EFFECTIVENESS OF SWADDLE AND CONVENTIONAL TUB BATH ON THERMAL STABILITY IN PREMATURE INFANTS
AT DUSTIRA HOSPITAL CIMAHI
Dior Manta Tambunan1, Henny Suzana Mediani2, Nunung Nurjanah1 [email protected]
1Department of Nursing, School of Health Sciences Jenderal Achmad Yani Cimahi, Indonesia
2Department of Nursing, Padjadjaran University, Indonesia
ABSTRACT
Giving a daily bath for premature infants often causes hypothermia due to there are limitations of premature infants in regulating body temperature and organ immaturity of premature infants. The research purpose was to determine the differences in the effectiveness of swaddle and conventional tub bath on thermal stability in premature infants. The research design used a quasi-experimental pre-posttest in 2 groups. The sampling technique was consecutive sampling. The samples number in this study were 36 respondents. Body temperature were measured by standard measurement at pretest and posttest (1, 15, and 30 minutes). Statistical tests using paired t, Wilcoxon, independent t, and Mann Whitney test. The results indicated that the swaddle bath had a significant influences on body temperature at 1 minute post-bath with p value = 0.001, and 15 minute post- bath with p value = 0.011. Conventional tub bath showed a significant influences on body temperature at 1 minute post-bath with p value = 0.001. It can be concluded that there were no a significant difference on thermal stability in preterm infants among both intervention group with p value > 0.05. It is recommended for further research to identify the effec of those interventions on physiological responses (vital signs) in preterm infants.
Keywords: Bathing, Premature Infants, Preterm Infants, Thermal Stability
INTRODUCTION
Bathing a newborn remains controversial, about when and how to give the first bath to a newborn, whether a newborn can be bathed in early life, and how to approach preterm infants’ bathing who are hospitalized in the neonatal intensive care unit (NICU) and perinatology unit (Lund, 2016).
Preterm infants experience an earlier life transition from the intra-uterine to extra-uterine environments in order to be able to adapt and maintain their lives especially during bath (Lissauer & Fanaroff, 2013;
Burns et al., 2017; Datta, 2018). Bathing is one of the routine activities that aimed to clean and protect the outer layers of the body, in addition to stimulating the general circulation of the skin and providing a sense of comfort and well-being (WHO, 2017; Elmeida, 2015; Paran, Edraki, Montaseri &
Nejad, 2014).
The benefits of bathing are still overshadowed by concerns for physiological effects and serious behavior in infants, most premature infants do not tolerate stress caused by sponge baths which had a negative impact on the physiological response as signs of tachypnea, dyspnea, and hypoxia (Neonatal Program Policy & Procedure Manual, 2016); sponge bath is no longer
recommended at European round table meetings (Blume-Peytavi et al., 2016; Blume-Peytavi et al., 2009). Premature infants have limitations in regulating body temperature, it can caused the physiological functions of the body because immaturity so that hypothermia tends to occur with premature infants’ body temperature <36.5 °C, that it requires assistance from the caregiver to give warm to the body (Oktiawati & Julianti, 2017;
Rustina, 2015). Hypothermia is considered as silent (slowly) a killer in neonates, which increases neonatal morbidity and mortality (Datta, 2018;
Oktiawati & Julianti, 2017).
Hypothermia is one of the most common problems that occur during bathing a newborn. For this reason, WHO (2014) recommends bathing a newborn at 24 hours after birth to protect vernix caseosa and prevent hypothermia, but due to cultural factors, newborns can be bathed after the age of 6 hours (El-Atawi & Elhalik, 2016; Lund, 2016). Maintaining the warmth of a neonate increases the survival of premature infants. The high incidence of hypothermia occurs in the first three hours of life and gestational age at birth and is an independent risk factor for hypothermia in the early stage of life (Mank et al., 2016). The body
temperature in preterm infants at 10 minutes post conventional tub bath were 36.8 °C and the body temperature at 10 minutes post sponge bath were 36.7 °C (Loring et al., 2012).
The results of field observations in two hospitals that have been carried out by the majority of premature babies are bathed by sponge baths.
Premature babies will be bathed by a combination of half sponge bath and half conventional tub bath when doctors allow premature babies to go home.
Search results through the database, research on swaddle bath intervention has never been done in Indonesia and the method of bathing with swaddle bath has never been done in hospitals in Indonesia, therefore more research is needed on swaddle bath, so nurses can use it routinely so that Swaddle baths can provide comfort to premature babies. The purpose of this study was to analyze the differences in the effectiveness of swaddle and conventional tub bath on body temperature stability in premature infants.
The results of field observations in two hospitals that have been carried out and the majority of preterm infants were bathed by sponge baths.
Premature infants were bathed by a combination of half sponge bath and half conventional tub bath when doctors allowed preterm infants to go home.
The engine search results through the database showed that the research on swaddle bath intervention has never been done in Indonesia and the method of bathing with swaddle bath has never been done in hospitals in Indonesia, therefore a research is needed on swaddle bath, so nurses can use it routinely because it can provide comfort to premature infants. The purpose of this study was to analyze the differences in the effectiveness of swaddle and conventional tub bath on thermal stability in premature infants.
METHODS Study Design
This study used a quasi-experimental pre- posttest in 2 groups to analyze the differences in the effectiveness of swaddle and conventional tub bath on body temperature stability in preterm infants.
The sampling technique used a consecutive sampling. This research was conducted during the period of May - September 2019 in the perinatology room at Dustira Hospital Cimahi.
Research Sample
Calculation of sample size used a comparative analytic of unpaired categorized
(Dahlan, 2014; Riyanto, 2017). The number of samples in this study were 36 respondents (18 respondents in each group).
Inclusion And Exclusion Criteria
Inclusion criteria in this study sample were infant with gestational age 30 - 37 weeks, body weight were 1,500 grams or more, body temperature were 36 °C - 37.5 °C, stable general condition, attended by parents or family, received routine procedures (bathing, feeding, oro gastric tube, etc.), had been given milk feeding 1 hour before bathing, room temperature were 24 °C - 26 °C, tub bath water temperature were 37.7 °C - 38.3 °C, and spotlight were available during the procedure.
Exclusion criteria in this study were premature infants with neurological problems, premature infants with congenital defects, premature infants with sedatives, premature infants who received analgesics, premature infants with muscle relaxation drugs that could affect pain and stress, and premature infants who were unwilling to participate in this research.
Instrument
Observation sheet for demographic data and body temperature. Sheet for recording descriptive data such as demographic data (initial of the child, date of birth, gestational age, gender, type of delivery, birth weight and body weight at bathed);
body temperature before and after bathing intervention as measured using an infrared thermometer that were purchased in new conditions.
Data Collection Procedure
Respondent of premature infants in the conventional tub bath group were given the first intervention in accordance with standard operational procedures used as a protocol in the perinatology room. While respondent of preterm infants in the swaddle bath group were given the last intervention which were adopted from various literature and modified (Denton & Bowles, 2018;
Finn, Meyer, Kirsten, & Wright, 2017; Medscape Nurses, 2019; Quraishy, Bowles, & Moore, 2013;
Edraki, Paran, Montaseri, Nejad, & Montaseri, 2014). The infants’ temperature were measured at pretest and posttest 1, 15, and 30 minutes. Each respondent were bathed for 4 - 8 minutes. The intervention of bathing in the two groups were carried out directly by the researcher.
Data Analysis
Data collection were analyzed using computerized program software. Numerical demographic descriptive data (minimum value, maximum value, mean and standard deviation) and categorical data (frequency value and total frequency value). Levene test were used to test data homogeneity. The sample were not homegen with p
= < 0.05 were read by equal variances not asummed (postbath 1 minute) and the homogen sample with p
> 0.05 were read by equal variances assumed (postbath 15 minutes). The normality data distribution were tested with Shapiro-Wilk. Test to the influence of swaddle and conventional tub bath on body temperature stability by parametric test using paired t test and non-parametric test using Wilcoxon test. To compare the data of the two interventions using the parametric test with the unpaired t test and the non-parametric test with the Mann Whitney test. The level of significance p value < 0.05, which means it is not significant.
Ethical Consideration
The ethical test needed to conduct this research were obtained from School Of Health Sciences Jenderal Achmad Yani Cimahi and the number were 02/KEPK/VI/2019. Information about the study was provided to families who cared for
school-aged children with HIV/AIDS and taking written informed consent.
RESULTS
The findings in this study indicated that the swaddle bath had a gestational age (minimum were 33 weeks, maximum were 37 weeks, and mean were 35.67 weeks); postnatal age (minimum were 6 hours, maximum were 129 hours, and mean were 25.56 hours); birth weight (minimum were 1,714 grams, maximum were 4,034 grams, and mean were 2,472 grams); body weight at bathed (minimum were 1,708 grams, maximum were 3,738 grams, and mean were 2,403 grams); type of labor (spontaneous were 50 % and caesarean section (C.S) were 50 %);
and gender (male were 50 % and female were 50
%). Conventional tub bath had a gestational age (minimum were 33 weeks, maximum were 37 weeks, and mean were 35.83 weeks); postnatal age (minimum were 10 hours, maximum were 144 hours, and mean were 47.83 hours); birth weight (minimum were 1,714 grams, maximum were 3,400 grams, and mean were 2,432 grams); body weight at bathed (minimum were 1,590 grams, maximum were 3,400 grams, and mean were 2,343 grams);
type of labor (spontaneous were 22.2 % and caesarean section (C.S) were 77.8 %); and gender (male were 38.9 % and female were 61.1 %). The figure can be seen in Table 1.s
Table 1. Demographic Respondents Data of Numerical and Categorics in Group A (Swaddle Bath, n = 18) and Group B (Conventional Tub Bath, n = 18) Characteristics
Group A (Swaddle Bath) n = 18 Group B (Conventional Tub Bath) n = 18 Min. Max. Mean (SD) n
(%)*
Min. Max. Mean (SD)
n (%) Total n (%)**
Gestational Age (Week) 33 37 35.67 (1.609)
33 37 35.83
(1.200)
Postnatal Age (Hour) 6 129 25.56
(30.174)
10 144 47.83
42.987) Birth Weight (Gram) 1714 4034 2472.22
(516.356)
1714 3400 2432.22 (392.879) Weight at Bathed
(Gram) 1708 3738
2403.67
(479.360) 1590 3400
2343.78 (403.978) Type of Delivery
1: Spontaneous 2: Sectio Caesarean
9 (50) 4 (22.2) 13 (36.10)
9 (50) 14 (77.8) 23 (63.90)
Jenis Kelamin 1: Male 2: Female
9 (50) 7 (38.9) 16 (44.45)
9 (50) 11 (61.1) 20 (55.55)
*n = Respondent numbers and % (frequency), **Total n & frequencies
Descriptive results on body temperature stability in preterm infants before and after the swaddle bath which data were not distributed normally at pretest and 30 minutes post-bath. Group
A swaddle bath had a pretest median body temperature in preterm infants were 36.70 °C, and the lowest mean value in group A swaddle bath were at 1 minute post-bath with 36.43 °C. While the
mean at 15 minutes post-bath were 36.57 °C and the median at 30 minutes post-bath were 36.60 °C.
Descriptive results on body temperature stability of respondent preterm infants before and after conventional tub bath were all distributed normally.
Group B conventional tub bath had a mean pretest body temperature were 36.70 °C, and the lowest
mean body temperature in group B conventional tub bath were at 1 minute post-bath 1 with 36.34 °C.
The mean value of body temperature at 15 minutes post-bath were 36.60 °C and the mean value at 30 minutes post-bath were 36.65 °C. The figure can be seen in Table 2.
Table 2. Description of Body Temperature Stability in Premature Infants Before and After Swaddle and Conventional Tub Bath
Variables
Group A (Swaddle Bath) n = 18 Group B (Conventional Tub Bath) n = 18 Min. Max. Mean Median S.D Min Max. Mean Median S.D Temperature (°C)
Pretest 36.4 36.9 36.68 36.70* 0.1353 36.2 37.2 36.70 36.70 0.2249 Postbath 1 Minute 36.2 36.6 36.43 36.40 0.1138 36.1 36.8 36.34 36.30 0.2064 Postbath 15 Minutes 36.4 36.8 36.57 36.60 0.1320 36.3 36.9 36.60 36.60 0.1534 Postbath 30 Minutes 36.5 36.9 36.64 36.60* 0.1092 36.4 36.9 36.65 36.65 0.1383
*= Abnormal Data Distribution.
The results showed the influence of swaddle bath on body temperature stability that variable of body temperature at 1 minute post-bath premature infants 1 found 17 respondents who experienced a decrease in body temperature, 0 respondent who experienced an increase in body temperature and 1 respondent who did not experience changes in body temperature. Wilcoxon statistical test results obtained p value = 0.001, it can be concluded that the value of p < 0.05 and its meant that there were an influence of swaddle bath at 1 minute post-bath body temperature of premature infants respondent.
The body temperature of preterm infants at 15 minutes post-bath showed that there were 11 respondents who experienced a decrease in body temperature, 4 respondents who experienced an increase in body temperature, and 3 respondents
who did not experience changes in body temperature. Wilcoxon statistical test results obtained p value = 0.011, it was concluded that the value of p < 0.05 and it meant that there were an influence of swaddle bath on body temperature at 15 minutes post-bath of preterm infants respondent.
Furthermore, the body temperature of preterm infant at 30 minutes post-bath found 8 respondents who experienced a decrease in body temperature, 4 respondents who experienced an increase in body temperature and 6 respondents who did not experience changes in body temperature. Wilcoxon statistical test results obtained p value = 0.169, and its concluded that there were no effect of swaddle bath on body temperature at 30 mintes post-bath of premature infants. The figure can be seen in Table 3.
Tabel 3. Effect of Swaddle and Conventional Tub Bath in Premature Infant on Body Temperature Stability Variables
Grup A (Swaddle Bath) n = 18 Grup B (Conventional Tub Bath) n = 18 Mean
(S.D)
Ranks Mean Ranks
n P Value Mean (S.D)
Ranks Mean Ranks
n P Value Temperature (°C)
Pretest
36.68 (0.1353)
36.70 (0.2249) Postbath 1 Minutes
36.43 (0.1138)
Negative 9.00 17 p=0.001b,
***
3.34 (0.2064)
p=0.001a, ***
Positive 0.01 0
Ties 1
Postbath 15 Minutes
36.57 (0.1320)
Negative 9.45 11 p=0.011b,
***
36,60 (0.1534)
p=0.055a, Positive 4.00 4 *
Ties 3
Postbath 30 Minutes 36.64 (0.1092)
Negative 7.00 8 p=0.169b,
*
36,65 (0.1383)
p=0.425a, Positive 5.50 4 *
Ties 6
a Paired Samples T Test, b Wilcoxon Test, ***Significant, *Not Significant
The influence of conventional tub bath on the body temperature stability in premature infant respondents showed that variable body temperature of premature infants at 1 minute post-bath 1 using paired samples t-test and obtained p value = 0.001, it was concluded that the value of p < 0.05, its meant that there were a significant influence of conventional tub bath on body temperature at 1 minute post-bath 1 in preterm infant respondents.
Next, the body temperature at 15 minutes post-bath with paired samples t-test obtained p value = 0.055 and at 30 minutes post-bath gained p value = 0.425, it can be interpreted that there were no significant effect on body temperature at 15 and 30 minutes post conventional tub bath in premature infant respondents. The figure can be seen in Table 3.
The results showed an analysis of differences in swaddle and conventional tub bath on the stability
of the body temperature in preterm infants at 1 minute post-bath with parametric independent samples t-test and obtained p value = 0.121, which means that it was concluded that there were no significant difference statistically at 1 minute post- bath body temperature. Furthermore, body temperature at 15 minutes post-bath with parametric independent samples t-test and obtained p value = 0.564, its concluded that there were no significant difference statistically at 15 minutes post-bath body temperature in preterm infants respondents. Next, body temperature at 30 minutes post-bath with non- parametric Mann Whitney test and obtained p value
= 0.756, its concluded that there were no significant difference statistically at 30 minute post-bath body temperature stability in preterm infants respondent.
The figure can be seen in Table 4.
Tabel 4. Difference in Mean Temperature Stability (After Bathing) Premature Infants Swaddle and Conventional Tub Bath Variables
Group A
(Swaddle Bath) n = 18
Group B (Conventional Tub Bath) n =
18 P Value
Mean (S.D) Mean Ranks Mean (S.D) Mean Ranks Temperature (°C)
Postbath 1 minute
36.43 (0.1138)
36.34 (0.2064)
p=0.121a,*
Postbath 15 Minutes 36.57 (0.1320) 36.61 (0.1534) p=0.564a,*
Postbath 30 Minutes 17.97 19.03 p=0.756b,*
a Independent Samples T Test, b Mann Whitney Test, ***Significant, *Not Significant, ****Not Homogeneity, **Homogeneity
DISCUSSION
The results showed that group A swaddle bath had a mean temperature of at 1 minute post-bath in preterm infants were 36.43 °C with the interpretation having decreased from pretest body temperature with a median of 36.70 °C. But it was clearly seen that it’s increased at 15 minutes post- bath with a mean of 36.57 °C. While the median body temperature at 30 minutes post-bath in premature infants were 36.60 °C. Normal values of body temperature in newborns are 36.5 °C - 37.5 °C (WHO, 2014; Datta, 2018; Hockenberry & Wilson, 2015; Lissauer & Fanaroff, 2013; Marmi, &
Raharjo, 2015; Datta, 2018; Oktiawati et al., 2017, Wong, Hockenberry-Eaton, Wilson, Winkelstein, &
Schwartz, 2009).
These findings explained that group B conventional tub bath had a mean body temperature at 1 minute post-bath in premature infants were 36.34 °C where the respondents of premature infant had decreased body temperature from pretest with a mean of 36.70 °C. Next, the body temperature at 15 minutes post-bath in preterm infants rose up with a mean of 36.60 °C. While the mean body
temperature of respondent preterm infants at 30 minutes post-bath were 36.65 °C, it were increasing closed to the pretest rate.
The body temperature preterm infant’s status at 1 minute post-bath in both groups were classified as mild hypotermia (cold stress) with body temperature range of 36 °C - 36.4 °C (Datta, 2018;
Rustina, 2015; Wong et al., 2009). Premature infants in both groups experienced a slight decreaseof body temperature at 1 minute post-bath because the mean postnatal age in group A were 25.56 hours and the minimum postnatal age in group A swaddle bath were 6 hours. Meanwhile, preterm infants in group B had a mean postnatal age of 35.83 hours and a minimum postnatal age of 10 hours. Premature infant respondents in this study had a mean birth weight of 2472.22 grams in group A and 2432.22 grams in group B, while the mean weight at bathed in group A were 2403.67 grams and in group B were 2343.78 gram.
WHO (2017) and Datta (2018) recommends of delayed bathing in a newborn until 24 hours after birth but if it is not possible due to cultural factors, bathing should be delayed at least 6 hours after the
infant were born, by cleaning the dirt on the body using baby oil to prevent the occurrence of hypothermia, because the act of bathing that causes heat loss by evaporation and radiation. The first bath in a newborn is aimed at removing unwanted dirt such as blood, meconium and leaving the remaining vernix caseosa intact. Bathing immediately in the postnatal period causes a risk of hypothermia, which is danger to breathing and increased oxygen consumption. Therefore, the first bath in a newborn should not be given until the vital signs and the baby's body temperature has stabilized (Kuller, 2014).
Ceylan and Bolisik (2018) in their study explained that the mean body temperature at 1 minute post swaddle bath in preterm infants were 36.64 °C with the mean pretest were 36.65 °C and the mean postnatal age for preterm infants were 4.44 days. While Caka and Gozen (2017) examined the body temperature of mature infants, the mean at 1 minute post swaddle bath were 36.25 °C with the mean pretest were 36.69 °C and the postnatal age of the infants were 1.38 days. Based on the results of this study and previous studies indicated that the supporting factors which were influencing decreased on body temperature at 1 minute post swaddle bath were the infants’ gestational age and the post-natal age.
Swapna, Nandhini, Ruthrani, Kanchana, and Celina (2017) stated that a mean body temperature at 10 minutes post conventional tub bath in preterm infants were 34.50 °C with mean at 10 minutes pretest were 36.46 °C. The frequency of the majority of birth weight of premature infants were 30 % with a body weight of 1701 - 1900 grams and the frequency of the majority of body weight at bathe of premature infants were 43.3 % with 1701 - 1900 grams and the mean postnatal age of premature infants were more than 7 days. Next, Caka and Gozen (2018) examined the body temperature of mature infants, the mean at 1 minute post conventional tub bath were 36.12 °C with a mean pretest value of 36.65 °C. The mean birth weight in mature infants in the Caka and Gozen (2018) study were 3200 grams and the mean postnatal age of the infants’ were 1.43 days.
The findings of De Freitas, Munhoz, Costa, and Kimura (2018) used a pilot study in 15 preterm infants found that the mean pretest body temperature of conventional tub bath were 36.5 °C, post conventional tub bath at 10 minutes were 36.2
°C and at 30 minutes were 36.3 °C. The mean weight of premature infants in the findings of De
Freitas et al. (2018) were 2098.6 grams with postnatal age inclusion criteria over 24 hours. Based on these findings and previous studies showed that the supporting factors that were affected decreasing on body temperature at 1 minute post swaddle bath were the infants’ gestational age, postnatal age, birth weight and body weight at bathed.
Based on the Wilcoxon test results in the study on body temperature variables in premature infant respondents identified that the body temperature at 1 minute post swaddle bath found 17 respondents who experienced a decrease in body temperature, 0 respondents who experienced an increase in body temperature and 1 respondent who did not experience changes in body temperature. Wilcoxon statistical test results obtained p value = 0.001, it can be concluded that the value of p < 0.05 means that there were an influence of swaddle bath on body temperature at 1 minute post-bath in premature infant respondents. Premature infant respondents in group B conventional tub bath using paired samples t-test on body temperature at 1 minute post-bath and obtained p value = 0.001, it was concluded that there were a significant influence of conventional tub bath at 1 minute post-bath on body temperature premature infant respondents.
Research of Edraki et al. (2014) explained that the mean body temperature at 10 minutes post swaddle bath in preterm infant were 36.42 °C (mild hypothermia or cold stress) with a paired t-test statistic and obtained p value = 0.220, which means there were no significant effect of swaddle bath on body temperature in premature infants respondents.
Meanwhile, the body temperature of preterm infant respondent at 10 minutes post conventional tub bath 10 minutes with mean were 35.96 °C (moderate hypothermia) and statistical test of paired t and obtained p value <0.001, it can be concluded that there were a significant influence of conventional tub bath on body temperature in premature infant respondents. Caka and Gozen (2017) found that the mean at 1 minute post swaddle bath on body temperature in mature infants were 36.25 °C and at 10 minutes post-bath were 36.50 °C and its compared with the pretest body temperature were 36.69 °C, it is found p value = 0.001, it means that there were an effect of swaddle bath on the body temperature at 1 and 10 minutes post-bath in mature infants. The conventional tub bath control group had a mean body temperature at 1 minute post-bath were 36.12 °C and at 10 minutes post-bath were 36.42 °C , it were found that p value = 0.001, then it were concluded that there were a significant influence on
the body temperature of premature babies at 1 and 10 minutes post-bath. Classification of moderate hypothermia is a body temperature of 32 - 35.9 °C, it is in danger for newborns (Datta, 2018).
Next, the body temperature at 15 minutes post swaddle bath in preterm infants were 11 respondents who experienced a decrease in body temperature, 4 respondents who experienced an increase in body temperature, and 3 respondents who did not experience changes in body temperature. Wilcoxon statistical test results obtained p value = 0.011; then it can be concluded that there were an effect of swaddle bath on body temperature at 15 minutes post-bath 15 in preterm infants respondents. But at 15 minutes post-bath body temperature of preterm infants were within the normal threshold of newborn infant’s body temperature because the mean body temperature at 15 minutes post-bath in preterm infants were 36.57
°C, although it was still lower than the mean pretest of 36.68 °C. Furthermore, the body temperature of preterm infant respondents at 15 minutes post conventional tub bath with paired samples t-test, and obtained p value = 0.055, which means that it can be concluded that there were no significant effect of conventional tub bath on preterm infant respondent on body temperature.
The findings in group A swaddle bath had the body temperature at 30 minutes post-bath in preterm infants with mean pretest were 36.68 °C and mean at 30 minutes post-bath were 36.64 ° C(normal limit), infants had adapted to the environment on regulating body temperature because premature infant were asleep, relaxed and comfortable. The Wilcoxon test found that there were 8 respondents who experienced a decrease in body temperature, 4 respondents who were premature babies who experienced an increase in body temperature, and 6 respondents who were premature babies who did not experience changes in body temperature.
Wilcoxon test results got a p value = 0.169, which can be concluded that there were no effect of swaddle bath at 30 minutes post-bath on body temperature in preterm infants. Meanwhile, the body temperature of preterm infant respondents at 30 minutes post conventional tub bath with paired samples t-test found p value = 0.425, which means that there were no significant influence on body temperature in preterm infant respondents at 30 minutes post conventional tub bath.
Newborns cope with heat loss (maintaining a stable body temperature) in 3 ways: shivering (not very efficient); muscle movements (only provide a
slight benefit); and heat production caused by the use of fat reserved (brown fat). It is merely infant who were born matured have a lot of brown fat, and after brown fat is used, infant cannot produce it again. This is one of the important reasons why nursing care providers must continue to keep a newborn warm (Rosdahl & Kowalski, 2015).
Newborns tend to experience hypothermia due to reasons such as thin skin, large surface area of the body, small deposits of brown fat, and low protection mechanisms (Lavender et al., 2013).
According to the Champlain Maternal Newborn Regional Program (CMNRP) (2013) explained that hypothermia can also occur due to greater body water levels, skin immaturity that causes increased water evaporation and heat loss, metabolic mechanisms that develop poorly to respond to thermal stress (for example: not shivering). Physiological and behavioral mechanisms regulate the balance between heat lost and inverted or thermoregulation in premature infants that are not constant and abnormal due to the immaturity of neural and vascular control in the hypothalamus (Potter, Perry, Stockert, & Hall, 2016). Shivering is the involuntary body's response to differences in body temperature. Striated motion when shivering requires considerable energy.
Shivering produces 4 - 5 times the normal heat production. This heat will help balance the body temperature so that the chills will stop.
Thermogenesis without chills occurs in newborns.
Newborns cannot shiver, so the vascular brown tissue present at birth is metabolized to heat production. The brown tissue is very limited in number (Potter et al., 2016). Covering the body with warm water ensures even distribution of temperature and reduces heat loss through evaporation. Maintain the shortest possible bathing duration; some clinical practitioners suggest 5 minutes to prevent cold stress (Blume-Peytavi et al., 2016).
The findings in this study aimed of seeing the differences in the effectiveness of swaddle and conventional tub bath on body temperature stability in preterm infants using independent samples t-test and showed that the body temperature in preterm infants with mean at 1 minute post-bath in group A swaddle bath were 36.43 °C (stage cold stress), whereas mean at 1 minute post-bath in group B conventional tub bath were 36.34 °C (cold stress stage) with p value = 0.121 which indicated that there were no significant difference at 1 minute post-bath on body temperature of preterm infants in
group A swaddle bath and group B conventional tub bath. Next, the body temperature of preterm infant respondents at 15 minutes post-bath preterm were also analyzed by independent samples t-test with the mean in group A swaddle bath were 36.57 °C (normal limit) and the mean in group B conventional tub bath were 36.61 °C (normal limit) with p value = 0.564 which explains that there were no significant difference on the body temperature of premature infant respondents in group A swaddle bath and group B conventional tub bath. Although there were a slight difference in the mean value because it were seen from the level of comfort in the way it were swaddled and not, bathing with safe and stress-free and not, but it still remained within normal limits.
The variable body temperature at 30 minute post-bath on preterm infants with non-parametric Mann Whitney test found that the mean ranks in group A swaddle bath was 17.97 and the mean ranks in group B were 19.03 with p value = 0.756 which means there were no significant difference on the body temperature of premature infant respondents in group A swaddle bath and group B conventional tub bath. Looking at the results above (Table 4), the mean body temperature at 30 minutes post-bath in group A swaddle bath (36.64 °C) is lower when compared to the mean at 30 minutes post-bath on body temperature in group B conventional tub bath (36.50 ° C). But the results were still within normal limits.
Previous research of Swapna et al. (2017) found by using an unpaired t-test that the mean body temperature at 10 minutes post-bath of preterm infants in group A swaddle bath were 35.36 °C (moderate hypothermia) with a mean pretest of 36.33 °C (cold stress phase), whereas at 10 minutes post-bath in group B conventional tub bath were 34.50 °C (moderate hypothermia) with mean pretest were 36.46 °C (cold stress phase), p value = 0.02 showed a significant difference at 10 minutes post- bath on body temperature in group A swaddle baths and group B conventional tub baths. Furthermore, the results of the study of Swapna et al. (2017) using unpaired t-test, the mean body temperature at 30 minutes post-bath of preterm infants in group A swaddle bath were 36.11 °C (cold stress phase, and not yet reached the pretest mean were 36.33 °C) and the mean body temperature at 30 minutes post-bath of premature babies in group B conventional tub bath were 35.11 °C (moderate hypothermia) and obtained p value = 0.001, which showed a very significant difference on body temperature at 30
minutes post-bath of preterm infants in group A swaddle bath and group B conventional tub bath.
Swapna et al. (2017) using inclusion criteria for preterm infants were 30 - 36 weeks with a postnatal age of more than 7 days.
Age is one of the factors that affects body temperature in newborns, especially premature infants. Newborns have a temperature mechanism immaturity so that there can be drastic changes in body temperature to the environment. Make sure the newborn is wearing enough clothing and avoid exposure to environmental temperatures. Newborns can lose 30 % of body heat through the head so newborns must always use a head cover to prevent heat loss (Potter et al., 2016). The phenomenon in the field that researcher found during data collection that some parents of premature baby respondents asked when the premature baby would be given bathed. Therefore, as a provider of nursing care, nurses must socialize to the family of premature infants the information on when the premature infants can be given the first bath. It can be done when taking informed consent from the family after the infant were born. Information about the time when to start bathing premature infant after birth, needs to be socialized to the family because some parents of premature infant respondents, ask when the premature baby was bathed.
Based on the results of this study and previous studies indicated that the supporting factors that influence body temperature when bathing premature infants were the infant’s gestational age, postnatal age, birth weight, weight at bathed, and the method of bathing were given. Then it can be concluded that the swaddle bath method is a type of bathing that is safer and more stable in measuring the body temperature of premature infant respondents because it is stress-free. Swaddle bath is a stress-free, safe and comfortable bathing method that simulates a well-known uterine environment.
Swaddle baths provide comfort during bathing and a pleasant bathing experience for premature infants. This bath method will be the best choice at NICU and perinatology unit that can be integrated with the concept of developmental care through routine bathing practices and allows parents to get involved in baby care so that it can be continued at home (Denton & Bowles, 2018; Kuller, 2014;
Edraki et al., 2014). Pretest body temperature in this study and previous studies had inclusion criteria of 36 °C - 37.5° C. Even though premature infant respondents had body temperature in the category
of cold stress or mild hypothermia, it can still be bathed by the swaddle bath method because the body temperature of premature infants will rise at 15 minutes post-bath to normal limits.
CONCLUSSION
These findings indicated that there were no significant difference in group A swaddle bath and group B conventional tub bath on thermal stability in preterm infants. But in general, the results of this study prove that the swaddle bath were more effective in maintaining body temperature stability even though the inclusion criteria were in cold stress or mild hypothermia. It is proven that the body temperature at 1 minute post-bath in preterm infant were in cold stress stage and returned to the normal threshold at 15 minutes post-bath. The dilemma faced by health workers so far is that cultural factors for bathing newborns can be answered by bathing premature babies with stable general conditions using the swaddle bath method with a minimum postnatal age of 6 hours and mean postnatal age of 25.56 hours. However, the results of this study can be the basic for further researcher to examine different variables to see the parameters of vital signs of premature babies, more stringent in the inclusion criteria of body temperature.
ACKNOWLEDGEMENTS
Special thanks to my fellow student Indri Iriani as research assistant in this study. Special gratitude also to Marni Sumarni, head of the perinatology unit at Dustira Hospital Cimahi and the team of nurses and midwives for their help, support and motivation.
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