Nappy Change Research Articles

Aotearoa's linguistic landscape: exploring the use of te reo Māori in English-medium early childhood education

ABSTRACT This research provides insight into current te reo Māori (the Indigenous language of Aotearoa, New Zealand) use in English-medium ECE settings. We videoed naturalistic conversations between kaiako (educators) and tamariki (aged 15–28 months) at 24 English-medium BestStart ECE centres. Te reo Māori was quantitatively assessed across five routines: kai (food) time, book time, group time, free play, and nappy change. The highest rates of te reo Māori use per minute were observed during the kai time, book time, and group time routines, respectively, and lowest during free play and nappy change. Although scripted/prepared te reo Māori use (e.g. karakia and waiata; prayer and song) were well used, opportunities for more complex and elaborate te reo Māori use remain. This research provides insight into the current use of te reo Māori in English-medium ECE settings, an enhanced understanding of kaiako contributions to te reo Māori revitalisation goals, and applications for practice.

“Oh, you’ve never done that before?!” Preservice teachers being ‘stirred in’ to unfamiliar practices with infants and toddlers

ABSTRACT Undertaking infant-toddler practicum during initial teacher education is critical to ensuring preservice teachers (PSTs) are well prepared for their future role as early childhood teachers. PSTs, however, can face challenges in infant-toddler practicum given the demands of this unique teaching and learning context. A knowledgeable, experienced educator as a guide is key to supporting PSTs’ learning during placement. This paper illuminates the practices of an infant-toddler educator who supported an international PST’s learning during her first nappy change on an infant-toddler practicum in an early childhood service in Australia. The paper addresses the scarce literature on PSTs’ experiences in infant-toddler settings, which can guide their relationships with colleagues. Drawing on the theory of practice architectures, we analyse a video vignette of the PST and educator during a nappy changing practice. We highlight the practices of both the educator and PST which helped the PST learn by being ‘stirred in’ to this common but unfamiliar practice for her and many other PSTs who may never have held a baby before. Implications call for cooperative and experienced educators who can support PSTs with pedagogical and practical elements of the practicum.

Assessment of salivary cortisol concentrations for procedural pain monitoring in newborns.

The study aimed to evaluate the usefulness of salivary cortisol (SC) for the assessment of procedural pain intensity in preterm and term newborns. Three groups of neonates (term, 370-416 weeks; moderate to late preterm, 320-366; and very preterm, <320) hospitalized in neonatal intensive care unit were assessed for the study. Response to nappy change, lung ultrasound (LUS), and blood sampling was analyzed. The intensity of pain was evaluated using continuous heart rate and blood oxygen saturation (SpO2) monitoring, Neonatal Infant Pain Scale (NIPS), and SC concentrations. Saliva samples were collected before and 20min after the procedure's end. Seventy-one infants were examined: 30 term, 21 moderate to late preterm, and 20 very preterm. SC has increased significantly in response to nappy change only in very preterm newborns (2.13ng/mL [1.55-3.68] vs. 2.84ng/mL [1.93-9.06], p=0.01). LUS did not affect concentrations of SC in any group. Significant increase in SC was observed after blood sampling in term and very preterm infants (2.2ng/mL [1.45-2.92] vs. 4.29ng/mL [3.88-5.73], p=0.002, and 1.88ng/mL [1.47-4.13] vs. 5.3ng/mL [3.42-8.02], p=0.002, respectively). A significant correlation between values of SC increase and NIPS scores was found (Spearman's rank correlation coefficient [rs]=0.31, p=0.001). We observed the increase in SC concentrations in response to painful stimulus. The presence of a correlation between NIPS scores and SC increase suggests that SC can be used as an objective parameter to assess pain in neonates.

Glucose variability increases during minimally invasive procedures in very preterm infants

The objective of this study is to assess the effect of neonatal procedures on glucose variability in very preterm infants. Preterm infants (≤ 32 weeks gestation and/or birthweight ≤ 1500 g) were started on continuous glucose monitoring (CGM) on day 2 of birth and monitored for 5 days. Minimally invasive (heel stick, venipunctures) and non-invasive (nappy change, parental presence) procedures were recorded. CGM data were analyzed 30 min before and after each procedure. The primary outcome was the coefficient of glucose variation (CV = SD/mean) before and after the procedure; SD and median glucose were also evaluated. We analyzed 496 procedures in 22 neonates (GA 30.5 weeks [29–31]; birthweight 1300 g [950–1476]). Median glucose did not change before and after each procedure, while CV and SD increased after heel prick (p = 0.017 and 0.030), venipuncture (p = 0.010 and 0.030), and nappy change (p < 0.001 and < 0.001), in the absence of a difference during parental presence.Conclusions: Non-invasive and minimally invasive procedures increase glucose variability in the absence of changes of mean glucose.What is Known:• Minimally invasive procedures - including nappy change - may increase neonatal stress in preterm infants.What is New:• Continuous glucose monitoring provides a quantitative measure of neonatal stress during neonatal care procedures demonstrating an increase of glucose variability.

698 mothers and babies, 38 390 nappy changes: what did we learn?

BackgroundSeveral industry funded studies between 2001–2018 have compared the use of a single brand of baby wipes to cleansing with water and either cloth or cotton wool during nappy changes. All of these studies found that wipes were safe and effective from birth. Recommendations from these studies have included the need for brand or formula comparison but to date, no previous study has done this.AimsThe ‘Baby skin integrity comparison survey’ (BaSICS) study was designed to compare three brands of baby wipes to determine if there was any difference in the incidence of irritant diaper dermatitis (IDD or nappy rash) during the first eight weeks of life.MethodsMothers who were allocated to a single brand of nappy but divided into three baby wipe allocation groups, collected and reported survey data on infant skin integrity during one nappy change daily with the use of a user-friendly smartphone application.FindingsAll brands of wipes were acceptable to mothers and safe and effective when cleaning during nappy changes. The brand containing the fewest ingredients showed a clinically significant advantage of fewer incidents of rash than the other two brands.ConclusionThis study demonstrated that wipe formulation is a significant factor in prevention or reduction of IDD during the first eight weeks of life.

The Recorded Interaction Task: A Validation Study of a New Observational Tool to Assess Mother-Infant Bonding.

Mother-infant bonding describes the early emotional connectedness between a mother and her infant. The quality of the mother-infant bond early in life is related to the subsequent quality of the child's attachment, the quality of further mother-infant interactions, and various other social outcomes across the child's life span. The Recorded Interaction Task (RIT) was developed to assess mother-infant bonding using observational methods in a naturalistic but standardized setting, thus addressing shortcomings of previous self-report tools. The RIT focusses on the common interaction between mother and infant (aged 2 to 5 months old), during a diaper (nappy) change. The interaction is video recorded and later assessed. The RIT must be validated before it can be used to assess mother-infant bonding in future research or in clinical practice. Face and content validity of the RIT were assessed by a panel of 6 experts in bonding and assessment of maternal and infant behavior. The RIT and self-reported Postpartum Bonding Questionnaire (PBQ) were administered to 15 mother-infant dyads with the correlation between their scores used to assess convergent validity. Acceptable face and content validity of the RIT was demonstrated. A weak correlation between the RIT and PBQ (r = -0.13) and their subscales (r = -0.22) were observed. A strong correlation between the RIT maternal behavior and infant behavior subscales was recorded (r = 0.69). The RIT appears to be a viable tool for the observational assessment of mother-infant bonding. Reliability testing and piloting will be required before the RIT can be used in future research or clinical practice.

OC09 - Early maternal contact has an impact on preterm infants' brain systems that manage stress.

Theme: Parenting/parenthood. Early maternal contact can protect the infants' brain from harmful effects of stress while deprivation increases the stress level and leads to increased sensitivity to stress. To evaluate the effects of continuous skin-to-skin contact (SSC) after preterm birth on stress. Late preterm infants from two neonatal care units were randomized to either SSC or standard care. Salivary cortisol was measured in response to a nappy change at one month, and again at four months in response to a still-face procedure. Infants randomized to SSC had a significantly lower salivary cortisol reactivity at one month and there was a correlation between the mothers' and the preterm infants' salivary cortisol levels at four months. The results show that close parental contact and human touch have a buffering effect on the infant's stress reactivity and stimulate a more rapid development of regularity.

The validity and reliability of the EValuation of INtervention Scale: preliminary report.

Pain management is a priority for infants receiving neonatal care as they undergo many necessary painful and stressful interventions, which are associated with negative short- or long-term consequences. This study aims to validate the content, and test the reliability, of the EValuation of INtervention Scale (EVIN), which is designed to evaluate the use of widely recommended nonpharmacological strategies to reduce neonatal pain and stress during procedures. The content of the EVIN was validated with multidisciplinary participation (N = 80), and consistency was established via observations on preterm infants (N = 12, at 31-34 weeks' gestation) during interventions in a neonatal unit. A revised scale was tested for inter-rater reliability with observations of invasive (blood sampling, N = 16) and noninvasive (nappy change, N = 18) interventions. The intraclass correlation coefficient (ICC) was used to determine inter-rater reliability. SPSS (PASW Statistics) version 18 was used for analysis. Very good intraclass correlation coefficients (>0.8) for both invasive (0.962) and noninvasive procedures (0.970) were achieved. These results indicate that the EVIN is suitable for the evaluation of nonpharmacological support during painful or stressful interventions.

Managing nappy rash

Approximately a quarter of infants develop nappy rash, which arises from the interaction between several mutually reinforcing factors. Three possible causes of nappy rash are: poor hygiene and skin care; sensitivity to detergents, fabric softeners and other external products; and infection. Once nappy rash develops, management aims to repair damage and prevent recurrence. The cornerstones of prevention and treatment are good routine skincare, frequent nappy changes, gentle cleansing and applying a barrier formulation at every nappy change. Candida albicans may cause moderate-to-severe nappy rash, for which topical antifungals may be appropriate. Brief courses of low-potency topical corticosteroids are suitable only when very inflamed dermatitis does not respond to other treatments. There is a need for further investigations of the pathogenesis (e.g. clarifying the role of C. albicans) and management of nappy rash, such as the relative efficacy of over-the-counter treatments.

Artrite Séptica Meningocócica Primária em Lactente de Dois Meses

Meningococcal septic arthritis, ocurring without signs of sepsis, is rare, including at pediatric age. The confinement of infection to a single articulation (monoarticular form) is even rarer in infections by Neisseria spp. We discuss the case of a two month-old caucasian girl, presenting with fever and persistent crying during nappy change. Absence of clinical sepsis was notable. She had had no previous anti-meningococcal immunizations. The ultrasound of the left hip revealed the presence of intra-articular fluid. Culture of the purulent sample after drainage by arthrotomy produced Neisseria meningitidis. She had a good clinical response to the antibiotics. Follow-up showed no sequels. Albeit a rare entity, primary meningococcal arthritis is a mandatory differential diagnosis concerning a feverish child with articular complaints.

A randomised trial of continuous skin-to-skin contact after preterm birth and the effects on salivary cortisol, parental stress, depression, and breastfeeding

AimTo evaluate the effects of almost continuous skin-to-skin contact (SSC) on salivary cortisol, parental stress, parental depression, and breastfeeding. Study designThis is a randomised study engaging families of late preterm infants (32–35weeks gestation). Salivary cortisol reactivity was measured in infants during a nappy change at one month corrected age, and in infants and mothers during still-face at four month corrected age. Both parents completed the Swedish Parenthood Stress Questionnaire (SPSQ) at one month and the Edinburgh Postnatal Depression Scale (EPDS) at one and four months. Ainsworth's sensitivity scale was used to control for parental sensitivity. SubjectsThirty-seven families from two different neonatal care units in Sweden, randomised to either almost continuous SSC or standard care (SC). ResultsInfants randomised to SSC had a lower salivary cortisol reactivity at one month (p=0.01). There was a correlation between the mothers' and the preterm infants' salivary cortisol levels at four months in the SSC group (ρ=0.65, p=0.005), but not in the SC group (ρ=0.14, p=0.63). Fathers in SSC scored lower on the SPSQ sub-scale spouse relationship problems compared to fathers in SC (p<0.05). ConclusionsAlmost continuous SSC decreases infants' cortisol reactivity in response to handling, improves the concordance between mothers' and infants' salivary cortisol levels, and decreases fathers' experiences of spouse relationship problems.

Newborn umbilical cord care in an Obstetric and Gynecology Hospital in Shanghai: a best practice implementation project

Background The umbilical cord stump may be a potential route for infection. There is still confusion regarding the best care of the umbilical cord stump, especially for new parents. This is highlighted by requests from new parents and midwives, and the need to improve umbilical cord care according to evidence-based practice. Objectives The purpose of this project is to evaluate the knowledge of new parents and nurses regarding evidence-based practice of umbilical cord care. Umbilical cord complications can be reduced by shortening the cord separation time, and also decreasing umbilical cord infection rates. This will lead to improved satisfaction rates for parents. Methods This project adopted a pre- and post-implementation audit approach. It utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The project utilized five audit criteria that are considered the best practice standards. Results The post-implementation audit findings revealed a significant improvement in staff and parent education, as well as the correct procedure for nappy change. Conclusion The introduction of an education program during the audit project improved umbilical cord care in the ward.

A 31 day old with head injury – developmental ‘milestones’ do not apply to everyone

<h3>Case history</h3> FD, a 36 week gestation well baby, presented from home after a head injury. During a nappy change, he had been positioned on a changing mat on top of a chest of drawers, one metre above a carpeted floor. He fell off the mat and was found lying on the floor, not losing consciousness. Developmentally, FD was reported to be a very active baby and parents believed he had ‘wriggled’ off the changing mat. They mentioned that FD had rolled from front to back previously. There was a boggy swelling 5 cm×8 cm in the left parieto-occipital region with no other bruising, injury or abnormality. He was not witnessed to be able to roll during initial assessment. Safeguarding protocols were followed as the mechanism of injury was not fully explained in a non-mobile infant. CT head revealed a left-sided parietal skull fracture associated with a subdural haematoma. No other parenchymal injury or stigmata of previous traumatic brain injury was seen. There were no retinal haemorrhages, other skeletal survey findings or blood test abnormalities. During his stay in hospital, the nursing and medical team witnessed (and digitally recorded) FD rolling from back to front: this is available for presentation and corroborated the parents9 history. <h3>Discussion</h3> Evidence shows that abusive and non-abusive skull fractures are commoner in younger infants and a recent meta-analysis calculated the overall probability that a skull fracture is due to abuse is 29%. Initial consensus opinion in FD9s case was that accidental head injury was very unlikely given his developmental age. This case highlights that normal developmental milestones do not apply to every child. The Denver II developmental screening test, constructed from 2,000 subjects, shows that a baby would not roll before two months. It is crucial in all cases to keep a non-judgemental attitude and be open to mechanisms of injury that seem unusual, particularly if there are Safeguarding concerns.

Maintaining healthy infant skin

Maintaining the health of a newborn's skin is an essential part of infant care and the choice of both nappies and hygienic nappy care play an important role in achieving this. The critical care points where compromise can occur are identified as the time the infant spends in a wet nappy (leading to mechanical, chemical and microbial trauma), the cleansing routine of the skin at nappy change time, the steps taken to preserve the skin's own defence mechanisms and control of infection through avoiding contamination of clothes, bedding and carers by faeces and urine. The purpose of fitting a nappy to an infant is to reduce the risk of clothes, bedding and carers becoming contaminated with faeces and urine and to help the baby's skin stay healthy by preventing soreness. However, great care needs to be taken to establish a routine to maintain skin health and hygiene whether at home or in a hospital setting.

Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age

Nappy dermatitis is a broad term used to describe an acute inflammatory reaction of the skin in the nappy area because of irritation from urine, faeces, moisture or friction. The prevalence is estimated to be between 7% and 35% in infants. Regular application of a barrier preparation at every nappy change may be a valuable component of nappy dermatitis prevention and/or treatment.

Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age.

Nappy dermatitis is a broad term used to describe an acute inflammatory reaction of the skin in the nappy area because of irritation from urine, faeces, moisture or friction. The prevalence is estimated to be between 7% and 35% in infants. Regular application of a barrier preparation at every nappy change may be a valuable component of nappy dermatitis prevention and/or treatment.

Is a nappy change stressful to neonates?

Objectives Infants in neonatal intensive care (NICU infants) are often cared for in a stressful environment that includes potentially painful or stressful interventions. The aim was to investigate whether NICU infants have different pattern of stress and pain responses than healthy newborns when challenged by a non-painful everyday care routine. Methods NICU infants born at 23–38 weeks gestation ( n = 39) were compared to healthy full-term newborns ( n = 30). Cortisol concentrations in saliva were determined before and 30 min after a standardised nappy change. The premature infant pain profile (PIPP) and the neonatal infant pain scale (NIPS) were evaluated before, during, directly after, 3 min after, and 30 min after the nappy change. The investigation was performed on two different occasions, first between postnatal days 2–7 and then between postnatal days 10–18. Results NICU infants had higher median baseline salivary cortisol levels compared to full-term newborns on both occasions (17.1 nmol/L vs. 6.2 nmol/L p < 0.01 and 8.5 nmol/L vs. 2.4 nmol/L p < 0.01, respectively). Salivary cortisol decreased in response to the second nappy change in NICU infants ( p = 0.01). NICU infants had higher PIPP scores during both nappy changes ( p < 0.001 for both occasions) and more sustained increases in PIPP and NIPS up to 30 min after the nappy changes compared to full-term newborns. Conclusions NICU infants have higher baseline salivary cortisol than healthy full-term newborns. There is a change in baseline cortisol by age in both groups. Full-term infants as well as NICU infants show an increased pain response to a standardised nappy change.

Skin conductance as a measure of pain and stress in hospitalised infants

Background Reliable and valid methods of measuring pain responses in infants continue to be sought as a means of evaluating the effectiveness of pain reduction strategies. Skin conductance has recently been shown to be a promising physiological indicator of pain and stress in premature and term infants. Aim To evaluate changes in skin conductance in hospitalised infants under different environmental conditions and during both painful and non-painful procedures. Methods Measurements of skin conductance activity were made in infants under three different environmental temperature conditions (open cot, incubator and overhead radiant heater), during the routine non-painful nursing procedure of either nappy change or oral feeding, and whilst undergoing the painful procedure of heel lancing for blood sampling. Results Skin conductance activity in 21 infants was studied on 43 separate occasions. Skin conductance activity was highly variable between infants but did not differ significantly under the three environmental conditions. Routine nursing care did not result in a significant increase in skin conductance activity above baseline; however, on cessation of care there was a significant reduction to levels below baseline ( p < 0.05). Conversely, during the heel lance procedure, skin conductance activity significantly increased upon lance ( p < 0.05) and remained elevated following completion of the procedure. There were no statistically significant differences between skin conductance activity changes from baseline as a result of routine nursing care compared to that of the heel lance procedure. Conclusion Due to large variability in skin conductance activity further studies are needed before this technology can be recommended as a clinically useful indicator of pain and stress in neonates.

Maintaining infant skin health and hygiene

Maintaining the health of a newborn's skin is an essential part of infant care and the choice of nappies and hygienic nappy-care plays an important role in achieving this. The critical care points where compromise can occur are identified as the time the infant spends in a wet nappy, leading to mechanical, chemical and microbial trauma, the cleansing routine of the skin at nappy change time, the steps taken to preserve the skin's own defence mechanisms, and control of infection through avoiding contamination of clothes, bedding and carers by soil and urine. There are factors common to infant care in both home and hospital although it is recognised there are added risks when many infants are cared for together.

189 Salivary Cortisol and Pain Profiles During Nappy Change in Neonatal Care.

Background: Infants in neonatal intensive care are exposed to an extremely stressful environment along with several potentially harmful or intrusive interventions as a part of their medical care. The aim of the present study was to investigate if infants exposed to neonatal intensive care have the same pattern of stress response as fullterm healthy infants. Methods: Infants in neonatal intensive care with gestational age range 23–38 w. (NICU) (n=34) and infants with congenital heart disease 36– 42 w. (CHD) (n=23) were compared to a group of healthy fullterm newborns (controls) (n=30). Salivary cortisol was measured at baseline and after a standardised nappy change. The premature infant pain profile (PIPP) and the neonatal infant pain scale (NIPS) were measured before, during, directly after, three minutes after and 30 minutes after the nappy change. The investigation was performed at two different occasions, on day 2–7 (1st) and on day 10–18 (2nd) respectively. Results: NICU and CHD infants had significantly higher cortisol than controls at 1st baseline. At the 2nd occasion all three groups had significantly lower cortisol compared to 1st occasion. NICU infants had a significant decrease in cortisol after their 2nd nappy change compared to baseline which was not seen at 1st occasion or in CHD infants and controls. All groups had a significant increase in pain scores during both nappy changes. The highest pain scores were found in NICU and CHD infants (p=0.000 and 0.008 respectively). The CHD infants had the shortest duration of response to the nappy change. The NICU infants had a prolonged increase in pain score that sustained until the three minutes measure point at 1st occasion and until the 30 minutes measure point at 2nd occasion. Conclusion: Infants exposed to neonatal intensive care (NICU and CHD infants) have a higher salivary cortisol during their first days of life than healthy fullterm infants. The NICU infants expressed a high and prolonged pain response to the nappy change. CHD infants on the other hand, expressed a high but shortlasting pain response to the nappy change. Our results show that infants exposed to neonatal intensive care have a different pattern of stress response than healthy fullterm infants.