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Research Article| Volume 64, e154-e158, May 2022

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Effects of swaddled and traditional tub bathing on stress and physiological parameters of preterm infants: A randomized clinical trial in China

  • Yuting Huang
    Yuting Huang
      Affiliations
      Nursing School of Central South University, Changsha, Hunan, PR China
      Search for articles by this author
    • Leshan Zhou
      Leshan Zhou
      Correspondence
      Corresponding author at: Nursing School of Central South University, 172 Tongzipo Road, Changsha, Hunan, PR China.
      Contact
      Affiliations
      Nursing School of Central South University, Changsha, Hunan, PR China
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    • Hawa Abdillah
      Hawa Abdillah
        Affiliations
        Nursing School of Central South University, Changsha, Hunan, PR China
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      • Ben Hu
        Ben Hu
          Affiliations
          Nursing School of Central South University, Changsha, Hunan, PR China
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        • Yiyao Jiang
          Yiyao Jiang
            Affiliations
            Nursing School of Central South University, Changsha, Hunan, PR China
            Search for articles by this author
          Open AccessPublished:December 22, 2021DOI:https://doi.org/10.1016/j.pedn.2021.11.028
          Effects of swaddled and traditional tub bathing on stress and physiological parameters of preterm infants: A randomized clinical trial in China
          Previous ArticleNovel instrument to guide nurse-led consultations with parents of three-year-olds in school health services in Flanders: A feasibility study of SPARK36
          Next ArticleThe complexity of having a child with a congenital heart defect in a developing country: A qualitative study of parental needs
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              Highlights

              • •
                Validated the advantages of swaddled bathing in China's preterm infants.
              • •
                Enriched the experimental data on swaddled bathing in different countries.
              • •
                Recommend that neonatal intensive care units use swaddled bathing.

              Abstract

              Purpose

              The present research aims to study the effects of swaddled and traditional tub bathing on premature infants to identify better ways to bathe.

              Design and methods

              Eligible premature infants (n = 60) were randomly assigned to either swaddled bathing or traditional tub bathing group. Stress scores and physiological indicators were measured 10 min before, immediately after, and 10 min after bathing. Crying times were also recorded for both groups. Data were reported as mean and standard deviation (SD) or frequency (percentage). For analyzing the data, the Student t-test and Chi-square test were employed.

              Results

              Swaddled bathing has less effect on the respiratory rate, heart rate, and oxygen saturation (p < 0.05). Both bathing methods led to a decrease in the temperature of infants. Still, the temperature of infants 10 min after bathing, in the swaddled bathing group was rose higher than the traditional tub bathing (t = 2.813, p < 0.05). The stress score of the swaddled bathing group, immediately after and ten minutes after bathing was lower than the traditional tub bathing group. The crying time of the swaddled bathing group was 32 ± 24.740(s) lower than the traditional tub bathing group 94.43 ± 41.625(s).

              Conclusions

              The advantages of swaddled bathing over traditional tub bathing were validated for feasibility in China's preterm infants. Swaddled bathing is recommended method for bathing technique in the neonatal intensive care unit.

              Practice implications

              Swaddled bathing is beneficial for the development of premature infants, as it results in less noxious stimuli and stress on the developing premature neonates.

              Keywords

              • Baths
              • Infant, premature
              • Stress, physiological
              • Stress, psychological

              Introduction

              Premature birth results possess significant health problems affecting the global population. Beck et al., analyzed data from 92 countries and reported the estimated global prematurity prevalence at 9.6% in 2005 (
              Beck et al., 2010
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              ). For premature infants, caregivers must pay attention to physiological changes and stress responses during bathing to take appropriate measures to relieve associated stress (
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              ). Swaddled bathing can improve comfort and reduce the stress caused by bathing and has been verified in other countries and regions. However, there is no uniform standard available to bath premature infants due to the different research procedures.
              Therefore, the current clinical trial is conducted to improve the procedure of swaddled bathing. This study also compared swaddled bathing with traditional tub bathing by assessing the physiological index and stress induction on premature infants in China.

              Methods

              Study design and setting

              The Institute Ethics Committee approved this study. This prospective randomized clinical trial study was registered in the Clinical Trial. Registry and conducted from 5th May to 30th June 2021. This study was performed with the guidance of the CONSORT 2010 statement.

              Study procedure

              Parents of enrolled infants were informed about the aim, study plan, time, duration of the study, and data collection through the “Participant Consent Form,” and their written consents were obtained. The information such as postnatal age, gender, birth weight, weight at bath time, Apgar score, time from the last feeding, and maternal information including the age of the pregnancy, gestational period, the number of births, week of maternal pregnancy, mode of delivery, and absence of pregnancy-associated morbidities, were collected through the “Participant Information Form”.
              This study was a prospective randomized controlled experimental trial conducted to determine the effect of “traditional tub bathing (TTB)” and “swaddled bathing (SB)” methods on the physiological parameters and stress levels in preterm infants. The studied variables included body temperature, respiratory rate, heart rate, oxygen saturation levels, crying time, and the Newborn stress scale score.
              The two groups were simultaneously assessed for body temperature, respiratory rate, heart rate, oxygen saturation levels, and the crying time using the same thermometer, stopwatch, and oximeter. The stress measurement was analyzed based on the Newborn stress scale (NSS) (
              Ceylan and Bolışık, 2017
              • Ceylan S.S.
              • Bolışık B.
              Examining psychometric properties of newborn stress scale.
              ACU Sağlık Bil Derg. 2017; 2: 97-103
              • Google Scholar
              ), developed in 2017 by Ceylan et al. The scale has been tested for its reliability and validity, including facial expression, color, respiration, activity level, consolation, muscle tone, extremities, and posture. Each parameter was scored on a scale of 0–2. The minimum score was 0, and the maximum score was 16 for this scale, where a higher score represented increased stress levels in premature infants. The advantage of this scale includes an efficient, convenient, and more personalized measure of the stress levels in premature infants.
              We measured all the variables 10 min before, immediately after, and 10 min after bathing, except for the crying time. The crying time was measured from the start of the bath to the end. The study was conducted at least 24 h post-birth on the preterm infants with no birth asphyxia, fed at least 1–3 h before bath, no analgesic sedation treatment before bathing, and stable the vital signs. The parents fully understood and volunteered to participate in this study, at the NICU of a hospital in China. Newborns who were critically ill, not eligible for baths, and unexplained crying before bathing were excluded from the study.

              Preparation for bath

              All the baths in the study were conducted by the same researcher who was trained in newborn bathing. Therefore, the bath time and order of the two groups were the same. Bathing hours were kept uniform from 8:00 a.m. to 9:00 a.m., with controlled bath time of 5 min per infant and constant environmental factors such as 1) bath water temperature (37–38 °C); 2) bathroom temperatures (26–28 °C); 3) relative humidity (50–60%); 4) indoor fresh and dry air-ventilated, following the 30-min ultraviolet sterilization before and after using the bathroom; and 5) circulating air in the bathroom after bathing.
              10 min before bathing, experimental data of infants were measured without the change in position and state. The items such as newborn bath basins, disposable plastic diaphragm, water thermometer, etc., were prepared beforehand except for the unique disposable bath towel of the experimental group.

              Application of bathing methods

              SB group bathing method: In a naked state, infants body was moderately wrapped by the bath towel in a single layer, maintaining a curvy midline position, with the natural bending of the torso, arms, and legs, and slowly soaking it in the warm water of the tub, keeping the waterline up to shoulder level to ensure that infants feet hit bottom. Each part of the body was washed in the regular order of bathing. Before cleaning each body part of infants, a bath towel was opened, and after cleaning, it was not wrapped again. Next, the bath towel was opened for the other parts to clean until the bath towel was removed entirely.
              TTB group bath method: Everything was similar with the SB group except that there was no bath towel used to wrap the newborns. To give a naked bath in the bathtub, the water level depth was kept about 9–12 cm to keep infants bodies submerged in water till the shoulder. The operator grasped infants shoulders with thumb and fingers. The operator's forearm provided firm support to ensure that newborns do not experience any adverse event in water due to body twisting. The infants were washed clean to contaminated areas, in order of top-down, front-to-back following head, face, chest, abdomen, limbs, etc.

              After bath procedures

              After bathing, infants in both groups were dried and kept warm to ensure the umbilical cord and buttocks were appropriately clean and dried. Experimental data were measured immediately after and 10 min after bathing.

              Sample size

              The G-power 3.1.9.2 was used to calculate the sample size by holding the medium effect size (0.15), α = 0.05, power (1-β) = 0.90. Based on the relevant review of the literature and the specified calculation, the minimum sample size of 50 newborns was required, with 25 newborns in each group. Therefore, the study was designed to be conducted with 60 newborns, where randomization was determined by the computer, with 30 newborns in each group, in case of unforeseeable possible loss of participants.

              Data analysis

              Two researchers checked the data for the accuracy, and feeded the data into SPSS.V.22 for analysis. Measurement data were done to test the normality, with normal distribution and were described by the standard deviation (SD). Thereafter the t-test was used for statistical analysis. Continuous variables were shown in frequency & percentage and analyzed using the chi-square test. A p-value of p < 0.05 was considered statistically significant.

              Results

              Sample characteristics

              After obtaining the informed consent from the parents, the researchers used the “Participant Information Form” to collect the information about the infants and mother. The final sample size consisted of 30 infants in the SB and TTB groups, with total of 60 participants. The differences in infants between two groups such as postnatal age, gender, birth weight, weight at bath time (grams), Apgar score, time from the last feeding time were not found to be statistically significant (P > 0.05). In the case of maternal record, the age of the pregnancy, gestational period, the number of births, week of maternal pregnancy, mode of delivery, and absence of pregnancy-associated morbidities were comparable for both the groups with no observed statistical significance (P > 0.05) (Table 1).
              Table 1Demographic and clinical characteristics of the participants in the swaddled bathing and traditional tub bathing groups.
              CharacteristicsSB (n = 30)TTB (n = 30)t/x2p
              Mean ± SDMean ± SD
              Infants
              Postnatal age (days)8.77 ± 8.4439.80 ± 7.788−0.493a0.624
              Gender (N,%)Male13(43.3)16(53.3)0.601b0.438
              Female17(56.7)14(46.7)
              Birth weight (grams)2899.83 ± 636.1762881.17 ± 874.7000.095a0.925
              weight at bath time (grams)3067.33 ± 481.0353055.67 ± 680.9510.077a0.939
              Apgar score, 1 min9.47 ± 1.1069.17 ± 1.4640.896a0.374
              Apgar score, 5 min9.83 ± 0.4619.97 ± 1.829−0.387a0.700
              From the last feeding time (min)86.40 ± 15.08786.93 ± 16.193−0.132a0.895
              Maternal
              The age of pregnancy30.80 ± 3.79131.07 ± 5.420−0.221a0.826
              Number of pregnancies2.23 ± 1.4552.47 ± 1.332−0.648a0.520
              Number of productions1.50 ± 0.5721.67 ± 0.661−1.044a0.301
              Gestational age (weeks)34.00 ± 1.66132.87 ± 2.3152.178a0.033
              Birth type(N,%)Vaginal13(43.3)11(36.7)0.278b0.598
              Cesarean section17(56.7)19(63.3)
              Pregnancy disease (N,%)Yes13(43.3)12(40)0.069b0.793
              No17(56.7)18(60)
              Note. aStudent t-Test, bChi-square test.
              • Open table in a new tab

              Assessment of physiological parameters

              We compared the body temperature, respiratory rate, heart rate, and oxygen saturation levels 10 min before, immediately after, and 10 min after bathing between the two groups. The physiological indicators 10 min before the bath in the two groups were comparable and had no statistical significance (P > 0.05) difference.
              Both bathing methods affected the body temperature before and after bathing in the premature infants, which decreased during but rose again ten minutes after the bathing. There was no difference between the groups on body temperature change caused by these two bathing methods (P > 0.05) immediately after bath. However, body temperature of infants risen significantly in the SB group than the TTB group, 10 min after the bathing.
              Both bathing methods led to the changes in respiratory rate and heart rate of the newborns during bathing. During the bathing process, premature infants respiratory rate and heart rate increased in the TTB group. In contrast, in the SB group, this increase was comparatively more minor. However, in both groups, respiratory rate and heart rate were stabilized 10 min after bathing. Bathing also led to changes in oxygen saturation in both groups of premature infants. However, the decline in oxygen saturation in the TTB group was more significant than that of premature infants in the SB group. Following 10 min after bathing, both groups oxygen saturation values rose again, though the fluctuation of oxygen saturation in the SB group was less than the TTB group (Table 2).
              Table 2Comparison of body temperature, breathing, heart rate and oxygen saturation levels in the swaddled bathing and traditional tub bathing groups.
              VariablesSB (n = 30)TTB (n = 30)tap
              Mean ± SDMean ± SD
              Body temperature (°C)
              Before bathing36.780 ± 0.297636.830 ± 0.2950−0.6540.516
              After bathing36.607 ± 0.299336.535 ± 0.25781.0170.313
              10 min after bathing36.850 ± 0.206436.723 ± 0.24172.8130.033*
              Respiratory rate (per minute)
              Before bathing41.37 ± 1.40241.07 ± 1.6390.7620.449
              After bathing43.50 ± 1.30646.17 ± 1.783−6.608<0.001**
              10 min after bathing42.00 ± 1.25943.07 ± 1.337−3.180<0.001**
              Heart rate (per minute)
              Before bathing130.23 ± 10.500141.40 ± 14.936−3.3500.401
              After bathing138.50 ± 9.982150.37 ± 13.682−3.838<0.001**
              10 min after bathing132.80 ± 10.682143.53 ± 13.452−3.431<0.001**
              Oxygen saturation levels (%)
              Before bathing96.33 ± 1.80794.03 ± 1.7520.1250.901
              After bathing94.03 ± 1.75291.43 ± 1.8325.618<0.001**
              10 min after bathing96.93 ± 2.14994.47 ± 2.1294.467<0.001**
              Note. aStudent t-Test, *p < 0.05, **p < 0.001.
              • Open table in a new tab

              Stress assessment

              While comparing the bathing time and crying duration of the two groups, it has been observed that the SB group bath time was 301.93 ± 14.377(s) more than that of the TTB group 280.33 ± 20.215 (s). However, the crying duration of premature infants in the TTB group was 94.43 ± 41.625(s) greater than 32 ± 24.740 (s) in the SB group during bathing. The NSS scores of two groups of these premature infants had no statistical difference 10 min before bathing. However, the NSS score of the TTB group was more significant than that of the SB group, immediately after and ten minutes after bathing (Table 3, Table 4).
              Table 3Comparison of crying time in the swaddled bathing and traditional tub bathing groups.
              VariablesSB (n = 30)TTB (n = 30)tap
              Mean ± SDMean ± SD
              Crying time (s)32 ± 24.74094.43 ± 41.625−7.062<0.001**
              Note. aStudent t-Test, **p < 0.001.
              • Open table in a new tab
              Table 4Comparison of newborn stress scale score in the swaddled bathing and traditional tub bathing groups.
              NSS scoreSB(n = 30)TTB(n = 30)tap
              Mean ± SDMean ± SD
              Before bathing3.47 ± 1.7954.93 ± 1.780−3.1780.402
              After bathing4.60 ± 1.9937.73 ± 1.799−6.39<0.001**
              10 min after bathing2.53 ± 1.1675.60 ± 1.499−8.841<0.001**
              Note. aStudent t-Test, **p < 0.001.
              • Open table in a new tab

              Discussion

              Premature infants have underdeveloped skin barriers, thinner skin, high susceptibility to skin infections and irritants, and impaired external heat stimulation that can alter the skin's blood flow (
              Albahrani and Hunt, 2019
              • Albahrani Y.
              • Hunt R.
              Newborn skin care.
              Pediatric Annals. 2019; 48: 11-15
              https://doi.org/10.3928/19382359-20181211-01
              • Crossref
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              • Google Scholar
              ;
              Kusari et al., 2019
              • Kusari A.
              • Han A.M.
              • Virgen C.A.
              • Matiz C.
              • Rasmussen M.
              • Friedlander S.F.
              • Eichenfield D.Z.
              Evidence-based skin care in prater infants.
              Pediatric Dermatology. 2019; 36: 16-23
              https://doi.org/10.1111/pde.13725
              • Crossref
              • PubMed
              • Scopus (36)
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              ;
              Lund, 2016b
              • Lund C.
              Issues in newborn skin care.
              Advances in Neonatal Care. 2016; 16: 1-2
              https://doi.org/10.1097/ANC.0000000000000346
              • Crossref
              • PubMed
              • Scopus (4)
              • Google Scholar
              ). Studies have shown that bathing can lead to deterioration of vital signs in infants, such as changes in heart rate and respiratory rate, temporary reduction in oxygen saturation levels, and hypothermia (
              Bembich et al., 2017
              • Bembich S.
              • Fiani G.
              • Strajn T.
              • Sanesi C.
              • Demarini S.
              • Sanson G.
              Longitudinal responses to weighing and bathing procedures in preterm infants.
              The Journal of Perinatal & Neonatal Nursing. 2017; 31: 67-74
              https://doi.org/10.1097/JPN.0000000000000228
              • Crossref
              • PubMed
              • Scopus (12)
              • Google Scholar
              ). Bathing can also increase distress in premature infants, further enhanced with consecutive care procedures (
              Liaw, Yang, Yuh and Yin, 2006
              • Liaw J.J.
              • Yang L.
              • Yuh Y.S.
              • Yin T.
              Effects of tub bathing procedures on preterm infants’ behavior.
              Journal of Nursing Research. 2006; 14: 297-305
              https://doi.org/10.1097/01.jnr.0000387589.12340.98
              • Crossref
              • Scopus (22)
              • Google Scholar
              ). Therefore, an essential focus of bathing in premature infants is to reduce the bathing procedures related to stimulation (
              Edraki, Paran, Montaseri, Razavi and Montaseri, 2014
              • Edraki M.
              • Paran M.
              • Montaseri S.
              • Razavi N.M.
              • Montaseri Z.
              Comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration in premature infants: A randomized clinical trial.
              Journal of Caring Sciences. 2014; 3: 83-91
              https://doi.org/10.5681/jcs.2014.009
              • PubMed
              • Google Scholar
              ), at the same time to provide the benefits of bathing. Assessment of physiological indicators reflected that the degree of stimulation in these infants causes instability of these parameters, although stabilizing these indicators in the newborn is essential.
              In this study, both the bathing patterns resulted drop in the body temperature of premature infants. Although the two bathing groups can cause hypothermia, the SB group was effective in restoring body temperature after bathing. The current study results concur with the previously reported results of Çaka (
              Çaka and Gözen, 2018
              • Çaka S.Y.
              • Gözen D.
              Effects of swaddled and traditional tub bathing methods on crying and physiological responses of newborns.
              Journal for Specialists in Pediatric Nursing. 2018; 23
              https://doi.org/10.1111/jspn.12202
              • Crossref
              • PubMed
              • Scopus (19)
              • Google Scholar
              ) study. In the present study, both types of bathing caused alteration in the respiratory rate, heart rate, and oxygen saturation immediately after and 10 min after bathing. This observation further confirms that bathing can affect physiological indicators of premature infants. Among the studied indicators, the increase in respiratory rate and heart rate after bathing and the decrease at ten minutes after bathing were relatively smaller than that of the naked bath group.
              Bathing resulted in decreased oxygen saturation levels in premature infants in the SB and TTB groups. Still, it increased after ten minutes of bathing, which contributed to the end of the bathing procedure, the reduction in care operations, and other stimuli. The alteration in terms of decline and increase of oxygen saturation in the SB group was minor than in the TTB group. Further, the overall stability was better in the SB group than in the TTB group.
              Numerous studies have found that (
              Çaka and Gözen, 2018
              • Çaka S.Y.
              • Gözen D.
              Effects of swaddled and traditional tub bathing methods on crying and physiological responses of newborns.
              Journal for Specialists in Pediatric Nursing. 2018; 23
              https://doi.org/10.1111/jspn.12202
              • Crossref
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              ;
              Ceylan and Bolւşւk, 2018
              • Ceylan S.S.
              • Bolւşւk B.
              Effects of swaddled and sponge bathing methods on signs of stress and pain in premature newborns: Implications for evidence-based practice.
              Worldviews on Evidence-Based Nursing. 2018; 15: 296-303
              https://doi.org/10.1111/wvn.12299
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              ;
              Çınar, Yalnızoğlu and Uslu, 2020
              • Çınar N.
              • Yalnızoğlu Ç.S.
              • Uslu Y.H.
              Effect of newborn bathing training with the swaddled and tub bathing methods given to primiparous pregnant women on the mother’s experience, satisfaction and newborn’s stress during the first bathing of the newborn at home: A mixed method study.
              Japan Journal of Nursing Science. 2020; 17: 123-163
              https://doi.org/10.1111/jjns.12363
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              ;
              de Freitas, Bueno, Holditch-Davis, Santos and Kimura, 2018
              • de Freitas P.
              • Bueno M.
              • Holditch-Davis D.
              • Santos H.P.
              • Kimura A.F.
              Biobehavioral responses of preterm infants to conventional and swaddled tub baths: A randomized crossover trial.
              The Journal of Perinatal & Neonatal Nursing. 2018; 32: 358-365
              https://doi.org/10.1097/JPN.0000000000000336
              • Crossref
              • PubMed
              • Scopus (9)
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              ;
              Edraki, Paran, Montaseri, Razavi and Montaseri, 2014
              • Edraki M.
              • Paran M.
              • Montaseri S.
              • Razavi N.M.
              • Montaseri Z.
              Comparing the effects of swaddled and conventional bathing methods on body temperature and crying duration in premature infants: A randomized clinical trial.
              Journal of Caring Sciences. 2014; 3: 83-91
              https://doi.org/10.5681/jcs.2014.009
              • PubMed
              • Google Scholar
              ) swaddled bathing not only effectively maintains the newborn's body temperature, oxygen saturation levels, and HR within the normal range but also reduces the crying time during bathing, which has a positive impact in reducing the stress and pain levels associated with bathing. In addition, it is reported to reduce the behavioral stress symptoms in newborns during bathing, such as crying, grimacing, abnormal muscle tone, etc., and makes infants feel relaxed.
              Stress can adversely affect the physical and mental development of premature infants. Excessive stress induces negative consequences on genetic and brain function as well as impacts the social and emotional well-being of premature infants (
              Craciunoiu and Holsti, 2017
              • Craciunoiu O.
              • Holsti L.
              A systematic review of the predictive validity of neurobehavioral assessments during the preterm period.
              Physical & Occupational Therapy in Pediatrics. 2017; 37: 292-307
              https://doi.org/10.1080/01942638.2016.1185501
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              • PubMed
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              ;
              Fumagalli et al., 2018
              • Fumagalli M.
              • Provenzi L.
              • De Carli P.
              • Dessimone F.
              • Sirgiovanni I.
              • Giorda R.
              • Montirosso R.
              From early stress to 12-month development in very preterm infants: Preliminary findings on epigenetic mechanisms and brain growth.
              PLoSOne. 2018; 13: 1902-1906
              https://doi.org/10.1371/journal.pone
              • Crossref
              • Scopus (48)
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              ). Furthermore, stress is highly detrimental to early childhood development and contributes to future diseases (
              Dimitrova et al., 2018
              • Dimitrova N.
              • Turpin H.
              • Borghini A.
              • Morisod H.M.
              • Urben S.
              • Müller-Nix C.
              Perinatal stress moderates the link between early and later emotional skills in very preterm-born children: An 11-year-long longitudinal study.
              Early Humandevelopment. 2018; 121: 8-14
              https://doi.org/10.1016/j.earlhumdev.2018.04.015
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              ). Swaddled bathing is a harmless and safe method of care that provides a calm, stress-free bathing experience for newborns by simulating a familiar and safe uterine environment(
              Fernández and Antolín-Rodríguez, 2018
              • Fernández D.
              • Antolín-Rodríguez R.
              Bathing a premature infant in the intensive care unit: A systematic review.
              Journal of Pediatric Nursing-Nursing Care of Children & Families. 2018; 42: 52-57
              https://doi.org/10.1016/j.pedn.2018.05.002
              • Abstract
              • Full Text
              • Full Text PDF
              • PubMed
              • Scopus (17)
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              ).
              This study measured the total time of crying in premature infants in different bathing modes, combined with the NSS scale score, to evaluate the stress level of premature infants. Both groups NSS scores had no statistical significance and were comparable before bathing. However, the preterm infants in the TTB group cried for longer than the SB group during the bath. In addition, the pressure score of the TTB group was also higher than that of the SB group soon after and ten minutes after bathing.
              Interestingly, the data was measured immediately after the bath, and the increase in the pressure score of the TTB group was significantly more significant than that of the SB group. This not only means that the bathing process of TTB causes more stress than SB on premature infants but also continues to affect them for longer duration.

              Practice implications

              The study assessed the effects of SB and TTB on premature infants. Our data showed that bathing itself could bring noxious stimuli and cause stress to the developing premature neonate. However, the results confirmed the benefits of SB for premature infants. Therefore, SB is recommended for preterm infants admitted to intensive care units to improve their care quality. Furthermore, our results enrich the experimental data and feasibility studies on SB in different countries. Overall, our findings may help in healthcare and social interventions to facilitate the development of premature infants.

              Limitations

              This study did not classify early or late-to-late-stage premature infants. However, several pieces of literature are available describing the effects of bathing on premature infants in the middle and late stages. In addition, smaller sample size was one of the limitations of this study as all the included subjects were enrolled based on the strict inclusion criteria. Lastly, similar studies are recommended to be conducted on a larger cohort to validate the results from the present study.

              Conclusion

              The study compared the TTB with the SB technique. The results demonstrated that the SB maintains the stable physiological indicators of premature infants, moreover the stress on premature infants was also minimal. Although the advantages of SB have been proved in various regions, this study is the first to validate its effect and feasibility on China's preterm infants.

              Author statement

              YT and LS designed and performed the study. YT and LS drafted the manuscript. YT, HAWA, YY participated in the design of the study. YT, LS and HB performed the statistical analysis and interpretation of data. All authors read and approved the final manuscript.

              Declaration of Competing Interest

              None.

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              Article info

              Publication history

              Published online: December 22, 2021
              Accepted: November 28, 2021
              Received in revised form: November 17, 2021
              Received: July 20, 2021

              Footnotes

              ☆This study was registration with ClinicalTrial.gov (Identifier ChiCTR2100046138). We have no conflicts of interest to disclose. We Thanks to the support of The Third Xiangya Hospital of Central South University.

              ☆☆This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

              Identification

              DOI: https://doi.org/10.1016/j.pedn.2021.11.028

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