Enter the Neonatal Intensive Care Unit. Turn to your left. There is Rudy. He was born addicted to heroin. You can tell without even looking, as almost all such babies have a distinctive keening wail. Any NICU nurse can imitate it.
Over on your right is Rebecca. She was born weighing only one kilogram and lies quietly, all extended and skeletal.
In front of you is Nora whose heart was stitched together improperly in the womb, her pipes all circulating incorrectly. The unit is full of infants who were brought into this world in distress.
Pain in Newborns
Research tells us that newborns, even dramatically premature newborns, feel pain. And because infants cry for so many reasons (hunger, fear, boredom, post-voiding, over-stimulation, under-stimulation and so on), pain is often unrecognised and untreated.
Sadly, pain in newborns left under-addressed can lead to a massive cascade of events, including shifts in the circulation of stress hormones, changes in blood flow to the brain and other organs, changes in the wake/sleep cycle, reduction in oxygen flow to the brain, and much more. And because preemies have such unorganised neurological systems, this pain translates poorly, leading to huge wastes in energy by the infant while attempting to adapt to the post-birth environment. Add to this equation the typical NICU environment with all the lights, noises, monitors, needle sticks and limited handling and you get the perfect environment for a chronically upset infant who won’t sleep or suck.
Bathing on the NICU
One of the danger times for all neonates is bath time. Bathing can produce stress, which can manifest as crying, arching, grimacing, tongue extension, hiccupping and truncal or extremity tremoring. All of these behaviours have been identified as signals of stress in preterm babies. And these stressors are only amplified by the temperature fluctuations with bathing. Infants have a larger surface area to body mass ratio and they do not have enough brown fat to maintain body heat. Preterm children have thinner skin, don’t shiver to create energy, and do not regulate their temperatures well.
Preterm children have thinner skin, don’t shiver to create energy and do not regulate their temperatures well.
The net result? Calories lost.
No neonatal nurse or therapist wants to be the reason that an infant on the NICU loses weight. In some clinical settings, the bath has got such a bad reputation that it has essentially been reduced to two washcloths and a prayer.
So what is the answer? Swaddled bathing.
Swaddled bathing weaves together the developmental principles that therapists routinely follow when working on the NICU together with routine caregiving, which is performed by nurses. With swaddled bathing, the neonate is positioned in a flexed (foetal) position, swaddled in a blanket and then immersed. The infant is unswaddled one limb at a time in order to wash and rinse and then is immediately reswaddled before moving onto another limb. Such a protocol allows the child to remain in a calm, midline, flexed position without the flailing of limbs and agitation often seen with tub bathing.
The preferred water temperature for swaddled bathing is between 37.7 and 38.3° C and the ideal bath time is around eight minutes.
Once swaddled bathing has been established on the unit by nursing or therapy, there is a next step called Neonatal Hydrotherapy, or Aquatic Physiotherapy, where developmental movements and postures are intentionally introduced into the bath time by a therapist.
Andrea Salzman, MS, PT graduated from the University of Alabama at Birmingham with a Master’s degree in physical therapy in 1992. Over the last two decades, she has held numerous prominent leadership roles in the physical therapy field, with a heavy emphasis on academic writing and administrative functions. Between 1995 and 1998, Salzman served as the Editor-in-Chief of an American Physical Therapy Association (APTA) journal. In 2010, Salzman received one of the highest honors given to a physical therapist from the American Physical Therapy Association, the Judy Cirullo Leadership Award. Between 2012 and the present, Salzman has written 12 physical therapy courses for Care2Learn, Relias Learning and reviewed over 100 other course offerings. Currently, Salzman continues in her writing, leadership and administrative roles at Aquatic Therapy University and 10K Health.