Marion Aylott

Chapter 15

CARE OF THE INFANT

Introduction

This presentation walks you through a series of skills associated with infant care:

Part 1 – Changing a NappyPart 2 – Swaddling

Part 3 – Giving a Sponge BathPart 4 – Umbilical Cord Care

Part 5 – Bathing a BabyPart 6 – Eye Care

Part 7 – Mouth Care

Part 1: CHANGING A NAPPY

Rationale

Until a child is toilet-trained, usually by 3 years of age, nappies are used to collect urine and bowel movements.

Evidence base

A baby's soft and delicate skin needs special care. This is especially important as their bottoms are in frequent contact with moisture, bacteria, and ammonia, and there is rubbing from the nappy (Darmstadt and Dinulos, 2000). Babies and toddlers are at risk of breached skin integrity as long as they are wearing nappies (McManus, 2001). Rashes and skin breakdown are much easier to prevent than to cure. Maintenance of skin integrity is achieved by:

• Changing nappies frequently• Gentle cleaning• Patting skin dry

Physiology: Urine

Infants wet their nappies with urine several times a day

The number of wet nappies is a useful sign of how much fluid the infant is taking in

Generally, an infant should have at least seven wet nappies in 24 hours (Candy et al, 2006)

Fewer wet nappies may mean that the infant is not taking in enough fluid and must be reported to a doctor

Normally, an infants’ urine is clear and yellow-tinged, Changes in colour and odour may indicate a problem such as urinary tract infection and must be reported to a doctor (Chon et al, 2001)

Physiology: Bowel Movements

The first bowel movement of a newborn is called meconium. This is a sticky, greenish-black odourless substance that forms in the intestines during foetal development (Boxwell, 2001). The newborn may have several meconium bowel movements before this substance is completely gone from the infant’s system.

The next bowel movements are seedy-greenish-yellow in appearance (Rudolf and Levene, 2006) and normally occur around day three

Breastfed infants usually have frequent bowel movements following every feeding. These bowel movements are often, loose, yellow and seedy

Formula-fed infants have thicker bowel movements that are more beige in colour and the consistency of toothpaste

Occasionally, formula-fed infants become constipated

Firm or formed stools that occur once a day or less may mean that the infant is constipated

Very runny or watery bowel movements, may mean the infant has diarrhoea

Suspected constipation and diarrhoea must be reported to the doctor

Mustard-yellow, seedy stools occur at day five (and beyond!)

Differences between boys and girls

For boys, be sure to tuck the penis down so his urine will flow down into the nappy instead of out the top (Lund, 1999). Cover the penis with cotton wool or a wipe whilst cleansing to prevent getting splashed byunexpected urination.Clean a girl from front to back to avoid getting bacteria into the urethra (Chon, Frank & Shortcliffe, 2001).

Nappy Rash

Nappy rash is a dermatitis confined to the area covered by the nappy. It is most commonly characterised by confluent erythema of the convex surfaces of the buttocks, the areas of skin in closest contact with the nappy and it spares the groin folds.

Factors which contribute to Primary Irritant Nappy Rash include:

Excess skin hydration  water in urine & stool  nappy change frequency

Skin trauma  friction between nappy and skin

Irritants ammonia (produced by urea splitting organisms in faeces) faeces (especially diarrhoea) soap & detergent residue agents present in Nappy Wipes napkin powders & creams Candida albicans (present in faeces and infects damaged moist skin)

The relative contribution of each factor may vary between cases. It is not generally helpful to distinguish between the causes of PINR as the treatment principles do not depend on this.

Nappy Rash: Treatment

Use disposable nappies Increase the frequency of changing and cleansing Use disposable towels or face washers soaked in water

or olive oil to cleanse the area Application of a barrier cream at every change. 

Effective barrier creams include zinc paste, white soft paraffin and VaselineR

Apply cream thickly and do not remove completely after each nappy change; rather, apply another layer over the top

Let the infant spend as long as possible without a nappy on, lying on a soft absorbent sheet that is changed as soon as it is wet. Sunlight plays a role

If there is associated candidal infection, leading to erythema in the folds and satellite pustules then topical anti-candidal therapy (an imidazole or nystatin) should be applied. This therapy is often combined with 1% hydrocortisone to reduce the associated inflammation

Part 2: Swaddling

Part 2: SWADDLING

Rationale

Swaddling a baby, newborn in particular, gives them a sense of security, like the womb (Gavey, 2002)

Evidence base

Swaddling keeps the infant’s arms and legs in a flexed midline position and facilitates infant ‘hands to face’ manoeuvres like life in the womb (LaMar and Hamernik, 2003)It often helps to comfort a distressed baby and can have a useful calming effect during procedures (Symington and Pinelli, 2003)

Psychology & Physiology

Research has shown that swaddling: decreases infant psychological and motor stress conserves energy (reduced flailing and startling) improveS state control (decreased crying and

agitation) facilitates social interaction by keeping the infant in a

calm, quiet alert state (Fern et al, 2002). Therefore, swaddling promotes a feeling of

security in theInfant despite a change in the environment

Swaddling keeps the infants’ arms and legs in a flexed midline position and facilitates infant ‘hands to face’ manoeuvres like life in the womb (LaMar and Hamernik, 2003)

Swaddling is also an important means of maintaining an infant’s thermoregulation (Noerr, 1997)

Procedure

Refresh your knowledge of the procedure for swaddling by reading p141 of the printed text and watching the online video demonstration.

Part 3: GIVING A SPONGE BATH

Anatomy & Physiology

Infants are susceptible to heat stress loss because:

The hypothalamus is immature (Leone and Finer, 2006)

Infants have a high surface area to body weight/volume ratio. The head and scalp In particular form a major portion of this surface area (Chamley et al, 2005)

Infants under 6 months of age in particular have an inability to shiver and heat is produced by brown fat thermogenesis (Campbell, 2006)

Brown fat forms only 2% of body weight in an infant as compared to 14% in adult (Tortora and Derrickson, 2006)

There is reduced insulation by subcutaneous white fat (Tortora, 2005)

The sweat mechanism is poor (Neill and Knowles, 2004)

Part 4: UMBILICAL CORD CARE

Rationale

The umbilical stump is a common means of entry for systemic infection in the newborn infant. Keeping the stump clean and dry is therefore very important in order to prevent infection

Evidence base

In developed countries, individual cases and epidemics of cord infections continue to occur (Anderson and Philips, 2004)

Infections are not the only concern. Bleeding from the cord stump - although more rare than infection - can rapidly be fatalBleeding can, however, be effectively prevented by tight tying or clamping and by prevention of infection (McCance and Huether, 2006)

The umbilical stump represents a significant portal for infection (Furdon and Clark, 2002)

It is important to keep the stump clean so that it does not get infected (McConnell et al, 2004; Zupan et al, 2004)

Anatomy & Physiology

The umbilical cord is a unique tissue, consisting of two arteries and one vein covered by a mucoid connective tissue called Wharton's jelly and a thin mucous membrane

During pregnancy, the placenta supplies all material for foetal growth and removes waste products. Blood flowing through the cord brings nutrients and oxygen to the foetus and carries away carbon dioxide and metabolic wastes

After the baby is delivered their umbilical cord is clamped with forceps and then cut with scissors, a few centimetres away from the belly button. There are no nerves in the cord so this is not painful (Boxwell, 2001)

The few centimetres of cord still attached to the baby make up the stump

When the cord is cut, the cord stump is suddenly deprived of its blood supply

Drying and separation of the stump is facilitated by exposure to air

The stump soon starts to dry and turns black and stiff (dry gangrene) and then drop off completely in about a week

The devitalised tissue of the cord stump can be an excellent medium for bacterial growth, especially if the stump is kept moist and unclean substances are applied to it. The umbilical vessels are still patent for a few days following birth, thus providing direct access to the bloodstream

The umbilical stump is a common means of entry for systemic infection in the newborn infant. Keeping the stump clean and dry is therefore very important in order to prevent infection

Factors that delay cord detachment

The application of antiseptics to the stump and infection (McConnell et al 2004)

After the cord separates, the umbilicus continues to elaborate small amounts of mucoid material until complete healing takes place, usually a few days after separation. During this time the umbilicus is still susceptible to infections, although less so than in the first 2-3 days. Infection may delay healing, causing the umbilicus to stay moist for longer periods

Drying and separation of the stump is facilitated by exposure to airTherefore keep cord stump out of the infant’s nappy

Omphalitis

The devitalised tissue of the cord stump can be an excellent medium for bacterial growth

Report signs of inflammation (erythema, oedema, tenderness) of the tissues surrounding the cord to a Doctor immediately as these are signs of omphalitis (WHO, 1998). As infection delays or prevents obliteration of the vessels, umbilical bleeding is a common sequel. There may also be a purulent discharge from the stump (WHO, 1998)

Procedure

Refresh your knowledge of the procedure for giving a umbilical cord care by reading p143 of the printed text and watching the online video demonstration.

Part 5: BATHING A BABY

Rationale

An infant’s skin is soft and delicate (Noonan et al, 2006). Proper skin care and bathing helps maintain the health and texture of the infant's skin while providing a pleasant experience.

Evidence base

With all the nappy changes and wiping of mouth and nose after feedings, most infants only need to be bathed two or three times a week or every other day (DOH, 2006). Bathing more frequently may lead to dry and irritant skin (Noonan et al, 2006)

Baths can be given any time of day. Bathing before a feeding is recommended as bathing after a feed may be uncomfortable and induce vomitingMany parents prefer their infant to be bathed in the evening, as part of the bedtime ritualCurrent recommendations direct that infants particularly in the neonatal period (first 28 days) should not be bathed routinely for thermal protection (DOH, 2006)

Anatomy & Physiology

Bathing during the neonatal period (first 28 days of life) should be as gentle and brief as possible

Infants are susceptible to heat stress loss because:

The hypothalamus is immature (Leone and Finer, 2006)

Infants have a high surface area to body weight/volume ratio. The head and scalp In particular form a major portion of this surface area (Chamley et al, 2005)

Infants under 6 months of age in particular have an inability to shiver and heat is produced by brown fat thermogenesis (Campbell, 2006)

Brown fat forms only 2% of body weight in an infant as compared to 14% in adult (Tortora and Derrickson, 2006)

There is reduced insulation by subcutaneous white fat (Tortora, 2005)

The sweat mechanism is poor (Neill and Knowles, 2004)

Using a bathing safety mat

Procedure

Refresh your knowledge of the procedure for umbilical cord care by reading p144 of the printed text and watching the online video demonstration.

Using a bath seat:

Used to support infants in bathOnly suitable if infant can sit on

its ownNot suitable if child can pull

itself up

Part 6: EYE CARE

Rationale

In the first few weeks of life, an infant does not secrete tears, which are protective and usually prevent contamination of the eyes (Lissauer and

Fanaroff, 2006). Therefore, in this early period the infant is at risk of contamination of the eyes through dust and bacteriaOny perform eye care when clinically indicated that is, when the eyes are ‘sticky’

Evidence base

Mild ophthalmia, frequently referred to as ‘sticky eye’ is common especially in the early neonatal period (Simpson, 1997)

The term ‘Ophthalmia Neonatorum is used to describe inflammation (redness and discharge) of the eyes of an infant within 28 days of birth (Simpson, 1997)

Anatomy & Physiology

Components of the eye: Orbit (bony socket ) Eyelids (conjunctiva: thin membrane covering anterior portion of eye) Eyebrows Eyelashes Tears Lacrimal glands (bathe eyes with lubricating fluid; fluid drains into nose)

The cause of ophthalmia neonatorum may simply be due to an irritation in the eye or a blocked tear duct which usually resolves with cleansing within a few days. However, bacteria may also cause an infection in the eye and the infant will require antibiotics Another risk factor for developing ophthalmia neonatorum is a maternal infection or sexually transmitted diseases at the time of delivery which include: Chlamydia, Gonorrhoea, Herpes Simplex. These infections usually present within 24 hours of delivery (Rubenstein and Lick, 2004).

Severe purulent ophthalmia neonatorum:

Refer to a doctor immediately This type of conjunctivitis starts soon after birth

because the baby was infected by the mother during delivery. The mother already had an infection of the vagina due to the presence of a sexually transmitted disease, in this case gonorrhoea

You can see that in both eyes there is a lot of purulent discharge

Be careful because the pus is infectious! Wear gloves and wash your hands carefully before and after care

Procedure

Refresh your knowledge of the procedure for eye care by reading p145-146 of the printed text and watching the online video demonstration.

Part 7: Mouth CarePart 6:

MOUTH CARE

Rationale

Oral diseases begin very early, from the time bacteria begin to live in the oral cavity

As new teeth erupt and the diet of the infant becomes more sophisticated, bacteria continue to produce acids and toxins that are harmful to hard and soft tissues in the mouth

Bacteria, predominant is mutans streptococci, metabolise simple sugars to produce acid that demineralises teeth, resulting in cavities (Douglass et al, 2004)

Evidence base

Primary teeth are key to healthy adult teeth (Pitts, 2004)Primary teeth hold a space for permanent teeth. If an infant or young child loses a tooth because of decay, the permanent tooth may erupt at an angle, causing crowding of the adult teeth. Early loss of primary teeth can also affect speech patterns, chewing ability and use of the tongue (Schafer and Adair, 2000)

Early childhood dental caries

Early childhood dental caries can develop as soon as the teeth erupt (Seow, 1998)

Cavities may be visible as early as 10 months of age (Sanchez and Childers, 2000)

Caries typically presents in children as white spots or lines on the maxillary incisors, which are among the first teeth to erupt and the least protected by saliva (Feathersone, 2000)

Early childhood caries is an infectious bacterial disease of the teeth

Bacteria predominantly mutans streptococci, metabolise monosaccharide and disaccharide sugars to produce acid that demineralises teeth and causes cavities (Kidd and Fejerskov, 2004)

The interplay of these three etiological factors controls the severity of the disease;

- Teeth- Bacteria- Sugar

Eruption of teeth in infants is highly variable. The primary incisors typically begin to erupt between 6 and 12 months of age. Teeth that erupt with enamel defects are at greater risk of caries. Defects are more prevalent in infants who are born prematurely, or have a low birth weight, or have special health care needs and in infants of low socioeconomic status (DeGrauwe et al, 2004)

The bacteria from periodontal disease can enter the blood stream and travel to major organs and begin systemic infections

Oral thrush:

Precocious teeth:

Epstein’s pearls on surface of gums:

Baby bottle decay:Never put your child to bed with

a bottle of anything but water. The sugar in milk and juice will

pool and constantly coat the teeth causing decay

Oral and Tooth Care

Breast feeding is the preferred source of nutrition. If the infant is bottle fed, the ‘feeder’ should hold the infant when feeding, and the bottle should not be propped or placed in bed

Only formula or breast milk should be used in the bottle. Fruit juice must be discouraged because it is cariogenic and has been associated with failure to thrive (Selwitz et al, 2007)

Some formulas, especially soy-based formulas contain sucrose, which is cariogenic (Selwitz et al, 2007)

At approximately 4 months of age teething symptoms include fussiness, increased sucking behaviour and loose stools. Increased drooling is common at this age, but not necessarily associated with teething (Wake et al, 2000). Temperatures higher than 38.10C are not associated with teething and should be evaluated for other causes (Tinanoff and Douglass, 2001)

Symptomatic relief of teething discomfort includes sucking on cool teething rings

Numbing gels are less helpful and, in high doses, can be harmful (Douglass et al, 2004)

All infants should receive appropriate topical fluoride and oral hygiene beginning at 6 months of age twice a day (Selwitz et al, 2007)

The ‘sippy cup’/’teacher beaker’ should be introduced at 6 months of age in preparation for weaning from the bottle or breast at 12 months

Drinks between meals should be limited to water and plain milk. Juice, if introduced, should be limited to no more than 100-150ml per day and consumed only in cups (Ramos-Gomez et al, 2002) and during a meal. Eating whole fruit is preferable to drinking fruit juice (Petersen, 2003)

Visits to the dentist should be instituted at 6-12 months of age (DOH, 2006)

Even before an infant has teeth, after feeding, wipe out baby’s mouth with warm washcloth or gauze. When teeth have erupted, brush with an infant brush along with a small amount of fluoride toothpaste twice daily

Fluoride is a mineralIt helps fight decay in areas where enamel

has started to breakdownIt prevents decay by strengthening the

enamel