Ask an answerable question (PICO)：
Bathing is a necessary nursing intervention during the hospitalization of preterm infants. In general, bathing is conducted using either tub bathing or sponge bathing. It has been observed that preterm infants often exhibit stress behaviors during bathing, such as crying, tension, furrowing of the brows, extending limbs, arching the body, and lifting legs in the air. In some cases, they may even experience hypothermia after bathing, which could lead to instability in vital signs and potentially affect future brain and neurological development.
Recent studies have proposed the use of swaddled bathing for preterm infants, prompting the authors to investigate whether swaddled bathing could stabilize the vital signs of preterm infants and reduce stress responses. Through a systematic review and appraisal, the authors aimed to explore the effectiveness of swaddled bathing in stabilizing vital signs and reducing the stress response.
The Method and Analysis of Literature Review：
This study followed the five steps of evidence-based medicine to define a clinical problem and analyze the current evidence. The PICO framework and key words were utilized for searching the literatures. We found a total of 27 articles from different databases, including the Airiti Library, PubMed, CINAHL, and the Cochrane Library. After removing 11 duplicates and reviewing the title / abstracts, nine articles were excluded. Upon examination of the full texts, three articles were excluded, including the subjects other than preterm infants (n=1), lacking vital signs as outcome measures (n=1), and inaccessible full text (n=1). Finally, two randomized controlled trials (RCTs) and two crossover trials were included for assessment.
Critical Appraisal：
The trials included in this study underwent quality assessment by two researchers using the 2019 version of the Cochrane Risk of Bias Tool 2.0 (RoB 2.0). The assessment yielded one trial with a low risk of bias, two trials with some concerns, and one trial with a high risk of bias. According to the Oxford Centre for Evidence-Based Medicine Levels of Evidence, the evidence level for all trials was rated as Level 2.
Clinical Application of Evidence：
This systematic review included a total of four trials (188 preterm infants) that used swaddled bathing as the intervention. The meta-analysis found that compared to a non-swaddled bath, the preterm infants receiving a swaddled bath showed no significant difference in heart rate and oxygen saturation at 10 min after bathing. The preterm infants receiving a swaddled bath had a higher body temperature (mean difference [MD] 0.24°C; 95% CI, 0.04 ~ 0.44; I² = 93%) and a shorter crying time during bathing (MD 58.09 seconds; 95% CI, -71.79 ~ -44.39, I² = 0%) compared to those receiving a non-swaddled bath.
Swaddled bathing involves wrapping preterm infants in a towel, keeping their limbs flexed midline. After cleansing the face and head, the infant is gently placed into the bath, ensuring the buttocks and feet touch the bottom. Each body part is then sequentially cleaned. During bathing, only the area being cleaned is exposed, and the towel is removed after all areas are washed. Following the steps of evidence-based knowledge translation, a protocol was developed for implementing the evidence-based intervention. After obtaining consensus from unit supervisors and the health provider team, the evidence-based protocol for swaddled bathing was initiated. The control group received conventional bathing without swaddling, following the same procedure as the swaddled bathing group.
A single-group crossover trial design was adopted, in which each preterm infant underwent both bathing methods. Initially, they received conventional bathing for three consecutive days, followed by three consecutive days of swaddled bathing. Measurements of body temperature, heart rate, oxygen saturation, and crying duration were recorded immediately before bathing, immediately after bathing, and ten minutes after bathing in both groups. Data were collected and statistically analyzed using Mann-Whitney U test using SPSS 18 software.
Evaluation of Effectiveness：
Between March 13th and March 31st, 2023, a total of eight preterm infants (four female and four male) were enrolled. Results indicated no statistically significant differences in heart rate, oxygen saturation, and body temperature between the two groups before bathing, as well as in heart rate and oxygen saturation ten minutes after bathing. However, the swaddled bathing group exhibited significantly higher body temperatures immediately after bathing and ten minutes after bathing compared to the conventional bathing group (37.00 ± 0.21℃ vs. 36.78 ± 0.21℃; 36.89 ± 0.24℃ vs. 36.62 ± 0.16℃) (p-values < .05). Additionally, the swaddled bathing group had a shorter crying time during bathing compared to the conventional bathing group (1.46 ± 2.55 seconds vs. 8.42 ± 13.02 seconds), which was also statistically significant (p = .038). The preterm infants bathed using the swaddled bathing method exhibited more stable body temperatures after bathing and shorter crying durations during bathing, suggesting potential benefits in reducing stress responses induced by bathing in preterm infants.
Conclusions and Recommendations：
Swaddled bathing is a gentle, feasible, and safe intervention measure. This study confirmed that swaddled bathing could not only contribute to stabilizing the body temperature of preterm infants but also reduce their crying durations and stress behaviors. According to this result, we suggested swaddled bathing as a routine practice in neonatal wards. Additionally, this practice could be one part of the discharge plan for preterm infants. Families should be taught this bathing method to comfort their preterm infants and to keep them feeling safe during bathing. This measure might also keep their family members from feeling overwhelmed by reducing their babies’ stress reactions, such as nervousness or crying, during bathing. Furthermore, the family might get more confidence and benefits in caregiving and establishment of parent-child relationships.
