Effect of Early Bathing on Temperature of Normal Newborn Infants

Iranian
J Publ Health, Vol. 36, No.2, 2007, pp.82-86
Iranian J Publ Health, Vol. 36, No.2, 2007,
pp.82-86
Original Articles
Effect of Early Bathing on Temperature of Normal Newborn
Infants
*P Alizadeh Taheri 1, H Fakhraee 2, K Sotoudeh 3
1
Dept. of Pediatrics, Medical Sciences/ University of Tehran, Iran
2
3
Dept. of Pediatrics, School of Medicine, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
Research Development Center, Bahrami Children’s Hospital, Medical Sciences/ University of Tehran,
Iran
(Received 6 Oct 2006; accepted 22 Apr 2007)
Abstract
Background: Nowadays there is a strong tendency for early bathing of healthy newborns but little is known about the thermal stability of newborns in response to early bathing. The aim of this study was to compare the thermal effect of bathing
on healthy newborn within 1-2 h of life versus 4-6 h after birth.
Methods: In this randomized comparative study 100 healthy newborns in a newborn nursery of a charity hospital in Tehran
were studied. The inclusion criteria were: healthy term (≥ 37 wk) newborn over 2500 grams with rectal temperature > 36.5
°C , apgar score > 7 in 1 and 5 min after birth and lack of manifestations of any diseases like sepsis or respiratory distress
syndrome .The exclusion criteria were the history of recent fever, leukocytosis , urinary tract infections and using medicines in their mothers. In the experimental group, 50 newborns were bathed within the first 1-2 h of birth; those in control
group were bathed at the 4-6 h of age. Rectal temperatures were measured in four different times: before bathing and
immediately as well as 30 and 60 min after bathing.
Results: Rectal temperatures as measured at four different times did not differ significantly between infants bathed within
1-2 h of birth and those bathed 4-6 h after birth .There were no significant differences between the groups in types of gender, birth weight, gestational age, parity, delivery route, interval time between rupture of membranes and delivery, apgar
scores at 1 and 5 min of age.
Conclusions: Healthy full term newborns with rectal temperature > 36.5 °C can be bathed within 1-2 h of birth without any
risk of hypothermia.
Keywords: Infant, Newborn, Body temperature
Introduction
In most Iranian hospitals and delivery facility
centers, newborns are routinely bathed within
several hours of birth to remove amniotic fluid,
blood and other birthing fluids. After the bath,
newborns are dressed and bundle in blankets or
placed under a radiant heater until body temperature is within normal limits and there after
when the temperature become stable, they are
returned to the family.
It is theoretically possible that bathing a newborn infant early after birth may affect its adaptation to extra uterine life, particularly by adversely
82
affecting its pulmonary and gastrointestinal circulation as well as its thermoregulation (hypothermia), by increasing evaporation and dilating the
peripheral vessels in skin (1). In fact some reports
have found a higher incidence of hypothermia in
newborns that were bathed early (2- 4). World
Health Organization (WHO) recommended that
bathing before 6 h of life is not suitable for newborns because of thermal instability (5), however in many hospitals of North America and
Europe newborns are bathed in the first few h of
life. A reason for early bathing of the newborns
is that they are presumed to be infectious until
*Corresponding author: Tel: +98 21 77556969, Fax: +98 21 77551584, E-mail: Bahrami_ch@yahoo.com
P Alizadeh Taheri et al: Effect of Early Bathing…
bathed. The potential harmful pathogens for health
care providers and family are include human immunodeficiency virus and hepatitis viruses (6).
In the past years concerning about hypothermia
and accompanied destabilization of vital signs
made health care providers to prefer the delayed
bathing, however newer studies showed the negligible risk of hypothermia associated with early
bathing and nowadays there is a strong tendency
to bathing normal newborn infants early after
birth (7-12).
There was a paucity of research that evaluated
the thermal change of newborn infants after
bathing in our country, therefore we conducted
a study to test the assumption that no difference
would occur in the temperatures of normal newborn infants when they were bathed after 1-2 h
after birth compared with 4-6 h after birth.
Materials and Methods
This study was conducted using a randomized
controlled trial design and the setting was a newborn nursery of a charity hospital (Third Sha’aban)
in Tehran, Iran.
From September to December 2005, all infants
born at the hospital who met our study criteria
were recruited for this trial. The inclusion criteria were: apparently normal and well newborn
from normal newborn nursery with a gestational age ≥ 37 wk, birth weight ≥ 2500 g, apgar scores of at least 7 in 1and 5 min of age,
rectal temperature ≥ 36.5 °C without any major
anomalies or any signs or symptoms of sepsis or
respiratory distress. The exclusion criteria were:
recent history of fever, leukocytosis or urinary
tract infections in mother, or maternal history of
disease that would adversely affect neonatal
morbidity such as diabetes mellitus, hyperthyroidism or hypothyroidism and infections. All
newborns were screened by a pediatrician before
the bath and were excluded if their condition
were not suitable for study.
Gestational age was estimated from both the
mothers’ menstrual history as well as early ultrasound dating. Ethical approval for the study was
obtained from the local ethics board and informed consent was obtained from the parents
of each neonate. Both parents and investigators
were blind to group assignment. The participants
were randomly divided in 2 groups, using random numbers table.
Demographic data obtained from the mothers’
chart including time and date of birth, maternal
age, type of birth, gestational age, maternal parity, as well as gender and weight of the newborns. It was confirmed in analysis that there
were no between group differences with respect
to demographic variables. Demographic data presented in Table 1. Newborns assigned to the experimental group were bathed within 1-2 h of
life and those assigned to the control group were
bathed within 4-6 h after birth. Bathing lasted
2-3 min with warm water (38±1 °C at the start
of the bath) without using soap in a especial
place; blood and meconium were removed but
vernix was not removed completely.
After bathing, neonates dried with a prewarmed
towel, dressed in diaper, shirt and hat and
wrapped in a blanket and thereafter transferred
to an open bassinet in nursery. Room temperature was kept constant between 24-26 °C. Rectal temperature was measured using mercury rectal temperature on four occasions: immediately
before bathing, immediately after bathing and at
30 and 60 min after bathing. Hypothermia was
defined as a rectal temperature below 36.5 °C.
The infant was transferred to an incubator if the
rectal temperature reached under 36.5 °C in two
consecutive measurements within 15 min. The
thermometer was kept inside the rectum not
more than one centimeter due to rectal perforation concerns. All staff members were instructed in the study protocol and received a
copy of study protocol. Stopwatch was used to
determine the time of bathing and times between
measurements.
Conventional criteria for type 1 and type 2 errors were used. The alpha level was set at 0.05
and beta level at 0.2 to set power at 80% and 50
newborns were required for each group to detect a difference of only 0.1 °C. After comple83
Iranian J Publ Health, Vol. 36, No.2, 2007, pp.82-86
tion of data collection, data were coded and entered twice into the computer files to verify accuracy. Analysis was carried out using SPSS
11.5 (Chicago-IL) using Chi- square test, student’s t- test and paired t- test. All t-tests were
two tailed and the level of significance was set
at 0.05. Normal distribution of all continuous
variables was confirmed in both groups and results are expressed as mean±standard deviation.
differ significantly before bathing, being 36.97±
0.18 °C and 36.95±0.22 °C in experimental and
control group, respectively. After bathing, the
rectal temperature of experimental group has decreased immediately after bathing and at 30 min
after bathing (P< 0.001, P< 0.001) and then increased in 60 min after bathing (P = 0.3).
In control group the rectal temperature has decreased immediately after bathing (P< 0.001) but
reached the before bathing temperature after 30
min (P= 0.21) and increased to above that at 60
min (P= 0.04). There were no significant differences between rectal temperatures in experimental and control groups in immediately before
and after bathing times as well as at 30 and 60
min after bathing (Table 1).
Hypothermia with rectal temperature under
36.5 °C was seen only in two infants of control
group. The temperature of those infants was
36.2 °C and 36.3 °C at 30 min after bathing .No
one required transfer to incubator.
Results
The subjects were 100 newborn infants (48 males
and 52 females) who randomly divided in “experimental “and “control groups“. The characteristics
of the two groups are summarized in Table 1.
Gestational age, birth weight, sex, Apgar score,
ratio of primipara to multipara and time of first
feeding did not differ significantly between the
two groups. All newborns fed by their mothers’
milk. Rectal temperature of the two groups did not
Table 1: Baseline variables in Experimental and Control groups
Baseline Measure
Experimental Group
(n = 50)
39.2 ± 0.88
Control Group
(n = 50)
39 ± 0.95
NS*
Male
22
26
NS
Female
28
24
3364 ± 413
3322 ± 424
NS
Vaginal
24
17
NS
Cesarean Section
26
33
Primipara
20
24
Multipara
30
26
Immediately before bath
36.97 ± 0.18
36.95 ± 0.22
NS
Immediately after bath
36.72 ± 0.19
36.80± 0.24
NS
30 Min after bath
36.85± 0.16
36.91± 0.23
NS
60 Min after bath
36.94 ± 0.15
37.02± 0.23
NS
Gestational Age (week)*
P
Gender
Birth Weight (gram)*
Birth Method
Parity
NS
Rectal Temperature (°C)**
*NS= Non Significant, **Mean±Standard Deviation
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P Alizadeh Taheri et al: Effect of Early Bathing…
Discussion
In recent decades several studies have been performed to evaluate the effects of timing of the
newborns’ first bathing on their thermal balance.
Based on the thermoregulatory theory, it is recommended that the bathing of the newborn infants is delayed until they achieve and maintain
a normal body temperature (1). Recently time
of first bathing has been modified within hospitals because of increasing concerns about the
transmission of communicable diseases through
blood or body fluid contact (6).
In the present study, newborn infants in both experimental and control groups showed comparable characteristics and rectal temperature did not
differ between the two groups immediately before
and after bathing as well as 30 and 60 min after
bathing. A clinical deduction for these findings
is that heat losing in newborns did not correlate
to the bathing time.
Temperature changes associated with bathing newborns have been evaluated in many studies. In
1975 Leboyer advocated bathing immediately follow birth (7). The Leboyer method shown to be
safe and hypothermia (<35 °C) did not develop
in newborns even after prolong immersion in water
when room and water temperatures were monitored (8, 9). Penny-McGillivray reported that
healthy full- term newborns with a rectal temperature above 36.5 °C could be bathed immediately
after the initial assessment examination and observed no significant differences in rectal temperature between the group bathed at 1 h of age and the
group bathed at 4 h of age (10). In other study,
Behring & colleagues (11) evaluated the effects of
bathing on thermoregulation of healthy newborns
within the first hour of life compared to bathing
4-6 h of life. Axillary temperatures did not differ
significantly between infants bathed within 1 h
birth and those bathed 4-6 h after birth (11).
The same conclusion was reported by Varda
and Behnke (12). In contrast to these studies,
Takayma & colleagues reported a decreased axillary temperature after early bathing among 114
neonates (13).
Bergstrom and colleagues in a clinical trial on
249 African newborn, noticed that bathing in
the first hour after delivery against no bathing resulted in a significantly increased prevalence of
hypothermia (under 36.5 °C at 70 & 90 min postpartum) (14).
Results of the current study are the same as previous studies by Behring, Penny- Mc Gillivray
and Varda & Behnke (10- 12).
Although type of delivery, sex, gestational age,
room temperature and route of temperature measuring were different in those studies, beyond
these differences the results were the same. In
the present study we used rectal thermometer (mercury type), however Behring, Varda & Behnke
measured axillary temperature and Penny- McGillivray used rectal thermometer. Measuring temperature in newborn infants can be difficult especially when they are restless. It is believed that
both rectal and axillary temperatures are reliable. The axilla is a safe and accessible site, but
concerns have been raised about its accuracy
(15, 16). Measurement of rectal temperature is
frequently preferred over other ways, however
the newborn can be exposed to cold air for up to
5 min while the temperature measured because it
may experience unnecessary cooling that interfere with the temperature assessment (17). We
considered this important point in our assessment.
The obstetric unit (as well as other units of hospital) is a high risk environment for trans-mission of pathogens (especially hepatitis B virus,
human immunodeficiency virus and herpes virus)
by blood or body fluids and this transmission
can occur during the birth process or by handling the newborn covered with maternal blood
and body fluids from the birth canal (6). Early
bathing of newborns after birth could decrease
the exposure of health care providers and family members to bloodborne pathogens.
A limitation of the present study is that data collection was limited to a single newborn nursery
and a sample of healthy, full-term newborns.
Further studies also could be included comparison groups of the low birth weight newborns.
85
Iranian J Publ Health, Vol. 36, No.2, 2007, pp.82-86
In summary the results of the present study did
not demonstrate any negative effect of early bathing on the early adaptation of newborns therefore we conclude that healthy full term newborns with rectal temperature over 36.5 °C can
be bathed within 1-2 h of birth without any risk
of hypothermia.
Acknowledgements
The authors wish to thank Dr AE Safarzadeh
and Dr O Mousavi for their helpful comments
and the staffs of the newborn nursery at the
Third Sha’aban Hospital for their cooperation
and also Mrs Z Jalili Tahmasbi for her kind
assistance in preparing the manuscript.
This study was performed with the financial
support of the first author.
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