Every Change Matters - All 10,000 Of Them

Amid the bustle of family birthing centers, we can be quick to forget the nervousness and anxiety filling new parents as they cycle through our doors. The excitement they feel when leaving the hospital may quickly be replaced with exhaustion from adjusting to their new family responsibilities. Just for a moment, imagine yourselves in their shoes, about 2 months after they leave the hospital:

It's 6 p.m., dinner is on the stove, the dog is barking at the mailman outside and the baby is crying. "ANOTHER diaper change?" you think. "Let's make this quick."

Pretty overwhelming, right? Many of us can relate as parents ourselves. Did you know that the average newborn goes through up to 12 diapers a day, totaling more than 10,000 diaper changes in their lifetime?

As nurses and healthcare professionals, we understand that diapering is a perfect opportunity to use developmentally appropriate interventions, such as skin-to-skin contact, proper positioning, and containment. These actions, commonly referred to as "developmental diapering care" can help foster physical and developmental growth in infants. These interventions may be second nature for us, but for parents could easily fall to the wayside. What if we could help parents and caregivers reconsider their routine diaper changes, and encourage them to view this time with baby as a special bonding experience?

Every Change MattersTM: A Guide to Developmental Diapering Care is the first research review to consider diapering within the context of developmental care, including skin care, physical development, sensory elements, and bonding. It was developed by the Huggies® Nursing Advisory Council, a multidisciplinary group of experts in neonatal care, that believe diapering is an opportunity for nurses and other healthcare professionals to integrate, model and educate parents, grandparents, siblings and other caregivers about the importance of developmental and skin care in diapering.

At the end of a long day, diapering can seem like a routine task that you can do with your eyes closed and one hand tied behind your back. But in reality, mindful diapering can enhance the infant's development, physical growth, emotional well-being, family bond, and sleep quality. Research has suggested that both full-term and pre-term babies have shown an increase in pain scores during diaper changes, but by providing developmental diapering care for infants, you can decrease the stress of a diaper change.

This research provides practical information on how healthcare professionals and other caregivers may incorporate elements of evidence-based skin care and developmental care into their diapering practices. Broken into five areas of focus, the model is captured in the guide by these five C's:

Calm and Clean with Infants

Healthcare professionals should encourage positive sensory experiences, physical privacy for families and parent involvement in infant care. During caregiving routines, there are many ways to encourage parental participation and bonding between parents and infants. Nurses can teach and model for parents the importance of approaching the infant calmly, intentionally and with a gentle, purposeful touch during diapering. Other tips, such as positioning the infant on a changing area to provide safety and physiologic stability or using two caregivers to change infants who weigh less than 3.3 pounds to provide stable motor support. Nurses can also talk with new parents about their infant's cues; insights into infant cues may lead to an increase in parents' confidence when providing care for their infant. An optimal changing area is also clean, so nurses should ensure parents know how to follow hospital hygiene and infection control protocol and know to wash their hands thoroughly after a diaper change.

Change and Check Infants

Healthy infants aged nine to 12 months of age have a higher risk of developing a rash, as do pre-term newborns. Currently, the Association of Women's Health, Obstetrics and Neonatal Nurses (AWHONN) recommends a focused skin assessment of the perianal area as a strategy to identify the earlier signs of diaper dermatitis and help early treatment. Parents and caregivers should be informed of the benefits of using formulated wipes during every diaper change to effectively remove urine and fecal irritants while maintaining a balanced skin pH. As another practice of prevention and treatment of diaper dermatitis, caregivers can apply a thick layer of barrier cream to protect infant skin from contact with moisture and irritants when appropriate. Caregivers should also be aware of the benefits of diaper-free time for infants, how to properly check the fringe of the diaper around the infant's legs and taking advantage of the hands-on care opportunity when diapering.

Comfort

Considering the many invasive procedures performed on premature infants in the NICU, infants often experience increased pain and stress levels than those not in those conditions. However, even routine caregiving has been linked to physiological markers of stress in premature infants, such as major cerebral hemodynamic fluctuations. Although nurses are trained to recognize stress cues - including specific facial expressions, body movements, crying, changes in heart or respiratory rate, sweating and restlessness - many parents only learn to read their infant's cues and indicators through interacting with them, an opportunity limited in the NICU setting. Nurses and other healthcare professionals can model the use of containment, postural support and non-nutritive sucking during potentially stressful situations while explaining to parents how to alleviate stress.

Champion Sleep for Newborns

Sleep plays a role in cognitive, psychomotor and temperament development in infants. This means sleep should be promoted and protected whenever possible. Using tools such as the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) and the Assessment of Preterm Infants' Behavior (APIB) before diapering lets caregivers assess infants' sleep-wake states. Healthcare providers and other caregivers can also help prevent unneeded awakenings by selecting diapers with superior absorption, leakage protection, and wetness indicators, as well as taking external factors into consideration that may affect infants' sleep such as lighting and noise levels. Nurses can educate on Kangaroo care, or skin-to-skin holding of the infant against the parents' chest, which has been demonstrated to improve sleep in infants.

Confidence and Closeness with Babies

Diaper changes are an opportunity for nurses to integrate and involve families early on in infant care, especially in the potentially overwhelming environment of the NICU. Healthcare professionals should look for opportunities to implement and encourage family-integrated care, such as the integration of parent-infant skin-to-skin contact and diaper changes, when possible. Helping parents in their new roles as caregivers through coaching will help both the parents and infant go home happier and more confident!