Timing of the First Bath in Term Healthy Newborns
by Anne Eglash MD, IBCLC, FABM
We bathe regularly to feel clean, remove particles from our skin, and to prevent infection. We apply these same values to newborns, with the assumption that we should remove vernix, amniotic fluid, and other proteinaceous materials to prevent infection and freshen them up for their social debut.
There are several strategies for bathing newborns, from sponge bathing to tub immersion.
According to the authors of today’s systematic review and meta-analysis on the effect of newborn bathing, studies have demonstrated that early newborn bathing can destabilize the newborn’s body temperature, leading to lower blood sugars and lethargy, along with poor feeding. An early first bath is also associated with respiratory problems such as a faster respiratory rate and lower oxygen level.
Early bathing also removes the infant from the mother or other parent, decreasing the benefits of early skin to skin such exclusive breastfeeding, infant cardiovascular stabilization, temperature control, and decreased risk of postpartum hemorrhage, among many others.
The authors point out that the World Health Organization recommends delaying the newborn bath for 24 hours, and, if not possible, for at least 6 hours after birth to allow for the newborn to stabilize their vital signs. This recommendation was based on expert consensus and not on evidence from a systematic review or meta-analysis.
The authors’ goals for this work were to determine the impact of delaying the first bath among term healthy newborns until after 24 hours on specific outcomes including neonatal mortality, hypothermia, low blood sugars, and exclusive breastfeeding.
This systematic review included 16 studies, and 12 were included for meta-analysis. They found that the definition of ‘delayed bath’ varied in different studies. The most used time designation for a delayed bath was > 6 hours, although some studies used > 9,12, or 24 hours. Twelve of the studies were conducted in high income, 2 from lower middle-income, and 1 from low-income countries, with a total of 39,020 neonates.
- Delaying the first bath for at least 24 hours after birth may reduce infant mortality and hypothermia, compared to bathing in the first 24 hours.
- Delaying the first bath for 6 hours may reduce hypothermia and low blood sugars.
- Delaying the first bath for 6 hours was associated with improved exclusive breastfeeding at discharge.
See the Answer
This systematic review of intervention trials and observational studies assessed the effect of delaying the first bath for at least 24 hours after birth, compared to conducting it within the first 24 hours, in term healthy newborns.
We searched MEDLINE via PubMed, Cochrane CENTRAL, Embase, CINAHL (updated till November 2021), and clinical trials databases and reference lists of retrieved articles. Key outcomes were neonatal mortality, systemic infections, hypothermia, hypoglycaemia, and exclusive breastfeeding (EBF) rates. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using relative risk (RR) or odds ratio (OR). The GRADE approach was used to assess the certainty of evidence.
We included 16 studies (two trials and 14 observational studies) involving 39 020 term or near-term healthy newborns. Delayed and early baths were defined variably in the studies, most commonly as >24 hours (six studies) and as ≤6 hours (12 studies), respectively. We performed a post-hoc analysis for studies that defined early bath as ≤6 hours. Low certainty evidence suggested that bathing the newborn 24 hours after birth might reduce the risk of infant mortality (OR = 0.46, 95% confidence interval (CI) = 0.28 to 0.77; one study, 789 participants) and neonatal hypothermia (OR = 0.50, 95% CI = 0.28-0.88; one study, 660 newborns), compared to bathing within first 24 hours. The evidence on the effect on EBF at discharge was very uncertain. Delayed bath beyond 6 hours (at or after nine, 12, or 24 hours) after birth compared to that within 6 hours might reduce the risk of hypothermia (OR = 0.47, 95% CI = 0.36-0.61; four studies, 2711 newborns) and hypoglycaemia (OR = 0.39, 95% CI = 0.23-0.66; three studies, 2775 newborns) and improve the incidence of EBF at discharge (OR = 1.12, 95% CI = 1.08-1.34; six studies, 6768 newborns); the evidence of the effect on neonatal mortality was very uncertain.
Delayed first bath for at least 24 hours may reduce infant mortality and hypothermia. Delayed bath for at least 6 hours may prevent hypothermia and hypoglycaemia and improve EBF rates at discharge. However, most of these conclusions are limited by low certainty evidence.
The authors state that their research provides support for the World Health Organization’s recommendation to delay the newborn bath for 24 hours, and if not possible, for at least 6 hours after birth.
They acknowledge that the research is based on low certainty evidence, with only small 1 randomized controlled trial. They call for well-designed studies, and to study the impact of different types of bathing. Further, there are no studies of the effect of bath timing on the timing of breastfeeding initiation, exclusive breastfeeding at 6 months, or harm from delaying bathing, such as bacterial infection. Even though the research is overall low quality, a 2021 survey of 109 US maternity hospitals found that 87% of hospitals delayed the bath for 6 hours, and 10% discharged infants without a bath, while the hospital newborn skin care routines varied greatly.
It is amazing how little we know about a simple washing.