathing procedures on preterm infants behavior. 28. Nursing and Midwifery Council. The NMC code of 28 conduct , knowingly exposing preterm J Nurs Res 2006; 14(4): 297-305. professional conduct: standards of conduct, infants to potential harm. Benefits of 13. Anderson G.C., Lane A.E., Chang H.P. Axillary performance and ethics. NMC, London. 2004.

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