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Bathing and Beyond: Current Bathing Controversies for Newborn Infants

Lund, Carolyn MS, RN, FAAN

Section Editor(s): Zukowsky, Ksenia

doi: 10.1097/ANC.0000000000000336
Clinical Issues in Neonatal Care

Background: Bathing the newborn infant is controversial, ranging from how and when to give the newborn their first bath, whether to bathe newborns at all in the initial days of life, and how to approach bathing the hospitalized premature and full-term infant in the neonatal intensive care unit (NICU).

Purpose: To review relevant literature about bathing newborn infants, as well as examine the controversies about bathing NICU patients including the use of daily chlorhexidine gluconate (CHG) baths.

Findings: Despite studies showing that temperature can be maintained when the first bath was at 1 hour after delivery, there are benefits from delaying the bath including improved breastfeeding. Tub or immersion bathing improves temperature, and is less stressful. It is not necessary to bathe infants every day, and premature infants can be bathed as little as every 4 days without an increase in skin colonization. No differences have been reported in skin parameters such as pH, transepidermal water loss, and stratum corneum hydration whether the first and subsequent baths are given using water alone or water and a mild baby cleanser. Concerns about systemic absorption suggests caution about widespread practice of daily CHG bathing in the NICU until it is known whether CHG crosses the blood–brain barrier, particularly in premature infants.

Implications for Practice and Research: Research regarding bathing practices for NICU patients should be evidence-based whenever possible, such as the benefits of immersion bathing. More evidence about the risks and benefits of daily CHG bathing is needed before this practice is widely disseminated.

Neonatal Intensive Care Unit, UCSF Benioff Children's Hospital Oakland, Oakland, California.

Correspondence: Carolyn Lund, MS, RN, FAAN, Neonatal Intensive Care Unit, UCSF Benioff Children's Hospital Oakland, 747 52nd St, Oakland, CA 94609 (clund@mail.cho.org).

Previous source of support: Recipient of an investigator-initiated grant from Johnson & Johnson Consumer Co Inc, to study the impact of the newborn's first bath on skin barrier function and the skin microbiome.

The author declares no conflict of interest.

There is controversy about when and how to bathe newborns infants, ranging from how and when to give the newborn their first bath, whether to bathe newborns at all in the initial days of life, and how to approach bathing the hospitalized premature and full-term infant during their neonatal intensive care unit (NICU) stay. This article reviews relevant literature in regard to these topics, as well as discuss daily bathing with chlorhexidine gluconate (CHG) for infants in the NICU.

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FIRST BATH

There is ongoing debate about when the first bath should be given, and even whether to bathe the newborn at all.1 There are currently a range of recommendations for when the first bath should be given. The Neonatal Skin Care Evidence-Based Clinical Practice Guideline, developed by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), recommends giving the first bath when thermal and cardiorespiratory stability has been achieved, proposing it ideal to wait at least 2 hours after delivery.2 The National Institute for Health and Clinical Excellence (NICE) with the Collaborating Centre for Primary Care in the United Kingdom3 advises that the bath and other treatments be initiated no sooner than 1 hour after birth, so that maternal–infant contact is not interrupted. The World Health Organization (WHO)4 recommends delaying the bath for 24 hours, or if this is not possible due to cultural reasons waiting at least 6 hours, in an effort to prevent hypothermia especially in developing countries.

A number of studies have documented the safety of bathing the full-term newborn in terms of preventing hypothermia as early as 1 hour of age, as long as the infant's initial axillary temperature is 36.8°C or higher, and appropriate care is taken to support thermal stability such as maintaining a higher ambient room temperature, and using radiant warmers and warming blankets to wrap the infant in following the bath.5–7 Much of the motivation for these studies was to permit healthcare professionals to dispense with using gloves, which are standard precautions to protect from diseases transmitted via amniotic fluid and blood. A study in Uganda showed that bathing at 1 hour of age resulted in a significant increase in hypothermia despite the use of skin-to-skin care after the bath.8 A large observational study in the Philippines found that routine newborn care practices including bathing delay thermoregulation and initiation of breastfeeding.9

Finally, a study from Japan reported that bathing the newborn as early as 2 to 5 minutes after delivery not only was safe, but resulted in a significantly higher temperature 30 minutes after the bath, compared with the control group who were not bathed.10 In Japan, early bathing is traditional. “Mokuyoku,” the term used to describe this practice, has been performed routinely for many years, and the authors sought to study the effects of this cultural practice on hypothermia. Babies delivered by cesarean section, or those with asphyxia or prematurity are excluded from early bathing. This study is an example of how cultural traditions may influence bathing practices, although the opportunity to educate providers and parents may change this over time.

Yet, there are circumstances, such as heavy meconium staining, excessive blood, or chorioamnionitis, which necessitate earlier bathing once physiologic stability is achieved, as it is important to many parents that visible debris be removed from their infant after the birth process. However, standard of care for both vaginal and cesarean section birth is to delay the first bath, to allow the infant to transition to extrauterine life with emphasis on maternal–infant bonding and increased success with breastfeeding, thereby offering substantial benefits to both infant and parents.11,12

Early bathing after delivery is in conflict with the WHO and AWHONN skin care guidelines, which recommend leaving residual vernix caseosa intact and allowing it to wear off with normal care and handling.2,4 Vernix caseosa, a protective fetal film, acts as a chemical and mechanical barrier in utero, with the thickest coating accumulating between 36 and 38 weeks of gestation. In the past, bathing was often initiated early to remove this substance, but the retention of vernix has been shown to have benefits in the immediate postbirth phase. Benefits include protection from infection, improved skin barrier function, skin cleansing and moisturizing, development of the acid mantle, and protection from the activity of host defense proteins important in innate immunity.13–15

There is also a misconception that bathing removes the benefits of vernix caseosa on skin adaptation following delivery. In a study of vernix and skin adaptation, the amount of skin covered by vernix in 430 newborns varied according to gestational age, reflecting natural detachment as the fetus reaches 40 weeks' gestation.13 Two cohorts were categorized at birth, the first with vernix covering 48% or more of the skin surface and the second with vernix covering 26% or less; infants were bathed around 2 hours of age. Subjects with 48% or more vernix had more hydrated skin surface and improved development of skin surface acidification, despite bathing with warm water and liquid baby cleanser. In another study, bathing with a liquid baby cleanser did not remove host defense proteins on newborn skin, including lysozyme.16

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Technique

The optimal technique for administering the first bath is also debated. Techniques used include sponge bathing with a small tub such as those provided in the hospital, or a large tub or immersion bathing. Immersion bathing places the infant's entire body, except the head and neck, into warm water (37.8°C-38.8°C), deep enough to cover the shoulders. Studies involving more than 1000 newborns report that tub or immersion bathing, compared with sponge bathing, maintains temperature better, causes less crying and distress for the infant, and does not result in increased infection, even with the umbilical cord in place (Table 1).17–21 In a study of 100 late preterm infants (35-36 6/7 weeks' gestation) randomized to immersion tub bathing or sponge bathing after 24 hours of life, infants had overall higher temperatures and less variability in body temperature when immersion tub bathed.22

TABLE 1

TABLE 1

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Bathing and Skin Colonization

Another aspect of bathing is how the bath may influence skin colonization with microorganisms. For many years it was thought that the skin of the fetus was sterile unless there was premature rupture of membranes. However the Human Microbiome Project has changed how we look at microorganisms in general, as the totality of microbes and their DNA that exist in various “habitats” of the human body are examined. Consequently, our understanding of the commensal or “good” bacteria that inhabit the body and that an imbalance of microorganisms can lead to disease.23 Newborn skin after delivery contains a variety of microorganisms, and is to some extent determined by the type of delivery, vaginal or cesarean section. Vaginally delivered newborn skin contains bacterial “communities” that resemble the mother's vaginal flora, whereas cesarean section newborns' skin microbiota reflects skin flora.24 Although we do not fully understand how the newborn's skin develops following delivery, the assumption is that vaginal delivery would afford the infant normal skin colonization. More cesarean section delivered infants were seen in the emergency department with MRSA infections on their skin in two reported series.25 However, whether this was due to differences in skin colonization, length of hospitalization or the use of antibiotics is not known. Recent research attempted to “inoculate” the skin of infants born by cesarean section with their mother's vaginal flora. A sterile gauze was placed in the vaginal tract for 1 hour before the delivery and used to swab the infant at specific anatomic locations following delivery.26 The microbiome of the skin, anus, and oral cavities were partially restored, resembling the mother's vaginal microbiome.

How bathing impacts the development of the microbiome is not fully understood. Yet, one consideration is whether the first bath should be given with water alone or with a mild baby cleanser be used. One study found that bacterial skin colonization increased over time, but there were no differences in colonization with the first bath when water alone was used versus water and a mild soap.27 However, this study was done using standard bacterial culture techniques, and may not reflect the overall skin microbiome. The Neonatal Skin Care Guidelines2 recommends using warm tap water with or without a mild cleanser that has a neutral or slightly acidic pH to assist in the removal of blood and meconium, as water alone may not easily remove some lipid-soluble substances such as meconium. NICE guidelines in the United Kingdom advise against adding cleansing products or lotions to the bath water directly, but that a mild, nonperfumed soap can be used.3 For premature infants younger than 32 weeks, warm water only is the recommendation,2 although there are no studies to date for this population.

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ROUTINE BATHING IN NICU PATIENTS

Many issues surround determining the optimal frequency of bathing and best techniques for administering the bath for hospitalized neonates. This population can range from full-term infants with illness, infection, or the need for surgical interventions to extremely low birth-weight premature infants.

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Bathing and Barrier Function

Knowledge about the impact of bathing on neonatal skin barrier function as measured by parameters such as skin surface pH, transepidermal water loss (TEWL), and stratum corneum hydration (SCH) are important to inform practice. Bathing has the potential to alter the development of the acid mantle of the skin. On the first day of life, the term newborn's skin surface pH is more than 6.0, falling to less than 5.0 during the first weeks of life.28–30 One study in premature infants found that the skin developed an acidic surface, reaching a pH of 5.5 at the end of the first week, and 5.0 by the end of the first month. However, the study did not report the skin care practices used during this time.31 Once the acid mantle of the skin surface is established, bathing can transiently alter the skin pH, even with water alone, in older infants and adults with sensitive skin.32,33 Bathing 2 to 3 times per week with cleansers compared with water alone has been shown to have little or no difference on skin pH, TEWL, and SCH in the neonatal period in full-term healthy infants.34–36 Similar studies involving measuring skin parameters have not been performed in hospitalized neonates, or in premature infants.

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Stress and Bathing Frequency

Sponge and tub bathing in premature infants can negatively impact physiologic parameters such as heart rate, oxygenation, and behavioral cues indicating distress with.37–40 Because of the concern about the stress on premature infants during bathing, studies evaluated the impact of bathing with a mild cleanser every 2 versus 4 days on skin colonization and pathogenic bacteria.41,42 An initial decrease in bacterial skin colonization was noted, but peaked at 48 hours and remained stable between 48 and 96 hours after bathing. Another study reported a decrease in skin colonization in premature infants of 28 to 35 weeks' gestation with coagulase-negative Staphylococcus at 30 minutes following the bath, regardless of whether the bath was given with water alone or water and liquid soap and water.43 Based on these studies, it does not appear that decreased bathing frequency in premature infants leads to an increase in skin colonization, and the use of bathing products or water does also not increase skin colonization with coagulase-negative Staphylococcus. Therefore, less frequent bathing is recommended as it subjects premature infants to less physiologic and behavioral stress.2

The role of immersion bathing using a swaddling technique to reduce stress during bathing may also benefit the hospitalized premature infant. Using this technique, the infant is swaddled in a flexed, midline position using a soft blanket or cloth, and then gently immersed in a tub of warm water. This method prevents some of the intense motor reactions to being unclothed or placed in water, and can be beneficial not only for premature infants but also for larger newborns for routine or even the first bath.44 Teaching parents swaddled and tub bathing for their babies in the NICU can be a very rewarding experience, with the goal of providing bathing and skin care an integral part of the parental role in this setting (Figures 1 and 2).

Figure

Figure

Figure

Figure

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Post Bathing

Following the bath, some nurses and parents will apply an emollient to the skin. Yet, there is little consensus to date about the routine use of emollients for full-term newborns.45 One study reports improved skin parameters in healthy full-term infants when the skin care regime included “baby cream” emollient after bathing, and did not adversely affect bacterial skin colonization.35 Pilot studies have been initiated to determine whether routine emollient therapy immediately following the bath may benefit infants at risk for the development of atopic dermatitis,46 and larger trials are being proposed.

For premature infants, emollient use has been reported to be beneficial,47,48 but in a large randomized, controlled trial there were more bloodstream infections for infants less than 750 g when an emollient was applied prophylactically twice daily, unrelated to bathing, for the first 14 days of life to infants less than 1000 g at birth.49 Yet, there continues to be an interest in the use of emollients in premature infants, especially in developing countries where infant massage with oils is traditionally used.50

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ANTIMICROBIAL BATHING

Although bathing with antiseptic cleansers for the first or subsequent baths are not currently recommended by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology51 or the Centers for Disease Control and Prevention,52 there has been renewed interest in antimicrobial bathing, particularly for hospitalized newborns and for full-term newborns in developing countries. A systematic review of the efficacy and safety of whole body skin cleansing with CHG in neonates included 9 studies in developing countries, and found that there was no benefit in terms of neonatal sepsis or mortality after a single bath with either liquid CHG or a CHG wipe,53 which is disappointing given the early positive results with this intervention.54,55

Studies on the effect of CHG bathing on skin colonization report that there is decreased colonization with Staphylococcus aureus in full-term newborns 24 hours after a bath with 0.25% CHG compared with using a baby cleansing product.56 Bathing premature infants of 28 to 36 weeks, 1000 to 2000 g with 0.25% CHG compared with bathing with normal saline or not bathing at all resulted in a decrease in skin colonization in the axilla, but not in the groin.57 Infants tolerated the CHG bath without hypothermia or skin irritation and there was a decrease in colonization at 24 hours, but not at 48 hours.

CHG bathing for patients hospitalized in intensive care units has recently become of great interest in the prevention of hospital-acquired infections, especially bloodstream infections. Daily CHG bathing in adults has been shown to reduce hospital-acquired infections in intensive care unit settings.58,59 However, other studies have reported that this intervention has not been beneficial in reducing bloodstream infection.60,61

A large trial in pediatric intensive care units in 5 US hospitals reported a 36% reduction in bacteremia in patients receiving daily CHG bathing.62 This study utilized a cluster-randomization strategy by type of unit (cardiac, medical, or surgical); in each hospital there was 1 unit that used the CHG bathing, and 1 that used soap and water baths. They report results of both the “intention to treat” (ITT) and “per protocol” (PP) populations. The ITT group included all eligible patients (older than 2 months, ICU stay predicted to be >2 days). The PP group was half the size of the ITT group, with patients excluded for length of stay less than 2 days, if parents either refused to consent to CHG bath or were not available to give consent. In the ITT group, the risk of bacteremia did not differ compared with standard bathing practices, but the PP group (64% of the study population) showed significantly fewer infections. It is important to note that infants younger than 2 months were not enrolled due to the FDA exclusion of this population at the time of the study. The median time of treatment was 3 days, with a range of 1 to 119 days, and the average age was 4 to 6 years, but a small number of infants 3 months and older were included. One percent of the children experienced skin irritation.

CHG bathing with a 2% CHG-impregnated wipe in an NICU was undertaken in a quasi-experimental design, comparing a historical cohort to one receiving the CHG intervention.63 Infants with a birth weight less than 1000 g who were younger than 28 days old did not receive a CHG bath. Infants more than 1000 g received the CHG bath twice weekly, every other day, or daily depending on their birth weight and postnatal age. The incidence of central line-associated bloodstream infections (CLABSIs) was reduced from 6/1000 central venous catheter (CVC) days to 1.92/1000 CVC days, although the rate for the excluded infants (<1000 g, <28 days) was not reduced. In addition, during the study period there were fewer catheter device days, perhaps reflecting a change in practice to more aggressively removing CVCs, or perhaps fewer catheter days because they had fewer CLABSIs. There were no reports of skin irritation.

One of the greatest concerns regarding CHG bathing in neonates is the potential for systemic absorption and toxicity due to a notable historic “error in neonatology.”64 In the 1950-60s, there was widespread use of another antimicrobial agent, hexachlorophene (HCP), to reduce infections with S. aureus. In 1973, the Mortality and Morbidity Weekly Report 65 released crucial information about the absorption of HCP and subsequent findings of vacuolation of brain tissue, called “spongioform myelinopathy,” that was present on autopsy in premature infants less than 1400 g, with the exposure of HCP bathing 3 times or greater. A later study indicated that infants less than 1750 g were also found to have this pathologic condition, particularly if they lived longer than 22 days and were thus exposed more often.66 In this study, 2 infants with spongioform myelinopathy also had infections in the brain, one with candida and the other with Escherichia coli.

Absorption of CHG was first reported in 1973; preterm and term infants had detectable amounts of CHG in the blood after an initial bath with CHG, and daily bathing.67 This finding was difficult to interpret because the samples were obtained via heel stick and therefore they may have been contaminated because CHG clings to the cells of the stratum corneum even after rinsing. A more recent study of CHG antisepsis for central-line placement in infants more than 1500 g found that 7 of the 10 infants who had levels obtained after initial skin preparation and weekly antisepsis with dressing changes had detectable CHG concentrations, ranging from 13 to 100 μg/L.68 In another study, 10 of the 20 premature infants (mean gestational age 28 weeks) had detectable levels of CHG, ranging from 1.6 to 206 μg/L after one limb was “washed” with 2% aqueous CHG before placement of a central venous catheter.69

Because of concerns about potential neurotoxicity, a laboratory study was undertaken by the National Institutes of Health.70 Neurotoxicity was assessed using an established in vitro model of neurite cells exposed to both CHG and HCP at levels seen with the highest levels detected in a newborn after topical exposure.67 They reported that CHG inhibited L1-mediated neurite growth, and concluded that it is important to determine whether the blood–brain barrier is permeable to CHG in premature infants. In addition to concerns of potential toxicity from absorption, the effect of antimicrobial cleansing on skin colonization with microorganisms and on the healthy microbiome of the skin in infancy is unknown.

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CONCLUSION

Reviewing the evidence about newborn bathing practices highlights a number of important clinical practices. Although the healthy full-term newborn can be bathed as early as 1 hour after delivery without hypothermia, there are potential benefits to delaying the bath although the optimal time is not clear. The beneficial effects of tub or immersion bathing for the first and subsequent baths include improved maintenance of normothermia, less crying and stress, and increased parental satisfaction. Premature infants also may find tub bathing less stressful, especially if swaddled while being placed in the tub.

For routine bathing both water alone and water and mild baby cleansing products have similar effects on physiologic skin parameters such as pH, TEWL, and SCH. Using an emollient immediately following the bath may improve skin barrier function for selected infants, especially those at risk for atopic dermatitis. For a number of reasons, it is not necessary to bathe newborns more than two to three times per week. Premature infants in particular can experience physiologic and behavioral stress during bathing, and can be bathed as little as every 4 days without increased skin colonization with microorganisms.

Daily bathing with CHG has been shown to reduce bloodstream infection in adult and pediatric intensive care units, and in a single study in an NICU. However, concerns about the potential negative effects from systemic absorption and on the developing skin microbiome suggest caution about the widespread practice of daily CHG bathing in hospitalized newborns until it is know whether CHG crosses the blood–brain barrier, particularly in premature infants.

The impact on the skin microbiome of bathing and skin care in general is of concern. The microorganisms that naturally inhabit the skin facilitate the natural defense system that the skin provides, and supports the development of the immune system. Many environmental influences are present in the NICU,71 and further studies about how the microbiome is affected by skin care practices such as CHG bathing are needed to evaluate the concerns raised about toxicity.

Summary of Recommendations for Practice and Research

Summary of Recommendations for Practice and Research

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Keywords:

bathing; chlorhexidine gluconate; newborn infant; premature infant; skin microbiome; skin pH; stratum corneum hydration (SCH); transepidermal water loss (TEWL)

© 2016 by The National Association of Neonatal Nurses