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Chapter 15
CARE OF THE INFANT
Marion Aylott
Introduction
This presentation walks you through a
series of skills associated with infant care:
Part 1 – Changing a Nappy
Part 2 – Swaddling
Part 3 – Giving a Sponge Bath
Part 4 – Umbilical Cord Care
Part 5 – Bathing a Baby
Part 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
Mustard-yellow, seedy stools occur
at day five (and beyond!)
 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
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 by
unexpected 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
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%
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
the
Infant 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
fatal
Bleeding 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 air
Therefore 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 vomiting
Many parents prefer their infant to be bathed in the evening,
as part of the bedtime ritual
Current 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)
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 mat
Using
a bathing
safety
bath
Only suitable if infant can sit
on its own
Not 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
bacteria
Ony 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 Care
Part 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:
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
Precocious teeth:
Epstein’s pearls on surface of gums:
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
 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 (RamosGomez 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 mineral
It helps fight decay in areas where enamel has
started to breakdown
It prevents decay by strengthening the enamel