Running Head: NEWBORN BATHS

Newborn Baths: Delayed Bathing and its Health Benefits on Extrauterine Life

Chelsea McNeal, Erin Bodine, Madison Stryffeler, Mary Duda, and Juliana Rotz

04/15/2020

NURS 3749: Nursing Research

Dr. Valerie O’Dell

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Abstract

The purpose of this research was to examine how bathing infants as soon as they are born

compared to delaying their baths until hours after birth can affect their overall well-being. When

delaying the bath, the health benefits of the newborn were researched. This included how they

maintained thermoregulation, skin integrity from allowing the vernix to soak in, how well they

breastfed, and glucose stability. The research that was used was found from qualitative studies

and literature reviews. It was concluded that there was significant evidence that supported

benefits to the newborn related to the delayed bathing. Newborns that had delayed baths

compared to being bathed right away were able to maintain their temperature better, their

glucose levels were more stable and consistent, breastfeeding rates increased, and their skin was

able to maintain adequate moisture.

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The Benefits of Delayed Newborn Baths

Babies continue to be born throughout the world and as healthcare workers, we

constantly reevaluate what we could do to better their overall health. There has been much

research done that may validate or contradict health claims. The World Health Organization does

advocate for delaying a newborn’s bath. By not bathing newborns after birth and allowing the

vernix to soak naturally into their skin benefits the baby in more ways than one. Allowing the

vernix to stay on the baby’s skin for hours after delivery helps with moisture retention and

thermoregulation. When the infant’s thermoregulation is maintained, glycemic control of the

newborn is more stable. Also, there is a correlation between delaying a bath and prolonging the

amniotic fluid exposure with increased breastfeeding rates. There has been a great amount of

focus on these four topics on newborns and they have been widely discussed in hospitals.

Therefore, the following research question was addressed: In newborns, how does waiting 24

hours to bathe compared to bathing within 24 hours influence newborn’s adaptation to

extrauterine life during the first 72 hours of life?

Literature Review

Introduction

In order to address the issue regarding delayed newborn baths, information was acquired

via OhioLINK databases, specifically CINAHL Plus with Full Text, MEDLINE, and Electronic

Journal Center. Eight sources were reviewed for comprehensive data collection regarding

delayed newborn baths. Skin moisture related to vernix, thermoregulation stability, glycemic

control, and breastfeeding rates will be further discussed.

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Skin

Healthy, full-term newborn babies’ skin is highly successful in being a protective barrier

for the baby in multiple aspects. In the womb, newborns reside in an aqueous environment

consisting of amniotic fluid and water, however their skin is unaffected by this. The protective

barrier responsible for the preservation of the skin in the womb is called vernix caseosa. Vernix

is first noticed on the fetus “at gestational week seventeen. As gestation continues, vernix starts

to cover the fetal skin surface progressing from head to toe and back to front” (Visscher &

Narendran, 2014, p. 142-143). Research by Visscher and Narendran (2014) shows that vernix

covers 72% of an infant's body if their gestational age is 33-37 weeks and decreases to about

38% if their gestational age is past 37 weeks (p. 143). When newborn baths are delayed to at

least 24 hours after birth, vernix left on the skin in that time has been shown to increase skin

hydration, decrease skin pH values, and decrease skin erythema (Visscher and Narendran, 2014,

p. 144).

A study done in 2018 by Duygu Gözen, PhD; Sinem Y. Çaka, Selda A. Besirik, and

Yildiz Perk, MD; described the effects of delaying a newborn’s first bath on the skin moisture of

the infant after birth. This study included two research groups; one group of infants was given a

bath 24 hours after birth, the second group was given a bath 48 hours after birth. To measure the

infant's skin moisture level, the researchers used a tool called the “DMM Skin Moisture Meter”

and the moisture measurements were taken “from the forehead, abdomen, forearm, and upper leg

region” ranging from 0-99.9% (Gözen et al., 2018, p. 4). The researchers measured the skin

moisture level before the bath, after the bath, and 10 minutes after the bath. The researchers in

this study concluded that:

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The moisture value measured in the 10th minute after bathing was statistically

significantly higher in the experimental group that was given a bath in the 48th hour

(25.50%) than that of the control group that was given a bath in the 24th hour (24.31%)

… 10th minute measurements suggested that postponing the first bath is effective in

preserving the skin moisture (Gözen et al., 2018, p. 8).

Evidence from this study shows that postponing a newborn bath to at least 24 hours after birth is

essential in order to positively affect skin development in newborns. Integrating delayed bathing

into modern nursing practice will protect the skin and preserve vernix on newborns, ultimately

improving future health because “the maturation of the skin structure and functions of newborns

starts from the first months and continues for a lifetime” (Gözen et al., 2018, p. 1). Delaying

newborn baths to preserve vernix on the skin not only benefits the development of the infant's

skin, but also allows the infant to maintain proper thermoregulation.

Thermoregulation

Multiple studies have looked at delaying the newborn bath and the effect it has on

thermoregulation. In these studies, 97.7 degrees Fahrenheit and lower was considered

hypothermic. One study stated that the vernix assists with temperature regulation (Brogan and

Rapkin, 2017). Keeping the vernix on the baby for a longer amount of time allows the vernix to

assist with temperature regulation for a longer period. Another study found that the "removal of

biofluids through bathing may result in increased incidents of hypothermia” (Warren, 2018, p.

11). Removal of these substances too quickly may result in a decrease in the body temperature of

the baby. One study found that “delaying the newborn bathing by 24 hours was associated with a

decrease in incidence of hypothermia” (Warren et al., 2020, p. 186). This study also determined

that when the initial newborn bath was only delayed for 1 to 12 hours, there was no significant
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difference in decreasing the rates of hypothermia (Warren et al., 2020). Another study agreed

that the newborn experiences thermoregulation benefits when the bath is delayed 24 hours

(Chamberlain et al., 2019).

Although some studies have found that delaying the bath helps with thermoregulation

post bath, Warren (2018) states that most hypothermic events occur before the bath is given,

therefore the hypothermia rates are 2.5 times greater in newborns who have their initial bath after

24 hours. Gözen et al. (2018) also found that the prebath temperature had a higher incidence of

hypothermia the longer the bath was delayed when they compared bathing 24 hours to 48 hours.

Another study found that there were no significant differences in the newborn temperatures

before the bath was performed, however in this study the bath was only delayed for a minimum

of 12 hours (Dicioccio et al., 2019). This research shows that both prebath and postbath

temperatures should be studied.

After taking a look at prebath temperatures, postbath temperatures will now be examined.

Chamberlain et al. (2019) found that postbath temperatures, after delaying the bath 24 hours,

showed a significant decrease in the number of newborns whose temperatures fell into the

hypothermic range. Another study found that “newborn postbath temperatures were more often

in the normothermic range after the intervention,” while the “preintervention group were less

often in the normothermic range,” (Dicioccio et al., 2019, pp. 192-193). In this study, the bath

was delayed a minimum of 12 hours and normothermic was considered any temperature above

97.7 Fahrenheit.

When comparing the prebath temperature to the postbath temperature, Gözen et al.

(2018) found the control group, where bathing was done within 24 hours of birth, decreased

significantly more than the experimental group where bathing was delayed at least 48 hours. This
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study also looked at the temperature 10 minutes after the bath was given, “it was determined that

the 10th-minute body temperature of the infants with the first bathing time 48 hr after birth were

significantly higher compared with the infants with the first bath time 24 hr after birth,” (Gözen

et al., 2018, p. 1). Both of the previous statistics from Gözen et al. (2018) showed benefits of

delaying the bath 48 hours after birth.

Research has been done in an attempt to determine the optimal time of the newborn bath

and the effect it has on newborn temperature. While all of these studies provide us with

information as to how the temperature is affected, it is still uncertain what is the optimal time for

the initial bath. Some of the evidence supported our research question stating it is best to wait 24

hours, while other information contraindicated it. The studies being compared delayed the bath

for different amounts of time including 12, 24 and 48 hours. In conclusion, more research needs

to be collected to come to a definitive answer in optimal timing of the newborn bath and the

results it has on thermoregulation.

Glycemic Control

There is a correlation between thermoregulation and glycemic control. For the purpose of

this paper and to maintain our health claims, medical research was analyzed to establish the role

delaying baths had on glucose levels in newborns. There have been many studies done on the

impact of bathing newborns using the conventional pattern of bath by six-hours after birth versus

the recommendation by the World Health Organization (WHO) that suggest delaying newborn

bathing for 24 hours. Along with the many benefits discussed in this research paper, the decrease

in hypoglycemia in newborns is supported through many research studies and is consistently

validated as a positive reason to delay bathing the newborn, thus contributing to glucose stability.
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One of the most relied upon studies, and frequently referred to in other studies, is from

the research done by Jill Chamberlain, Susan McCarty, Joanne Sorce, Betsy Leesman, Sara

Schmidt, Elizabth Meyrick, Simone Parlier, Linda Kennedy, Debra Crowley, and Lori Coultas.

The study began practicing the delayed bathing standard in 2017, and referenced many studies

before it, with their outcomes, settings, and results. This study defined newborns as those “born

without complications or need for specialized care” (Chamberlain et al., 2019, p. 75). This study

chose a multitude of variables including breastfeeding rates, temperature, weight loss, and the

stability of glucose levels. A large part of this research included an online survey that was given

to nurses to establish their knowledge of delaying bathing benefits. Chamberlain et al. (2019)

noted that there were 330 charts reviewed both pre and post implementation (p.75) . Blood

glucose levels were collected from the participants. According to the research, “the paired-

samples t-test scores did show a statistically significant decrease in the number of blood glucose

level checks post intervention (M=1.53, SD 2.67(, t(3.08), p=.002 when compares to pre-

intervention (M=2.53, SD 3.71)” (Chamberlain et al., 2019, p. 76). In addition to this data, the

paired-samples t-test scores went on to further support the evidence that glucose levels were

decreased after bathing was delayed. These researchers referenced the previous work of others,

specifically Brogan and Rapkin (2017) that was used to substantiate the research in this paper on

thermoregulation. From the evidence of the role of thermoregulation and delayed bathing, the

claim was made that because baths were being delayed “the number of cold stress events in

neonates decreased and when newborns are cold-stressed, an increased metabolic rate is required

to generate warmth, thus decreasing their glucose stores causing hypoglycemia” (Chamberlain et

al., 2019, p. 76). This study suggests that delaying a newborn’s bath by 24 hours does have a

positive correlation in reducing hypoglycemia in babies. Chamberlain et al. (2019) used a

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hypoglycemia criteria that was recognized as a blood glucose level that was less than or equal to

45 mg/dL (p. 76).

In December of 2020, another group of researchers led by Susan Warren, William K.

Midodzi, Leigh-Anne Allwood Newhook, Phil Murphy, and Lauren Twells used Chamberlain et

al’s (2019) research discussed above and went on to further study glucose stability and delayed

bathing. The group set out to research the likelihood of exclusive breastfeeding and ended up

concluding through what Warren et al. (2020) called “secondary endpoints” - further proof that

delaying bathing does decrease hypoglycemia in what is considered a healthy newborn. In their

study they referred to hypoglycemia as a “glucose level less than 2.6 mmol/L (47 mg/dL)”

(Warren et al., 2020, p. 184). Warren et al. (2020) established that in order to properly assess

glucose stability this study raised their number of participants from 350 before and 350 after the

bathing policy was changed to a total of 1,225 healthy newborns born at 34 0/7 weeks gestation

after they assessed high-risk and average risk subgroups (p.185-185). Of this 1,225, “680

newborns born before implementation and 545 born after implementation” were evaluated

(Warren et al., 2020, p. 185). Their results concluded that there was a decrease in hypoglycemia

“in the total sample and in the high-risk subgroup, p=.03 and p=.016, respectively,” (Warren et

al., 2020, p. 186). These researchers did not statistically conclude a decrease in average risk

newborns. In their overall conclusion the researchers concur that by delaying the baths of

newborns to 24 hours post-delivery they did note a decrease in hypothermia as well as

hypoglycemia.

Breastfeeding

Numerous studies have been conducted in order to assess the effect of delaying the

newborn bath and the exclusivity rate of breastfeeding. Heather Condo DiCioccio, Candace Ady,
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James F. Bena, and Nancy M. Albert conducted a study with the main goal being “to examine

whether delayed newborn bathing would increase rates of in-hospital exclusive breastfeeding and

plans to use human milk at discharge” (2019, p. 189). Exclusive breastfeeding was detailed as no

formula nutrition from birth until the hospital discharge (DiCioccio et al., 2019, p. 190). For this

study, an evidence-based rationale was used for the intervention of delayed bathing. The

evidence suggests that acids, particularly fatty acids, found in the amniotic fluid can be a sensory

que for the newborn. This, in turn, then guides them to the breast for feedings. This study also

made a note to the fact that the suckling reflex lasted longer in newborns that were exposed to

their own amniotic fluid for a longer period of time (DiCioccio et al., 2019, p. 190). In order to

conduct this experiment, the newborn bathing policy of the hospital had to be updated. Instead of

bathing at about 2 hours of life, the policy was altered to state that newborns were to be bathed

no sooner than 12 hours. The nurses were even encouraged to wait until at least 24 hours of life

to bathe (DiCioccio et al., 2019, p. 191).

For this study, exactly 996 mother and newborn pairs were observed (N = 996). Of the

996 pairs, “448 were pre-intervention pairs and 548 were post intervention pairs” (DiCioccio et

al., 2019, p. 189). According to the study, “in-hospital exclusive breastfeeding increased from

59.8% before the intervention to 68.2% after the intervention” (DiCioccio et al., 2019, p. 189). In

other words, by delaying the newborn bath for at least 12 hours after birth, researchers saw a

14.05% increase in exclusive breastfeeding on their unit. Upon inspection of the post

intervention discharge feeding plan, the study also saw an increase in the use of human milk

(DiCioccio et al., 2019, p. 189).

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In another study conducted by Kathleen Long, June Rondinelli, Ashley Yim, Catherine

Cariou, and Regina Valdez, research was done to “determine if changing the timing of the initial

newborn bath would have an impact on exclusive breastfeeding during hospitalization” (2020, p.

110). Implications set out by this study state:

Delaying the first newborn bath may be one factor that can influence exclusive

breastfeeding rates during postpartum hospitalization. Results have been mixed based on

recent literature. In our study, the exclusive breastfeeding rate was already above

average, as would be expected in a Baby-Friendly designated hospital and may be a

reason we did not see a significant change in the rate among mother-infant couplets in

our study (Long et al., 2020, p. 110).

Long et al. (2020) noted here that a significant increase in exclusive breastfeeding was not

necessarily the cause of delaying the newborn bath (p. 115). Researchers explained this evidence

to be due to an already above average rate of exclusive breastfeeding on the unit floor.

Conclusion

When addressing how delayed baths affected the newborns overall health, studies showed

that there are many benefits to doing so. It was concluded that there was a sufficient amount of

evidence that proved that allowing vernix and other substances to remain on the infant’s skin

improved the moisture of their skin, thermoregulation, glycemic control and breastfeeding rates.

Although, not enough studies have been conducted to determine the newborns’ adaptation to

extrauterine life during the specific time frame of their first 72 hours of life as stated in our

research question. However, research has concluded that delaying a newborn bath can benefit the

newborn beyond 72 hours by establishing healthy bodily functions from the start.
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References

Brogan, J., & Rapkin, G. (2017). Implementing evidence-based neonatal skin care with parent-

performed, delayed immersion baths. Nursing for Womens Health, 21(6), 442–450. doi:

10.1016/j.nwh.2017.10.009

Chamberlain, J., Mccarty, S., Sorce, J., Leesman, B., Schmidt, S., Meyrick, E., Parlier, S.,

Kennedy, L., Coultas, L. (2019). Impact on delayed newborn bathing on exclusive

breastfeeding rates, glucose and temperature stability, and weight loss. Journal of

Neonatal Nursing, 25(2), 74–77. doi: 10.1016/j.jnn.2018.11.001

Dicioccio, H. C., Ady, C., Bena, J. F., & Albert, N. M. (2019). Initiative to improve exclusive

breastfeeding by delaying the newborn bath. Journal of Obstetric, Gynecologic &

Neonatal Nursing, 48(2), 189–196. doi: 10.1016/j.jogn.2018.12.008

Gözen, D., Çaka, S. Y., Beşirik, S. A., & Perk, Y. (2018). First bathing time of newborn infants

after birth: A comparative analysis. Journal for Specialists in Pediatric Nursing, 24(2).

doi: 10.1111/jspn.12239

Long, K., Rondinelli, J., Yim, A., Cariou, C., & Valdez, R. (2020). Delaying the first newborn

bath and exclusive breastfeeding. MCN, The American Journal of Maternal/Child

Nursing, 45(2), 110–115. doi: 10.1097/nmc.0000000000000606

Visscher, M., & Narendran, V. (2014). Vernix caseosa: Formation and functions. Newborn and

Infant Nursing Reviews, 14(4), 142–146. doi: 10.1053/j.nainr.2014.10.005

Warren, S. (2018). In healthy full and later pre-term babies, does delaying the first bath until at

least 24 hours of life effect in-hospital breastfeeding rates, thermoregulation and

glycemic control? [Unpublished master’s thesis]. Memorial University of Newfoundland.

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Warren, S., Midodzi, W. K., Newhook, L.-A. A., Murphy, P., & Twells, L. (2020). Effects of

delayed newborn bathing on breastfeeding, hypothermia, and hypoglycemia. Journal of

Obstetric, Gynecologic & Neonatal Nursing, 49(2), 181–189. doi:

10.1016/j.jogn.2019.12.004