Effect of Kangaroo Care Following Immersion Bath on Body Temperature in Preterm Neonates

Introduction

Preterm neonates in the neonatal intensive care unit (NICU) are open to the elements of different stressors such as painful procedures, interrupted sleep, unnecessary noise and light levels, and separation from the mother. One of the aspects of routine care in a stable preterm in ward is bathing. Bathing can be a significant factor influencing successful extra uterine transition and parental bonding during the early neonatal period. Immersion bathing, sponge bathing, and swaddle bathing are some of the different techniques which are used in bathing preterms. However, bathing has been shown to cause hypothermia, pain, and stress in the post bath period. Studies have also recommended postponing the first bath ¹ and also reducing the bathing frequency ² to once in 96 h to prevent these complications. The effect of different bathing techniques on the physiological variables and infant behavior have also been studied.^{3, 4}

Kangaroo mother care (KMC), first developed by Rey and Martinez, is defined as an early, continuous, and prolonged skin to skin contact between the newborn and the mother. ⁵ It has been proven to be an effective way to maintain thermoregulation. KMC also reduces the risk of severe illness, nosocomial infection, and length of hospital stay and also contributes to growth, breastfeeding, and mother-infant attachment.^{6, 7}

To deal with this problem of hypothermia post bathing, we hypothesized that providing KMC after bath may help in better thermoregulation. The aim of this study was to compare body temperature variations following KMC as compared to standard care of wrapping the baby in cloth following immersion bath in stable preterm neonates in the postnatal ward.

Materials and Methods

This was a prospective nonrandomized interventional study done in the postnatal ward of a tertiary care hospital from November 2018 to September 2019 after approval from the institutional ethics committee. Preterm neonates in the postnatal ward with corrected gestational age between 34 weeks and 37 weeks and beyond the seventh day of postnatal age with weight between 1500 and 2000 g at the time of enrollment were included in the study after written informed consent from the parents. Preterm neonates with major congenital anomalies, chromosomal abnormalities, neurological disorders, those on IV fluids, inotropes, and antibiotics and other sick neonates such as sepsis, meningitis, were excluded from the study.

The neonates were breast-fed half an hour prior to the bath. The investigator checked the physiological parameters 10 min before bath and then checked whether the neonate was wet with urine or stool. When the preterm newborn was wet, the neonate was cleansed at the bedside, weight and temperature were checked before bath, the neonate was received with an autoclaved thick, soft towel, and eye care was performed from inner canthus to outer canthus by one stroke using separate swabs for each eye.

Neonates received immersion bath in a tub using water temperature adjusted to 98.6°F to 100.4°F (37–38°C) by a trained nurse (trained by investigator) under the supervision of investigator. Neonate was undressed, immersed till neck. Pattern of bath was the trunk, genitalia, and limbs followed by head and neck. The entire procedure was completed in 2 min following which neonates were immediately dried with sterile gauze. On the first day of the study, after immersion bath, the neonate was wrapped with a clean cloth (standard care). On second day of the study, the same neonate after immersion bath, was dried with a towel and was given KMC for one hour instead of being wrapped in a cloth. Thus each newborn served as his/her control and intersubject variability and effect of covariates was taken care of. Axillary temperature was recorded before and immediately after bath and subsequently at 15 min, 30 min, 45 min, and 60 min after bath. Blinding could not be done due to the nature of intervention.

Results

Of the 38 preterm neonates, 23 (60.5%) were males. The mean (SD) birth weight of the newborns was 1656 (275) g with a range of 960 to 2200 g. The mean weight (SD) of the newborns at the time of enrollment into the study was 1677 (175) g. There were 25(65.8%) newborns with a weight between 1500 and 1750 g and 13 (34.2%) between 1751 and 2000 g. The newborns had a gestational age ranging from 30 to 36 weeks 5 days at the time of birth with a mean gestational age of 33 weeks.

In the standard care group, the mean difference from the baseline temperature before and immediately after immersion bath was 0.1°C showing that there was rise in temperature immediately after bath. At 15- and 30-minutes post bathing a difference in temperature of –0.06°C and 0.12°C from the mean baseline value was noted, though it was not statistically significant. Further at 45 min and 60 min after bath there was a rise in body temperatures with a mean difference of 0.22°C and 0.35°C, respectively, from baseline, both of which were found to be statistically significant (p < .05) (Table 1).

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Table 1.

Comparison of Mean Axillary Temperature in Standard Care and Kangaroo Mother Care by Immersion Bath Type at Different Time Intervals.

Study Time Point	Standard Care (n = 38)		Kangaroo Care(n = 38)		Mean Diff	SE Diff	95% CI	t Value	P Value
	Mean	SD	Mean	SD
Baseline	36.27	0.46	36.47	0.28
Immediate	36.36	0.42	36.44	0.36	0.076	0.089	–0.103 to 0.255	0.845	.401
15 min	36.32	0.37	36.45	0.31	0.125	0.078	–0.030 to- 0.281,	1.608	.112
30 min	36.39	0.36	36.59	0.29	0.200	0.074	0.051 to 0.349	2.678	.009
45 min	36.49	0.3	36.74	0.24	0.251	0.061	0.128 to 0.374,	4.078	.000
60 min	36.61	0.26	36.8	0.24	0.187	0.057	0.073 to 0.301	3.279	.002

In the KMC group, there was no significant difference in the mean temperature between prebath, immediately after and 15 min after bath. However, the mean difference from baseline temperature at 30 min, 45 min, and 60 min post-bath was 0.12°C, 0.27°C, and 0.33°C, respectively, all of which were found to be statistically significant (p < .05) (Table 1).

On comparing the 2 groups, although the baseline temperature was higher in the KMC group, it was observed that the mean temperature difference from the baseline at 30 min, 45 min, and 60 min postbath was 0.2°C, 0.25°C, and 0.19°C, respectively, all of which were statistically significant (p < .05) (Table 1). Hence, it was noted that the neonates receiving KMC had consistently higher temperature as compared to neonates who received standard care. There was no evidence of harm noted in the intervention group.

Discussion

Maintaining thermoregulation in preterm newborns is an important aspect of nursery care in the postnatal period. Routine bath is an essential nursing procedure in order to remove contaminants, waste material, creams, and emollients from the skin and reduces microbial colonization. However, it is a stressful procedure and the newborns are also prone to hypothermia in the postbath period. KMC is a well-established practice for preterm thermoregulation. Ensuring adequate thermoregulation in the postbath period can also contribute to better weight gain and prevent complications due to hypothermia. A study conducted by Bera A et al ⁹ on effect of KMC on vital physiologic parameters showed improvement in temperature maintenance (mean temperature increased by 0.4°C) following KMC in low-birth-weight newborns. The role of KMC in the postbathing period has not been assessed. We attempted to study the benefit of KMC as a means to solve the problem of hypothermia faced by the preterm neonates following bath.

Many studies have assessed the temperature variation soon after the different bathing technique. In a study by Henningsson et al, ¹⁰ sponge bath made the baby uncomfortable with increased heat loss, mostly through evaporation. During tub bathing neonates were calmer, quieter, and more comfortable. Rectal temperature fell in 40 of 98(41%) infants in tub bath group and in 66 of 88 (75%) neonates cleaned with towel immediately after bathing. This difference was statistically significant (P < .001). According to a study by Anderson et al, ¹¹ immersion bath had a difference in temperature of 0.2 + 0.5 ^°F between prebath and immediately postbath which was statistically not significant (P value .1453).

Studies^{3, 4} comparing tub bathing with sponge bath in late preterm neonates has shown the former to be having lesser variability in temperature with neonates being warmer at 10- and 30-min post bath and also being more comfortable. An RCT ³ comparing swaddled bathing with conventional bathing also concluded that mean temperature loss as well as the crying time was significantly less in the former. So, immersion bathing has been shown to be better in maintaining stability in temperature.

A study ⁸ on effect of KMC versus standard care on preterm neonates after sponge bath showed that with standard care there was a fall in temperature at 15 min and slow rise by 30 min till 60 min, whereas in KMC group temperature started rising immediately after KMC was provided which was significant. Our study also showed similar results with the KMC group being significantly warmer than the control group at 30, 45 min postbath.

This is the first study comparing standard care with KMC following immersion bath. Our study has certain limitations. One of the most important limitation is that the study was not a randomized study. Second, the sample size was small. Third, the study was done in controlled temperature; hence, these changes cannot be generalized for any seasonal variation. Also the baseline temperature was higher in the KMC group to begin with. Another limitation is that KMC was given on second day and hence that group would have the advantage of skin maturity. We studied only the short term effects of KMC following bathing on temperature regulation. Its long-term effects on weight gain could also be a potential area for research. Further studies with randomization and using a larger sample size would help in better generalizability of the results. Also, other aspects such as neonatal comfort, weight gain could also be studied along with temperature regulation.