JOGNN CLINICALSTUDIES
The Effect of Timing of Initial
Bath on Newborn's Temperature
Karen E. Varda, RN, MSHSA, Rita S. Behnke, RN, DNS
= Objective: To determine the effect of the early
timing of an initial bath on newborn temperature.
Design: Random assignment to group, com-
parative study.
Setting: Newborn nursery of a 20-bed obstet-
ric unit in a regional hospital in the Midwest.
Patients: 80 healthy, full-term newborns.
Interventions: 40 neonates were bathed at 1
hour of age and 40 were bathed at 2 hours of age.
Main Outcome Measures: Axillary tempera-
tures were measured before the admission bath and
at 10, 20, and 60 minutes after the bath with dis-
posable thermometers; the maximum drop in tem-
perature also was determined.
Results: N o significant differences were noted
in axillary temperatures between the two groups
before the bath or at 10,20, or 60 minutes after the
bath. The groups did not differ significantly by gen-
der, birth weight, length of bath in minutes, room
temperature during bath, Apgar score at 5 minutes,
or gestational age.
Conclusion: Healthy full-term newborns with
an axillary temperature 2 36.8"C (98.2"F) can be
bathed after 1 hour of age when appropriate care
is taken to support thermal stability. JOG", 29,
27-32; 2000.
Keywords: Newborn-Temperature-Thermal
stability-Thermoregulation
Accepted: July 1999
The cleansing of newborns after birth varies
in time and procedure across cultures. The reasons
for these practices include cultural rituals, aesthet-
ic appearance, and cleanliness. The bathing of
newborns has been modified within hospitals in
recent times because of increasing concerns about
the transmission of communicable diseases
thruugh blood or body fluid contact.
IanuarylFebruary 2000
As in the hospital in general, the obstetric unit
is an environment where there is risk of exposure to
pathogens transmitted by blood or body fluids.
This transmission can occur during the birth
process itself or by handling the newborn covered
with maternal blood and body fluids from the birth
canal. Bathing the infant to remove these fluids
after birth may decrease the risk of transmitting
infections such as human immunodeficiency virus
(HIV), herpes, and hepatitis (American Academy of
Pediatrics and the American College of Obstetri-
cians and Gynecologists, 1997). Human immuno-
deficiency virus and hepatitis B are two bloodborne
pathogens of special concern. As of 1997,52 docu-
mented cases of HIV seroconversion in health care
workers through occupational exposure were
reported to the Centers for Disease Control and Pre-
vention (CDC) (1998), along with an additional
114 possible cases of occupational transmission.
Infection with hepatitis B is more prevalent in health
care workers than is HIV. An estimated 1,450 cases
of hepatitis B acquired through occupational expo-
sure were reported to the CDC in 1993, but this fig-
ure represents a 90% decrease in the estimated
number of cases acquired through occupational
exposure in 1985 (CDC, 1997). Bathing newborns
earlier than usual after birth could decrease the
exposure of health care providers and family mem-
bers to bloodborne pathogens.
To "reduce the risk of transmission of
microorganisms," health care workers are required
by standard precautions to wear gloves when they
come in contact with blood or body fluids (Garner,
1996). Latex allergies, however, have become a
problem of considerable magnitude with health
care workers experiencing reactions ranging from
urticaria to anaphylaxis (Slater, 1994). Bathing
newborns earlier after delivery would reduce the
use of latex gloves in the newborn nursery.
JOG" 27
 When considering the timing of baths, it is impor-
tant to remember that bathing is a thermal stressor for
newborns that may have implications for their health
and well-being. Therefore, thermoregulatory factors
must be taken into account during the bath. Due to
their large body surface area in relation to body mass,
newborns are vulnerable to evaporative, conductive,
convective, and radiant heat loss. This vulnerability is
increased because newborns have only a relatively thin
insulating layer of subcutaneous fat. Keeping newborns
warm and dry, using radiant warmers in the nursery,
limiting air drafts, warming objects which come in con-
tact with them, and swaddling them with warm blan-
kets will all help reduce heat loss (Thomas, 1994).
There is a paucity of research that evaluates the
relationship between timing of the initial newborn bath
and temperature stability. Penny-MacGillivray (1996)
studied the effect of early bathing on 100 healthy new-
borns. The control group was bathed at 4 hours of age,
whereas the experimental group was bathed after the
admission assessment at approximately 1 hour of age.
There were no significant differences in mean rectal
temperatures between the two groups immediately after
bathing or at l o r 2 hours after the bath.
In 1994, Varda and Behnke conducted a pilot
study in the same nursery where the current study was
conducted. At that time, the newborn's initial bath was
routinely given at 4 hours of age. Newborns were ran-
domly assigned to be bathed at 2 ( n = 20) and 4 ( n = 20)
hours of age, and temperatures were compared at 10,
20, and 60 minutes after the bath using the same brand
of thermometer and temperature-taking method as in
the current study. The maximum change in axillary tem-
peratures from prebath was 0.6"C for both groups and
occurred at 10 minutes postbath. The change at 20
minutes postbath was 0.3"C and at 60 minutes was
0.1 "C. Temperatures were not significantly different
between groups at any of the data points.
Because the pilot study revealed no significant dif-
ferences in postbath temperatures between newborns
bathed at 2 and 4 hours of age, the purpose of the cur-
rent study was to see if the bath could be moved even
closer to the time of birth without compromising the
newborn's thermal stability. It was hypothesized that
there would be no significant differences in postbath
temperatures between newborns bathed at 1 hour of age
and those bathed at 2 hours of age.
Method
Participants
Eligible study participants were drawn from the
population of normal healthy newborns delivered on a
20-bed obstetric unit in a Midwestern acute care hospi-
tal. Prior to data collection, the study was reviewed and
28 JOG"
approved by the facility's institutional review commit-
tee. The study was begun July 1996 and completed May
1998. During that time the facility averaged 925 births
per year, with 71% of newborns remaining in the
obstetric unit and not requiring care in the neonatal
intensive-care unit.
Any newborn admitted to the normal newborn
nursery with a birth weight of six pounds or more, a
gestational age of 38 weeks or more, and a 5-minute
Apgar score greater than 7 was eligible for inclusion in
the study. However, breastfeeding and family attach-
ment were not interrupted to bathe an infant unless the
parents indicated their preference for their newborn to
be included in the study.
Infection, fetal distress, hypoglycemia, and other
factors can predispose an infant to temperature insta-
bility. Thus, newborns considered at risk for this con-
dition were excluded from the study. Maternal risk
factors for newborn infection include prolonged rup-
ture of membranes greater than 24 hours, fever over
37.8"C (100°F) before delivery or 38.3"C (101°F) by
the time of the newborn's bath, and screening as posi-
tive for group B streptococcus. Additional maternal
factors that place newborns at risk for temperature
instability include illicit drug use, treatment with beta
blockers, poly- or oligohydramnios, or maternal dia-
betes. Newborn risk factors for temperature instabili-
ty include a cord p H less than or equal to 7.2, meco-
nium stained vocal cords, a blood sugar below .022
mmol/L (40 mg/dl), and an axillary temperature below
36.4"C (97.6"F) by 1 hour of age. Each newborn was
assessed by a registered nurse before the bath and
was excluded if his or her condition was considered
unstable.
A power analysis was performed to determine an
appropriate sample size for comparing changes in tem-
perature between the two study groups (Cohen, 1988).
By using a .05 significance level and assuming a stan-
dard deviation of O.S"F, it was determined that a sample
size of 40 per group would allow detection of a differ-
ence of only 0.3"F with a power of 80%. Consequently,
80 consecutive newborns who met eligibility criteria
and whose parents gave informed consent were enrolled
and randomly assigned to a group.
Procedure
Newborns admitted to the normal newborn nurs-
ery were first screened for any of the risk factors previ-
ously noted. The study was described to the parents of
newborns who qualified, and questions about the study
were answered by one of the data gatherers or the pri-
mary investigator. Informed consent was obtained from
the newborn's mother or father. Participating newborns
were randomly assigned to one of two study groups
using a random numbers table.
Volume 29, Number 1
 All participants were bathed by unit staff members
according to the unit's newborn bath policy. The staff
members were instructed in the bath study protocol and
given a copy of the unit procedure for bathing new-
borns. A data form on which each participant's race,
birth weight, and time of birth were already recorded by
the admitting nurse was placed on a clipboard at the
foot of the newborn's crib to facilitate collection of tem-
perature data.
The water temperature was regulated to 36.7"C
(98°F) using a wooden-backed bath thermometer.
Room temperature was measured with a Digital Pocket
Thermometer Model PT-100, which registered to the
nearest tenth of a degree Fahrenheit (Sealed Unit Parts,
Co., Inc., Allenwood, NJ).
The newborn's temperature had to be 36.8"C
(98.2"F), and the bath had to begin within 10 minutes of
the 1 hour or 2 hour bath time for him or her to be
included in the study. All participants were bathed in the
newborn nursery under either an Air Shields Mobile
Infant Warmer (Narco Scientific, Hatboro, PA) or an
above-counter built-in warmer. The newborn was placed
under a radiant warmer for a minimum of 1 0 minutes
after the bath and until his or her temperature returned
to at least 36.7"C (98°F). The length of the bath and the
duration of time under the warmer were recorded in
minutes for each participant. When the warmer was dis-
continued, the newborn was dressed in a long sleeve T-
shirt, diaper, and wrapped in two blankets. If the new-
born's temperature was 37.1"C (98.8"F) or greater, only
one blanket was applied before returning him or her to
the mother's room. Family members were encouraged to
keep the newborn swaddled to deter heat loss after dis-
continuation of the radiant warmer.
Temperatures of each study participant were
recorded before the bath and at 10,20, and 60 minutes
after the bath. The newborns' temperatures were taken
-
by the axillary method with the Tempa Dot single-use
thermometer, which measures to the nearest 0.2"F. All
temperatures were then converted to degrees Celsius.
The axilla was wiped dry with gauze before inserting
the thermometer, and the participant's arm was held
close to the chest to maintain skin contact with the
TempaODot. The thermometer was kept under the arm
for 1 minute, removed, and then given 10 to 15 seconds
to fade before being read. This temperature measuring
instrument and protocol were chosen for the study
because the study facility used them in the newborn
nursery for temperature monitoring.
The primary author coordinated the study,
instructed the nursing staff in data collection, monitored
and participated in data collection, and addressed any
questions or problems encountered by the nursing staff
during this study. Data were collected using two differ-
ent tools. A hypothermia risk assessment form was used
JanuarylFebruary 2000
Swaddling, avoiding drafts, using
radiant warmers, and placing
newborns on warm surfaces minimize
heat loss associated with bathing.
to screen newborns for study eligibility. The bath data
form located at the foot of the crib was used to record
the time the bath began and ended, the temperature
before the bath and at 10, 20, and 60 minutes after the
bath was completed, the time each of the temperatures
was measured, and the time the radiant warmer was dis-
continued. Temperatures not taken within 5 minutes of
the designated time were treated as missing data.
Data Analysis
Baseline data of the participants included birth
weight, gestational age, type of delivery, gender, Apgar
score at 5 minutes, time under a radiant warmer, length
of bath, and axillary temperature before the bath. Four
outcome variables were identified for the study: (a)tem-
peratures at 10, 20, and 60 minutes after the bath; (b)
magnitude of change at each of the time intervals; (c)
maximum change in temperature for each newborn dur-
ing the 60 minutes after the bath; and (d) designation of
the newborn as recovered or not recovered, based on
whether the temperature 60 minutes after the bath had
returned to or exceeded the baseline temperature or was
at least 36.7"C.
Baseline variables were compared using the chi
square test for dichotomous, categorical data and the t
test for independent samples for continuous data. A
repeated measures analysis of variance was used to
examine the temperatures from before the bath to 60
minutes after the bath both within and between groups.
The specific change in temperature from baseline to
each data point was calculated but not subjected to sta-
tistical analysis for different groups because of the vari-
ations in baseline temperatures. Testing of null
hypotheses regarding differences in findings between
newborns bathed at 1 hour after birth and newborns
bathed at 2 hours after birth was carried out using an
alpha level of .05.
Findings
The characteristics of the sample are summarized
in Table 1. Types of delivery were recorded either as
spontaneous vaginal, cesarean section, or deliveries
assisted by vacuum extraction or forceps. For purposes
JOGNN 29
 TABLE 1

-Baseline Characteristics of Participants

Newborns at 1 Hour Newborns at 2 Hours
After Birtb 11 = 40 After Birth n = 40
Variables M SD M SD p value
Birth weight 3,578 g 402 g 3,557 g 453 g ns
Gestation 39.9 weeks 1 week 39.7 weeks 1 week ns
5-min Apgar 8.9 .32 9.0 .42 ns
Time under warmer 18.1 min 8.7 rnin 19.4 min 8.9 min ns
Length of bath 7.6 min 2.4 min 7.6 rnin 2.3 min ns
Prebath temp 37.1"C 0.2"C 37.1"C 0.2"C ns
Room temp 23.5"C 0.7"C 23.6"C 0.7"C ns
Other Data
SVD' 27 28 ns
Gender of participants 20 males; 20 females 23 males; 17 females ns
%" = spoiitiiiicoiis vaginal dclivery.

of analysis, the cesarean section and assisted deliveries

were combined into a single category based on the
rationale that these manipulated deliveries would be
more stressful to the newborn than a spontaneous vagi-
nal delivery. No significant differences were found
between the two groups for any of the baseline data.
Temperatures before the bath ranged from 36.8"C to
37.7"C for newborns bathed at 1 hour after birth and
for newborns bathed at 2 hours after birth.
Comparison data for temperatures across time are
summarized in Table 2. For the group bathed at 1 hour,
the average decrease in temperature at 10 minutes was
0.4"C. The average drops at 20 minutes and 60 minutes
were 0.2"C and O.O4"C, respectively. Decreases in tem-
perature for newborns bathed at 2 hours were similar:
03°C at 10 minutes, 0.2"C at 20 minutes, and 0.1C at
60 minutes.
At 10, 20, or 60 minutes after the bath no signifi-
cant differences were found in the temperatures of new-
borns bathed at 1 hour after birth as compared to new-
borns bathed 2 hours after birth. At 10 minutes after
the bath, 88% of newborns bathed 1 hour after birth
were below their prebath temperature as compared to
93% of newborns bathed 2 hours after birth. Drops in
temperature were distributed similarly across both
groups and ranged from 0.1"C to 1.1"C. Fewer new-
borns were below their baseline 20 minutes after the
bath: 64% bathed at 1 hour and 70% bathed at 2
hours. Temperatures at 60 minutes remained below
their baseline for 47% and 60% of newborns, respec-
tively. However, only 4 newborns fell below the 36.7"C
standard for recovery. Drops in temperature at 60 min-
utes after the bath also were distributed similarly for
T h e axillary temperatures of
newborns bathed at 1 hour of age
did not vary significantly from those
of newborns bathed at 2 hours.
both groups of newborns and ranged from 0.1"C to
0.8"C.
An infant was considered to have "recovered" if
his or her temperature 60 minutes after the bath was at
or above the baseline temperature or at least 36.7"C.
Table 3 displays data for the 4 newborns who did not
achieve a status of recovered. Only 1 infant bathed at 1
hour failed to meet the criteria. This male was delivered
by cesarean section at 41 weeks gestation and had a 5-
minute Apgar of nine. The birth weight was slightly
above the mean for his group. Three infants bathed 2
hours after birth failed to reach their baseline tempera-
ture or at least 36.7"C at 60 minutes after the bath. The
two males and one female were delivered vaginally; the
two males had 5-minute Apgar scores of nine, whereas
the female had a score of eight. One infant had a birth
weight slightly above the mean for this group, and the
other two were slightly below. Gestational ages ranged
from 39 to 41 weeks. Newborns designated as nonre-
covered exhibited a pattern of partial recovery of tem-
perature at 20 minutes, followed by a drop to less than
baseline and less than 36.7"C at 60 minutes postbath.

30 JOG" Volume 29, Number 1

 - TABLE 2
Newboms' Temperature Recovery

r.
Bathed 1 Hour Afier Birth Bathed 2 Hours Afier Birth
1i m p s M SI) M Sl) p value
Prebath 37.1"C 0.2"C 37.1"C 0.2"C ns
10 min after bath 367°C 0.3"C 36.6"C 0.3"C ns
20 min after bath 36.9"C 0.3"C 36.9"C 0.2"C ns
60 min after bath 37.0S"C 0.3"C 36.9"C 0.3"C ns

Although between-group differences at all data
points were not significant, within-group changes in
temperature from baseline to 10 minutes postbath were
significant for both groups at p =.001. This significant
drop in body temperature for newborns would be
expected as a result of evaporative and convective heat
loss during the bathing process.
Discussion
Little is known about the thermal stability of new-
borns in response to events in the early postpartum peri-
od, such as bathing and attachment with parents and
family. This study provides a contribution to this body
of literature.
The patterns of change in temperature at each data
point were consistent between the newborns bathed 1
hour after birth and those bathed 2 hours after birth.
The drop in temperature was greatest at 10 minutes for
both groups, a finding which supports that newborns
are susceptible to thermal instability. The temperature
patterns of recovery, improvement at 20 minutes, and
either improvement or drop at 60 minutes also support
the importance of maintaining body temperature during
the first hours of life. By 2 hours of age, a newborn may
have been away from a warmed surface for 60-90 min-
utes. Also, although family members are informed of the
importance of keeping a newborn warmly swaddled
until his or her temperature stabilizes, the urge to
unwrap the infant to explore "fingers and toes" may be
overwhelming. In this study, the temperature of the nurs-
ery where infants were bathed was monitored and var-
ied only by 4°C. The air temperature in the mothers'
rooms was not monitored and may have contributed to
the drops in temperature noted at 60 minutes after the
bath, as compared to 20 minutes when most newborns
would have been on a warm surface in the nursery.
Findings from the current study confirm those of
the pilot project (Varda & Behnke, 1994). The patterns
of change in mean temperatures for the two groups in
1994 and the groups in the current study were virtually
identical from baseline to 10 minutes, 20 minutes, and
60 minutes after the bath. In the pilot study 95% of
newborns bathed at 4 hours after birth were designated
as recovered at 60 minutes as compared to 90% bathed
2 hours after birth. This pattern is strongly similar to
that of the 98% of newborns bathed at 1 hour and des-
ignated as recovered and the 92% of those bathed at 2
hours and designated as recovered in the current study.
The findings of this study support the findings by
Penny-MacGillivray in 1996. In that study, two of the
lowest rectal temperatures, 35.7"C and 35.8"C,
occurred in the experimental group 2 hours after the
bath and immediately after birth, respectively. The third
lowest temperature, 35.9"C, was recorded 2 hours after

TABLE 3
Temperatures of Newboms Designated as Nonrecovered
Male 1 Hour Female 1 Hour Male 2 Hours Female 2 Hours
After Birth After Birtb After Birth Afier Birth
Baseline 37.3"C 37.1"C 36.8"C 37.1"C
10 min after bath 37.2"C 36.S"C 36.7"C 365°C
20 min after bath 37.2"C 36.8"C 37.1"C 36.8"C
60 min after bath 36.S"C 36.5"C 36.4"C 36.S"C
Maximum drop 0.8"C from baseline 0.6"C from baseline 0.TC from baseline 0.6"C from baseline
to 60 rnin to 10 min and to 10 min and to 10 rnin and
60 min 60 min 60 rnin

JanuarylFebruary 2000 JOGNN 31


To reduce the exposure of health care
providers and family members to
bloodborne pathogens, normal newborns
can be bathed soon after delivery without
compromising their thermal stability.
birth in the control group. In the current study, 35.9”C
was the lowest axillary temperature sustained by a new-
born, who went on to recover to 36.9”C axillary at 60
minutes after the bath.
A limitation of the current study is that data col-
lection was limited to a single facility and a sample of
healthy, full-term newborns. Thermal stability is more
difficult to achieve in the compromised or premature
newborn. The newborn may be contending with respi-
ratory distress or other stressors that require oxygen
and glucose which would otherwise be used in heat pro-
duction. Generalizations, therefore, cannot be made
beyond the boundaries of this study. From examination
of these data, however, the investigators concluded that
varying the time of bath after birth did not affect these
normal newborns or place them at risk.
Conclusions and Recommendations
Based on the findings of the current study the
investigators concluded that bathing can occur as soon
as 1 hour after birth providing the newborn’s condition
is stable and appropriate care is provided. However,
they recommend further investigation into the relation-
ship between the newborn’s age at bath time and tem-
perature regulation using larger samples and differing
environments (i.e., in large nurseries and/or bathing
newborns in the mothers’ rooms). Future studies also
could include comparison groups of newborns who are
small for gestational age, large for gestational age, and
of appropriate size for gestational age. In addition, the
amount of time away from a heat source before the bath
may be of some importance. All of these data could be
examined for their influences on the newborn’s post-
bath temperature. Finally, an investigation measuring
rectal and axillary temperatures concurrently during a
postbath temperature study would provide information
as to the newborn’s temperature in response to non-
shivering thermogenesis from the brown fat in the axil-
la during the thermal stress of bathing compared to
temperature measurement in the rectum.
32 JOG”
Recommendations for practice based on the cur-
rent study include monitoring the temperature of a new-
born during the first few hours of life, especially when
he or she is moved from nursery to mother’s room. Less
environmental temperature fluctuation may be experi-
enced by the newborn if bathing occurs under a radiant
warmer in the mother’s room. This would require regu-
lating air temperature in that location, including mini-
mizing drafts by keeping the door to the room closed.
However, bathing the newborn in the mother’s room
has the advantage of promoting uninterrupted family
attachment, teaching parents about infant cues, and
facilitating instruction in the bathing process.
REFERENCES
American Academy of Pediatrics and The American College of
Obstetricians and Gynecologists. (1997). Guidelines for
perinatal care (4th ed.). Elk Grove Village, IL: Author.
Centers for Disease Control and Prevention. (1997). Immu-
nization of health-care workers: Recommendations of
the Advisory Committee on Immunization Practices
(ACIP) and the Hospital Infection Control Practices
Advisory Committee (HICPAC).Morbidity and Mortal-
ity Weekly Report, 46, (RR-18), 1 4 2 .
Centers for Disease Control and Prevention. (1998). Public
health service guidelines for the management of health-
care worker exposures to HIV and recommendations
for afterexposure prophylaxis. Morbidity and Mortality
Weekly Report, 47, (RR-7), 1-33.
Cohen, J. (1988).Statistical power analysis for the behavioral
sciences. Hillsdale, NJ: Lawrence Erlbaum Associates.
Garner, J. S., & Hospital Infection Control Practices Advisory
Committee. (1996). Special report: Guideline for isola-
tion precautions in hospitals. Infection Control and
Hospital Epidemiology, 17, 54-80.
Penny-MacGillivray,T. (1996).A newborn’s first bath: When?
Journal of Obstetric, Gynecologic, and Neonatal Nurs-
ing, 25, 481-487.
Slater, J. (1994). Latex allergy. Journal of Allergy & Clinical
Immunology, 94, 139-149.
Thomas, K. (1994). Thermoregulation in neonates. Neonatal
Network, 13, 15-25.
Varda, K. E., & Behnke, R. S. (1994).[Effect of initial bath on
infant temperature]. Unpublished raw data.
Karen E. Varda is quality clinical coordinator at St. Mary’s
Health Care Services-Welborn Campus, Evansville, IN.
Rita Behnke is a professor and the chair of the Department of
Nursing and Health Sciences, University of Evansville,
Evansville, IN.
Address for correspondence: Karen Varda, RN, MSHSA, St.
Mary’s Health Care Services-Welborn Campus, Quality
Department, 401 Southeast Sixth Street, Evansville, I N
47713.
Volume 29, Number 1