ICEA Position Paper tasks and the OB team to finish up the post-delivery
care. This became the “vision of birth. The impact
of these practices on mom and baby were not
considered for many years. In 1990, an article was
published in the Lancet looking at removal of baby
Delayed Bathing from mom for newborn care and the impact that
removal had on breastfeeding. At that same time
the push from United Nations International
Children’s Emergency Fund (UNICEF) and the World
Health Organization (WHO) were forming the Baby
Friendly Initiative; looking at birth practices and the
Position effect on breastfeeding began to be studied much
more in depth. As practices changed for the better,
International Childbirth Education the bath still remained an early procedure; almost
Association (ICEA) encourages evidence- immediately after birth. Whether it was a lack of
based information for decision making insight on the affects, or the “gross factor,” the
newborn bath was expected to be done right away.
around pregnancy, birth, breastfeeding Yet, as early as 1998, The Association of Women’s
and new parenting. Recent research has Obstetric, Health, and Neonatal Nurses (AWOHNN),
shown that delaying the first bath after the National Association of Neonatal Nurses
(NANN), and WHO recommended that “removal of
birth can have significant impact on the
all vernix is not necessary for hygienic reasons.”
newborn transition and early
With only preliminary data on the effects of the
breastfeeding. Because of this research,
newborn bath at an early stage, it was dismissed as
we encourage parents and care having little impact, and continued to be the
providers to look at delaying the first standard practice in most hospitals. Meanwhile,
bath as an option. This practice is skin to skin care immediately after birth was being
studied in depth. The recommendation to place
endorsed by regulating bodies and when
baby skin to skin within 5 minutes of birth and to
done right is safe for families and care remain there at least one hour and until the first
providers breastfeed is what began the delay in the newborn
bath.
Background
Delay the Bath
With the move to hospitalized birth, it became
standard practice to give the first bath fairly soon In 2012, that thinking changed from the newborn
after birth. Baby would be taken from mom for bath as a standard care to really looking at when
routine newborn care, bathed and brought back that bath should be done emerged. The WHO gave
swaddled up and ready to sleep. This practice time parameters stating, “bathing should be
allowed for the pediatric team to complete their delayed until 24 hours after birth. If this is not
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possible due to cultural reasons, bathing should be month of gestation. The periderm continues to
delayed for at least six hours. Appropriate clothing form and by 21 weeks it sheds and combines with
of the baby for ambient temperature is sebum secretions to form the vernix. Vernix is 81%
recommended. This means one to two layers of water, 9% protein containing lipids and 10% other
clothes more than adults, and use of hats/caps. The fat. Thirty-nine percent of the vernix proteins have
mother and baby should not be separated and components of innate immunity and 29% have
should stay in the same room 24 hours a day” direct antimicrobial properties.
Around that same time, AWHONN came out with
their “Wait for Eight” campaign stating that Purpose of Vernix
delaying the bath by at least 8 hours would reduce
the instability associated with cold stress. While the baby is still in the uterus, vernix forms a
hydrophobic barrier. It protects against the loss of
In 2015, AWHONN pushed this campaign again, fluids and electrolytes. Along with amniotic fluid,
encouraging the delay not only for cold stress but vernix is frequently swallowed where it coats the
also for better stability overall. Their presentation gut and aids in its formation.
at the annual conference stated that delayed
bathing and leaving vernix on the skin would lead to During labor and birth, vernix acts as a bio-film that
decreases in hypoglycemia, weight loss, jaundice minimizes friction through the birth process.
along with better temperature stability and other Additionally, it acts as an antimicrobial barrier to
positive effects due to the antibacterial and protect the baby as he or she passes through the
antimicrobial properties of vernix. birth canal.
After the birth of the baby, the vernix still plays a
Vernix Caseosa role in protection. The newborn skin goes through
some dramatic changes in the first few days. In
When a baby is born, he or she may be completely
particular, there is a decrease in PH and surface
covered in vernix caseosa or may just have some
hydration. If vernix is left in place the skin stays
remaining (particularly in the creases of the neck
hydrated and has less cracking and peeling.
and between fingers and toes). Gestational age has
an impact on the amount of vernix with shorter There is some evidence that vernix acts a thermos-
gestational age typically meaning more visible regulator and although this was the function used
vernix. This substance comes from the Latin origin to drive practice change for delaying bath
where vernix means varnish and caseos means (AWOHNN 2012) it is not thought to be its primary
cheesy. A cheesy varnish is a very descriptive way function.
to describe vernix. However, the bigger question is,
“what is it and why is it there?” If that is not enough, there are other purposes for
this substance. Vernix has antioxidant properties.
Vernix is a coating on the skin that consists of fatty Birth is a time of high oxidative stress and the
secretions from the sebaceous glands and dead vitamin E and Melanin are thought to offset this
epidermal cells. Its purpose is to protect the skin of stress. Vernix contains antibiotic properties that
the developing fetus. Skin begins to form at 3 can protect against meconium, inter and extra-
weeks of gestation. After many divisions and uterine infections and bacterial pathogens. The
changes, the epidermis begins formation by the 4th high water count is moisturizing to the skin; better
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than the best moisturizing products in stores. hours after birth (WHO, AWHONN, Save the
Finally, vernix helps with both wound healing and Children). It is suggested that the bath be done
skin cleansing. with the parents involved so that they can learn the
process and limit separation. Additionally, it is
Vernix and Breastfeeding important to get baby back in a skin to skin position
immediately after to minimize effects from the cold.
One study, (Preer et al. 2013) looked at the
correlation between delayed bathing and increased Contraindications
hospital breastfeeding rates. In this Boston
There are times when the newborn bath is
hospital, 702 qualified babies were included in the
recommended immediately. If the mom is HIV
study. Before the study, the average time after
positive or has a hepatitis virus then a bath is done
birth until the first bath was 2.4 hrs. With the study
to limit transmission to others who come in contact
the average time of the first bath was 13.5 hrs.
with the baby. In some facilities, a bath is also done
They found that with the delay in time to first bath
with chorioamnionitis or significant meconium
there was an increase from 32.7% exclusive
staining. It is recommended that health care
breastfeeding to 40.2% exclusivity rate (p< .05) and
providers use gloves when handling an unbathed
concluded that there was a significant likelihood of
baby.
increased breastfeeding if the bath was delayed.
Numerous studies have found that skin to skin from In Summary
birth until the first breastfeed is critical for
successful breastfeeding. Patting the baby dry but Delaying bathing for at least 8 hours after birth
not washing and leaving the amniotic fluid on the protects the newborn’s skin from bacterial invasion,
hands increases the baby’s ability to make the keeps their skin conditioned, keeps their blood
neural connections for breastfeeding to happen. By sugar stable since bathing might lower their
keeping mom and baby together, many hormonal temperature and often causes the baby to cry, both
and neurobiological changes will occur. All of these of which can promote hypoglycemia. Delaying the
help with newborn transition, regulation and brain first bath encourages the establishment of
synapsis. Taking baby for a bath; separating him or breastfeeding along with the bonding that mothers
her from their mom interferes in the natural post get which being skin-to-skin with your newborn
birth process and put the baby in a state of fight or promotes.
flight increasing catecholamine in the system.
References
So When Should the Bath Akinbi, H. T., Narendran, V., Pass, A. K., Markart, P.,
Occur? & Hoath, S. B. (2004). Host defense proteins in
vernix caseosa and amniotic fluid. American Journal
There is no set time that it should happen. Many of Obstetrics and Gynecology
parents are delaying that first bath past the hospital
DiCioccio, H, Ady, C, Bena, J, & Albert N (2019)
stay and doing it at home when they feel ready.
Initiative to Improve Exclusive Breastfeeding by
The minimum time recommended falls between 6-8
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Delaying the Newborn Bath JOGNN Vol 48 Issue 2 Righard L1, Alade MO. Lancet. Effect of Delivery
pgs 189-196 Room Routines on Success of First Breast-
feed.1990 Nov 3;336(8723):1105-7.
Delay Diana V. Lipka, RN, BA, MPA, RNC-OB , "Wait
for Eight”: Improvement of Newborn Outcomes by Smith, E. Delaying the First Bath 2013 Perinatal
the Implementation of Newborn Bath Mother/Baby Professionals Conference
and Lactation, Baycare/ Saint Joseph's Women's Visscher, M. O., Utturkar, R., Pickens, W. L., LaRuffa,
Hospital, Tampa, FL A. A., Robinson, M., Wickett, R. R., Hoath, S. B.
Liberth, M. &Fontan, J (2018) Benefits of Delayed (2011). Neonatal skin maturation--vernix caseosa
Bathing JOGNN vol 47 Issue 3 pgs S30-S31 and free amino acids. Pediatr Dermatol, 28(2), 122-
132. doi: 10.1111/j.1525-1470.2011.01309."
Marcia K. Schulz, RNC, MS , Mother/Baby and
Lactation, Baycare/ Saint Joseph's Women's WHO Maternal, Newborn, Child and Adolescent
Hospital, Tampa, FL (2012) AWOHNN Health Review Committee
ConventionDPreer G1, Pisegna JM, Cook JT, Henri
AM, Philipp BL. Breastfeed Med. Delaying the Bath
and In-hospital Breastfeeding Rates. Dec;8(6):485-
90. doi: 10.1089/bfm.2012.0158. Epub 2013 May 2.
Narendran V. Hoath SB. The Biology of Vernix
Caseosa. J Neonatol.
> 2002;16:9–17
Authors: Elizabeth Smith and Terriann Shell
International Childbirth Education Association
110 Horizon Drive, Ste. 210 • Raleigh, NC 27615 • Phone: 919.674.4183 • [Link]
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