Ksenia Zukowsky, PhD, APRN, NNP-BC ❍ Section Editor

Clinical Issues in Neonatal Care

Bathing and Beyond

Current Bathing Controversies for Newborn Infants
Carolyn Lund, MS, RN, FAAN
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ABSTRACT
Background: Bathing the newborn infant is controversial, ranging from how and when to give the newborn their first
bath, whether to bathe newborns at all in the initial days of life, and how to approach bathing the hospitalized premature
and full-term infant in the neonatal intensive care unit (NICU).
Purpose: To review relevant literature about bathing newborn infants, as well as examine the controversies about bath-
ing NICU patients including the use of daily chlorhexidine gluconate (CHG) baths.
Findings: Despite studies showing that temperature can be maintained when the first bath was at 1 hour after delivery,
there are benefits from delaying the bath including improved breastfeeding. Tub or immersion bathing improves tem-
perature, and is less stressful. It is not necessary to bathe infants every day, and premature infants can be bathed as little
as every 4 days without an increase in skin colonization. No differences have been reported in skin parameters such as
pH, transepidermal water loss, and stratum corneum hydration whether the first and subsequent baths are given using
water alone or water and a mild baby cleanser. Concerns about systemic absorption suggests caution about widespread
practice of daily CHG bathing in the NICU until it is known whether CHG crosses the blood–brain barrier, particularly in
premature infants.
Implications for Practice and Research: Research regarding bathing practices for NICU patients should be evidence-
based whenever possible, such as the benefits of immersion bathing. More evidence about the risks and benefits of daily
CHG bathing is needed before this practice is widely disseminated.
Key Words: bathing, chlorhexidine gluconate, newborn infant, premature infant, skin microbiome, skin pH, stratum
corneum hydration (SCH), transepidermal water loss (TEWL)

T
here is controversy about when and how to Practice Guideline, developed by the Association of
bathe newborns infants, ranging from how Women’s Health, Obstetric and Neonatal Nurses
and when to give the newborn their first bath, (AWHONN), recommends giving the first bath
whether to bathe newborns at all in the initial days when thermal and cardiorespiratory stability has
of life, and how to approach bathing the hospital- been achieved, proposing it ideal to wait at least 2
ized premature and full-term infant during their neo- hours after delivery.2 The National Institute for
natal intensive care unit (NICU) stay. This article Health and Clinical Excellence (NICE) with the Col-
reviews relevant literature in regard to these topics, laborating Centre for Primary Care in the United
as well as discuss daily bathing with chlorhexidine Kingdom3 advises that the bath and other treatments
gluconate (CHG) for infants in the NICU. be initiated no sooner than 1 hour after birth, so that
maternal–infant contact is not interrupted. The
FIRST BATH World Health Organization (WHO)4 recommends
delaying the bath for 24 hours, or if this is not pos-
There is ongoing debate about when the first bath sible due to cultural reasons waiting at least 6 hours,
should be given, and even whether to bathe the new- in an effort to prevent hypothermia especially in
born at all.1 There are currently a range of recom- developing countries.
mendations for when the first bath should be given. A number of studies have documented the safety
The Neonatal Skin Care Evidence-Based Clinical of bathing the full-term newborn in terms of pre-
venting hypothermia as early as 1 hour of age, as
long as the infant’s initial axillary temperature is
Author Affiliation: Neonatal Intensive Care Unit, UCSF Benioff
Children’s Hospital Oakland, Oakland, California. 36.8°C or higher, and appropriate care is taken to
Previous source of support: Recipient of an investigator-initiated grant support thermal stability such as maintaining a
from Johnson & Johnson Consumer Co Inc, to study the impact of the higher ambient room temperature, and using radiant
newborn’s first bath on skin barrier function and the skin microbiome.
warmers and warming blankets to wrap the infant in
The author declares no conflict of interest.
following the bath.5-7 Much of the motivation for
Correspondence: Carolyn Lund, MS, RN, FAAN, Neonatal Intensive
Care Unit, UCSF Benioff Children’s Hospital Oakland, 747 52nd St, these studies was to permit healthcare professionals
Oakland, CA 94609 ([email protected]). to dispense with using gloves, which are standard
Copyright © 2016 by The National Association of Neonatal Nurses precautions to protect from diseases transmitted via
DOI: 10.1097/ANC.0000000000000336 amniotic fluid and blood. A study in Uganda showed

Advances in Neonatal Care • Vol. 16, No. 5S • pp. S13-S20 S13

Copyright © 2016 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
S14 Lund

that bathing at 1 hour of age resulted in a significant surface and improved development of skin surface
increase in hypothermia despite the use of skin-to- acidification, despite bathing with warm water and
skin care after the bath.8 A large observational study liquid baby cleanser. In another study, bathing with a
in the Philippines found that routine newborn care liquid baby cleanser did not remove host defense pro-
practices including bathing delay thermoregulation teins on newborn skin, including lysozyme.16
and initiation of breastfeeding.9
Finally, a study from Japan reported that bathing Technique
the newborn as early as 2 to 5 minutes after delivery The optimal technique for administering the first
not only was safe, but resulted in a significantly bath is also debated. Techniques used include sponge
higher temperature 30 minutes after the bath, com- bathing with a small tub such as those provided in
pared with the control group who were not bathed.10 the hospital, or a large tub or immersion bathing.
In Japan, early bathing is traditional. “Mokuyoku,” Immersion bathing places the infant’s entire body,
the term used to describe this practice, has been per- except the head and neck, into warm water
formed routinely for many years, and the authors (37.8°C-38.8°C), deep enough to cover the shoul-
sought to study the effects of this cultural practice on ders. Studies involving more than 1000 newborns
hypothermia. Babies delivered by cesarean section, report that tub or immersion bathing, compared
or those with asphyxia or prematurity are excluded with sponge bathing, maintains temperature better,
from early bathing. This study is an example of how causes less crying and distress for the infant, and
cultural traditions may influence bathing practices, does not result in increased infection, even with the
although the opportunity to educate providers and umbilical cord in place (Table 1).17-21 In a study of
parents may change this over time. 100 late preterm infants (35-36 6/7 weeks’ gesta-
Yet, there are circumstances, such as heavy meco- tion) randomized to immersion tub bathing or
nium staining, excessive blood, or chorioamnionitis, sponge bathing after 24 hours of life, infants had
which necessitate earlier bathing once physiologic sta- overall higher temperatures and less variability in
bility is achieved, as it is important to many parents body temperature when immersion tub bathed.22
that visible debris be removed from their infant after
the birth process. However, standard of care for both Bathing and Skin Colonization
vaginal and cesarean section birth is to delay the first Another aspect of bathing is how the bath may influ-
bath, to allow the infant to transition to extrauterine ence skin colonization with microorganisms. For
life with emphasis on maternal–infant bonding and many years it was thought that the skin of the fetus
increased success with breastfeeding, thereby offering was sterile unless there was premature rupture of
substantial benefits to both infant and parents.11,12 membranes. However the Human Microbiome Proj-
Early bathing after delivery is in conflict with the ect has changed how we look at microorganisms in
WHO and AWHONN skin care guidelines, which general, as the totality of microbes and their DNA
recommend leaving residual vernix caseosa intact that exist in various “habitats” of the human body
and allowing it to wear off with normal care and han- are examined. Consequently, our understanding of
dling.2,4 Vernix caseosa, a protective fetal film, acts as the commensal or “good” bacteria that inhabit the
a chemical and mechanical barrier in utero, with the body and that an imbalance of microorganisms can
thickest coating accumulating between 36 and 38 lead to disease.23 Newborn skin after delivery con-
weeks of gestation. In the past, bathing was often ini- tains a variety of microorganisms, and is to some
tiated early to remove this substance, but the reten- extent determined by the type of delivery, vaginal or
tion of vernix has been shown to have benefits in the cesarean section. Vaginally delivered newborn skin
immediate postbirth phase. Benefits include protec- contains bacterial “communities” that resemble the
tion from infection, improved skin barrier function, mother’s vaginal flora, whereas cesarean section
skin cleansing and moisturizing, development of the newborns’ skin microbiota reflects skin flora.24
acid mantle, and protection from the activity of host Although we do not fully understand how the new-
defense proteins important in innate immunity.13-15 born’s skin develops following delivery, the assump-
There is also a misconception that bathing removes tion is that vaginal delivery would afford the infant
the benefits of vernix caseosa on skin adaptation fol- normal skin colonization. More cesarean section
lowing delivery. In a study of vernix and skin adapta- delivered infants were seen in the emergency depart-
tion, the amount of skin covered by vernix in 430 new- ment with MRSA infections on their skin in two
borns varied according to gestational age, reflecting reported series.25 However, whether this was due to
natural detachment as the fetus reaches 40 weeks’ ges- differences in skin colonization, length of hospital-
tation.13 Two cohorts were categorized at birth, the ization or the use of antibiotics is not known. Recent
first with vernix covering 48% or more of the skin research attempted to “inoculate” the skin of infants
surface and the second with vernix covering 26% or born by cesarean section with their mother’s vaginal
less; infants were bathed around 2 hours of age. Sub- flora. A sterile gauze was placed in the vaginal tract
jects with 48% or more vernix had more hydrated skin for 1 hour before the delivery and used to swab the

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 Newborn Bathing S15

TABLE 1. Studies Comparing Sponge to Tub (Immersion) Bathing for the First Bath
Study
Study Method Population Intervention Primary Outcomes
Hennigsson Cohort study 232 healthy bathing (tub) Rectal temperature decreased in more
et al20 full-term vs washing infants with sponge bath compared
newborns (sponge bath) with tub bath (P < .001), more
infants cried with washing (sponge)
bath
Clinical signs infection, bacterial colo-
nization of umbilical cord same in
both groups
Hylen Cohort study of 618 healthy Bathing (tub) Fewer infants had drop in temperature
et al19 2 wards in the newborns vs washing with bathing (tub); P < .001
same hospital (sponge bath) Fewer infants cried with bathing (tub);
P < .001
No difference in bacterial colonization
of umbilical cord
Anderson Pre- and postbath 20 healthy Immersion bath Prebath temperature 36.8°C vs 37.6°C
et al18 axillary newborns postbath, not significantly different
temperatures (P = .1453)
Cole et al17 RCT 20 healthy Tub vs sponge 9/10 of sponge-bathed infants had
newborns bath drop in temperature, fussed and
cried
10/10 of tub-bathed infants main-
tained or increased temperature
(within normal range), 7/10 were
drowsy
Umbilical cord looked same
Bryanton RCT 102 healthy Tub vs sponge Tub-bathed infants had less tem-
et al21 newborns bathing perature loss (P = .00), were more
content (P = .00) compared with
sponge-bathed infants. Mothers
rated their pleasure with the bath
higher with tub bathing (P = .00)
No difference in cord healing or infec-
tion
Loring RCT 100 late-preterm Tub vs sponge Tub vs sponge bath given 24 h after
et al22 infants bathing delivery; tub-bathed had less varia-
bility in body temperature and were
warmer at 10 and 30 min compared
with sponge-bathed (P = .024)
Abbreviation: RCT, randomized controlled trial.

infant at specific anatomic locations following deliv- a mild cleanser that has a neutral or slightly acidic
ery.26 The microbiome of the skin, anus, and oral pH to assist in the removal of blood and meconium,
cavities were partially restored, resembling the as water alone may not easily remove some lipid-
mother’s vaginal microbiome. soluble substances such as meconium. NICE guide-
How bathing impacts the development of the lines in the United Kingdom advise against adding
microbiome is not fully understood. Yet, one consid- cleansing products or lotions to the bath water
eration is whether the first bath should be given with directly, but that a mild, nonperfumed soap can be
water alone or with a mild baby cleanser be used. used.3 For premature infants younger than 32 weeks,
One study found that bacterial skin colonization warm water only is the recommendation,2 although
increased over time, but there were no differences in there are no studies to date for this population.
colonization with the first bath when water alone
was used versus water and a mild soap.27 However, ROUTINE BATHING IN NICU PATIENTS
this study was done using standard bacterial culture
techniques, and may not reflect the overall skin Many issues surround determining the optimal fre-
microbiome. The Neonatal Skin Care Guidelines2 quency of bathing and best techniques for adminis-
recommends using warm tap water with or without tering the bath for hospitalized neonates. This

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S16 Lund

population can range from full-term infants with position using a soft blanket or cloth, and then gen-
illness, infection, or the need for surgical interven- tly immersed in a tub of warm water. This method
tions to extremely low birth-weight premature prevents some of the intense motor reactions to
infants. being unclothed or placed in water, and can be ben-
eficial not only for premature infants but also for
Bathing and Barrier Function larger newborns for routine or even the first bath.44
Knowledge about the impact of bathing on neonatal Teaching parents swaddled and tub bathing for their
skin barrier function as measured by parameters such as babies in the NICU can be a very rewarding experi-
skin surface pH, transepidermal water loss (TEWL), ence, with the goal of providing bathing and skin
and stratum corneum hydration (SCH) are important to care an integral part of the parental role in this set-
inform practice. Bathing has the potential to alter the ting (Figures 1 and 2).
development of the acid mantle of the skin. On the first
day of life, the term newborn’s skin surface pH is more Post Bathing
than 6.0, falling to less than 5.0 during the first weeks of Following the bath, some nurses and parents will
life.28-30 One study in premature infants found that the apply an emollient to the skin. Yet, there is little con-
skin developed an acidic surface, reaching a pH of 5.5 at sensus to date about the routine use of emollients for
the end of the first week, and 5.0 by the end of the first full-term newborns.45 One study reports improved
month. However, the study did not report the skin care skin parameters in healthy full-term infants when
practices used during this time.31 Once the acid mantle the skin care regime included “baby cream” emol-
of the skin surface is established, bathing can transiently lient after bathing, and did not adversely affect bac-
alter the skin pH, even with water alone, in older infants terial skin colonization.35 Pilot studies have been
and adults with sensitive skin.32,33 Bathing 2 to 3 times initiated to determine whether routine emollient
per week with cleansers compared with water alone has therapy immediately following the bath may benefit
been shown to have little or no difference on skin pH, infants at risk for the development of atopic derma-
TEWL, and SCH in the neonatal period in full-term titis,46 and larger trials are being proposed.
healthy infants.34-36 Similar studies involving measuring For premature infants, emollient use has been
skin parameters have not been performed in hospital- reported to be beneficial,47,48 but in a large random-
ized neonates, or in premature infants. ized, controlled trial there were more bloodstream
infections for infants less than 750 g when an emol-
Stress and Bathing Frequency lient was applied prophylactically twice daily,
Sponge and tub bathing in premature infants can unrelated to bathing, for the first 14 days of life to
negatively impact physiologic parameters such as infants less than 1000 g at birth.49 Yet, there contin-
heart rate, oxygenation, and behavioral cues indicat- ues to be an interest in the use of emollients in pre-
ing distress with.37-40 Because of the concern about mature infants, especially in developing countries
the stress on premature infants during bathing, stud- where infant massage with oils is traditionally used.50
ies evaluated the impact of bathing with a mild
cleanser every 2 versus 4 days on skin colonization ANTIMICROBIAL BATHING
and pathogenic bacteria.41,42 An initial decrease in
bacterial skin colonization was noted, but peaked at Although bathing with antiseptic cleansers for the
48 hours and remained stable between 48 and 96 first or subsequent baths are not currently
hours after bathing. Another study reported a
decrease in skin colonization in premature infants of
28 to 35 weeks’ gestation with coagulase-negative FIGURE 1
Staphylococcus at 30 minutes following the bath,
regardless of whether the bath was given with water
alone or water and liquid soap and water.43 Based on
these studies, it does not appear that decreased bath-
ing frequency in premature infants leads to an
increase in skin colonization, and the use of bathing
products or water does also not increase skin colo-
nization with coagulase-negative Staphylococcus.
Therefore, less frequent bathing is recommended as
it subjects premature infants to less physiologic and
behavioral stress.2
The role of immersion bathing using a swaddling
technique to reduce stress during bathing may also
Developmental specialist assisting a mother with a
benefit the hospitalized premature infant. Using this swaddled bath in the NICU.
technique, the infant is swaddled in a flexed, midline

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 Newborn Bathing S17

bloodstream infections. Daily CHG bathing in adults

FIGURE 2 has been shown to reduce hospital-acquired infections
in intensive care unit settings.58,59 However, other
studies have reported that this intervention has not
been beneficial in reducing bloodstream infection.60,61
A large trial in pediatric intensive care units in 5
US hospitals reported a 36% reduction in bactere-
mia in patients receiving daily CHG bathing.62 This
study utilized a cluster-randomization strategy by
type of unit (cardiac, medical, or surgical); in each
hospital there was 1 unit that used the CHG bathing,
and 1 that used soap and water baths. They report
results of both the “intention to treat” (ITT) and
“per protocol” (PP) populations. The ITT group
included all eligible patients (older than 2 months,
ICU stay predicted to be >2 days). The PP group
was half the size of the ITT group, with patients
excluded for length of stay less than 2 days, if par-
ents either refused to consent to CHG bath or were
not available to give consent. In the ITT group, the
risk of bacteremia did not differ compared with
standard bathing practices, but the PP group (64%
of the study population) showed significantly fewer
infections. It is important to note that infants
younger than 2 months were not enrolled due to the
Mother unwrapping her premature infant during FDA exclusion of this population at the time of the
swaddled bath.
study. The median time of treatment was 3 days,
with a range of 1 to 119 days, and the average age
was 4 to 6 years, but a small number of infants 3
recommended by the American Academy of Pediat- months and older were included. One percent of the
rics and the American College of Obstetrics and children experienced skin irritation.
Gynecology51 or the Centers for Disease Control and CHG bathing with a 2% CHG-impregnated wipe
Prevention,52 there has been renewed interest in anti- in an NICU was undertaken in a quasi-experimental
microbial bathing, particularly for hospitalized new- design, comparing a historical cohort to one receiv-
borns and for full-term newborns in developing ing the CHG intervention.63 Infants with a birth
countries. A systematic review of the efficacy and weight less than 1000 g who were younger than 28
safety of whole body skin cleansing with CHG in days old did not receive a CHG bath. Infants more
neonates included 9 studies in developing countries, than 1000 g received the CHG bath twice weekly,
and found that there was no benefit in terms of neo- every other day, or daily depending on their birth
natal sepsis or mortality after a single bath with weight and postnatal age. The incidence of central
either liquid CHG or a CHG wipe,53 which is disap- line-associated bloodstream infections (CLABSIs)
pointing given the early positive results with this was reduced from 6/1000 central venous catheter
intervention.54,55 (CVC) days to 1.92/1000 CVC days, although the
Studies on the effect of CHG bathing on skin colo- rate for the excluded infants (<1000 g, <28 days)
nization report that there is decreased colonization was not reduced. In addition, during the study
with Staphylococcus aureus in full-term newborns period there were fewer catheter device days, per-
24 hours after a bath with 0.25% CHG compared haps reflecting a change in practice to more aggres-
with using a baby cleansing product.56 Bathing pre- sively removing CVCs, or perhaps fewer catheter
mature infants of 28 to 36 weeks, 1000 to 2000 g days because they had fewer CLABSIs. There were
with 0.25% CHG compared with bathing with nor- no reports of skin irritation.
mal saline or not bathing at all resulted in a decrease One of the greatest concerns regarding CHG bath-
in skin colonization in the axilla, but not in the groin.57 ing in neonates is the potential for systemic absorp-
Infants tolerated the CHG bath without hypothermia tion and toxicity due to a notable historic “error in
or skin irritation and there was a decrease in coloniza- neonatology.”64 In the 1950-60s, there was wide-
tion at 24 hours, but not at 48 hours. spread use of another antimicrobial agent, hexachlo-
CHG bathing for patients hospitalized in intensive rophene (HCP), to reduce infections with S. aureus.
care units has recently become of great interest in the In 1973, the Mortality and Morbidity Weekly
prevention of hospital-acquired infections, especially Report65 released crucial information about the

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S18 Lund

absorption of HCP and subsequent findings of vacu- premature infants. In addition to concerns of poten-
olation of brain tissue, called “spongioform myeli- tial toxicity from absorption, the effect of antimicro-
nopathy,” that was present on autopsy in premature bial cleansing on skin colonization with microorgan-
infants less than 1400 g, with the exposure of HCP isms and on the healthy microbiome of the skin in
bathing 3 times or greater. A later study indicated infancy is unknown.
that infants less than 1750 g were also found to have
this pathologic condition, particularly if they lived CONCLUSION
longer than 22 days and were thus exposed more
often.66 In this study, 2 infants with spongioform Reviewing the evidence about newborn bathing prac-
myelinopathy also had infections in the brain, one tices highlights a number of important clinical prac-
with candida and the other with Escherichia coli. tices. Although the healthy full-term newborn can be
Absorption of CHG was first reported in 1973; bathed as early as 1 hour after delivery without hypo-
preterm and term infants had detectable amounts of thermia, there are potential benefits to delaying the
CHG in the blood after an initial bath with CHG, and bath although the optimal time is not clear. The ben-
daily bathing.67 This finding was difficult to interpret eficial effects of tub or immersion bathing for the first
because the samples were obtained via heel stick and and subsequent baths include improved maintenance
therefore they may have been contaminated because of normothermia, less crying and stress, and increased
CHG clings to the cells of the stratum corneum even parental satisfaction. Premature infants also may find
after rinsing. A more recent study of CHG antisepsis tub bathing less stressful, especially if swaddled while
for central-line placement in infants more than 1500 g being placed in the tub.
found that 7 of the 10 infants who had levels obtained For routine bathing both water alone and water
after initial skin preparation and weekly antisepsis and mild baby cleansing products have similar effects
with dressing changes had detectable CHG concen- on physiologic skin parameters such as pH, TEWL,
trations, ranging from 13 to 100 μg/L.68 In another and SCH. Using an emollient immediately following
study, 10 of the 20 premature infants (mean gesta- the bath may improve skin barrier function for
tional age 28 weeks) had detectable levels of CHG, selected infants, especially those at risk for atopic der-
ranging from 1.6 to 206 μg/L after one limb was matitis. For a number of reasons, it is not necessary to
“washed” with 2% aqueous CHG before placement bathe newborns more than two to three times per
of a central venous catheter.69 week. Premature infants in particular can experience
Because of concerns about potential neurotoxic- physiologic and behavioral stress during bathing, and
ity, a laboratory study was undertaken by the can be bathed as little as every 4 days without
National Institutes of Health.70 Neurotoxicity was increased skin colonization with microorganisms.
assessed using an established in vitro model of neu- Daily bathing with CHG has been shown to
rite cells exposed to both CHG and HCP at levels reduce bloodstream infection in adult and pediatric
seen with the highest levels detected in a newborn intensive care units, and in a single study in an
after topical exposure.67 They reported that CHG NICU. However, concerns about the potential nega-
inhibited L1-mediated neurite growth, and con- tive effects from systemic absorption and on the
cluded that it is important to determine whether the developing skin microbiome suggest caution about
blood–brain barrier is permeable to CHG in the widespread practice of daily CHG bathing in

Summary of Recommendations for Practice and Research

What we know: • Delaying the first bath is beneficial for mother and baby.
• Tub or immersion bathing is beneficial for full-term and late-preterm newborns.
• Reduced bathing frequency is recommended during the first month of life.
• Water alone or water and mild baby cleansing products have similar effects on
skin.
What needs to be studied: • The impact of bathing on skin barrier function, determined by parameters such
as pH, TEWL, and hydration of stratum corneum in premature infants of varying
gestational ages.
• Additional research about the benefits of delaying the first bath on breastfeed-
ing, physiologic stability, hypoglycemia, and the skin microbiome.
• Assessment of the potential toxicity of CHG bathing on premature and full-term
infants in the NICU with repeated application, including determining whether
CHG crosses the blood–brain barrier.
• Evaluation of the effect of repeated CHG bathing on the skin microbiome of
infants in the NICU.
What we can do today: • Adopt a protocol for swaddled bathing for the NICU patients.
• Reduce frequency of bathing to every other day or 3 times weekly.

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 Newborn Bathing S19

hospitalized newborns until it is know whether multiple body habitats in newborns. Prac Natl Acad Sci USA.
2010;107:11971-11975.
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