Every Change Matters: A New Look at Developmental Diapering
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Huggies Sponsored Breakfast Symposium Every Change Matters: A New Look at Diapering for Healthy Skin and Development
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Every Change Matters: A New Look at Developmental Diapering
- 1. Every Change Matters*: A New Look at Diapering for Healthy Skin and Development October 24, 2016
- 2. Before we start To thank you for your participation today, Huggies® will be donating a days worth of diapers to Food Banks of Canada for every attendee. 2
- 3. Huggies® Nursing Advisory Council • Sharon Dore, RN, BScN, M Ed, PhD, Clinical Associate Professor, McMaster University, Ontario, Canada • Media Esser, NNP-BC, APNP, Neonatal Nurse Practitioner, Children's Hospital of Wisconsin • Felicia Fitzgerald, BSN, RNC-OB, C-EFM, Perinatal Outreach Educator, Chicago, Illinois • Kelli Kelley, Founder & Executive Director, Hand to Hold • Joanne Kuller, RN, MS, Neonatal Clinical Nurse Specialist, UCSF Benioff Children’s Hospital • Sue Ludwig, OTR/L, Founder & President, National Association of Neonatal Therapists • Debianne Peterman, PhD, MSN, RNC-NIC, NE-BC, Assistant Vice President, Women's and Obstetrics Services, Hospital Corporation of America 3
- 4. Meet the Speaker 4 Sharon Dore, RN, BScN, M Ed, PhD, Clinical Associate Professor, McMaster University, Ontario, Canada
- 5. A New Look at Diapering Care Diapering = a repetitive, routine task ?? But ... it can create a strong connection with the infant fostering growth & neurodevelopment. This literature review the first to consider diapering • within the context of developmental care and • discuss comprehensive diapering care (skin care, physical development, sensory elements and bonding 5
- 6. Learning Objectives 1. Review the evidence regarding • physiological and psychological developmental care associated with diapering • Physiology of skin care re diapering and diaper dermatitis 2. List 5 focus areas of developmental diapering care 3. Provide examples of education for parents, family and health professionals regarding developmental diapering care 6
- 7. 7 Audit of literature showed: Majority of existing research focuses on • prevention, diagnosis or resolution of diaper dermatitis, • research related to diapering, diapers and baby wipes Several studies showing that even standard caretaking procedures like diapering can lead to increased pain and stress responses in newborns Identified a gap in the literature regarding a comprehensive document discussing diapering in a holistic manner
- 8. 8 Literature review- methodology Extensively reviewed AWHONN’s Neonatal Skin Care: Evidence-Based Clinical Practice Guidelines A PubMed search of > 80 diaper-related terms An analysis of over 400 articles Reviewed in detail over 70 citations Conducted 4 detailed reviews of the material by members of the council
- 9. Every Change Matters: A New Look at Diapering for Healthy Skin and Development operationalized through 5 core foci Focus Area Description Calm and Clean The Optimal Environment Change and Check Developmental Activities of Daily Living Comfort Pain and Stress Assessment and Management Champion Sleep Protected Sleep Confidence and Closeness Family-integrated Care 9
- 10. 10 Calm and Clean The Optimal Environment • Ensure infant safety and comfort • Use appropriate sanitation and hygiene measures • Practice mindfulness • Provide caregiving based on infant cues • Moderate noxious sensory stimulation • Provide developmentally appropriate touch, movement, other environmental stimuli • Encourage bonding and emotional connection between infant & caregiver Benefits of an optimal environment can include improved physiological & psychological responses, early brain maturation and healthy neurodevelopment.2,3 • 1. Coughlin ME. Trauma-Informed Age-Appropriate Care. In: Transformative Nursing in the NICU. New York, NY: Springer Publishing Company; 2014:29-40; 2. Doheny L, et al. Pediatr Int. 2012;54:e1-3; 3. McMahon E, et al. Ann NY Acad Sci. 2012;1252:17-24. To promote an optimal diapering environment1
- 11. Change and Check Developmental Activities of Daily Living To promote healthy infant skin: 11 1. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal skin care, evidence-based clinical guidelines, 3rd ed. Washington, DC: AWHONN; 2014; 2. Counts JL, et al. Clin Pediatr (Phila). 2014;53(suppl 9):10S-13S; 3. Heimall LM, et al.. Maternal Child Nursing. 2013;17:10-6; 4. Helmes CT, et al. Clin Pediatr (Phila). 2014;53(suppl 9):14S-16S; 5. Odio M, Thaman L. Pediatr Dermatol. 2014;31(suppl 1):9-14; 6. Shin HT. Pediatr Clin N Am. 2014;61:367-82; 7. Stamatas GN, et al. Pediatr Dermatol. 2010;27:125-31; 8. Clark-Greuel JN, et al. Clin Pediatr (Phila). 2014;53(suppl 9):23S-26S; 9. Lund CH, et al. J Obstet Gynecol Neonatal Nurs. 2001;30:30-40; 10. Blume-Peytavi U, et al. Pediatr Dermatol. 2014;31:413-29. Perform focused assessment of perianal area at each change Use disposable diapers with super absorbent polymers1-6 Change diapers every 1-3 hours during the day; with each feeding, or at least 1 time per night1 Use baby wipes to thorough clean genital area at every change1 Encourage diaper-free time6,7 Ensure proper diaper fit2,4,5,8 Skin integrity is a challenge for all infants when exposed to situations known to compromise the skin; diaper dermatitis is the most common skin condition in infants. 9,10
- 12. Comfort Pain & Stress Assessment / Management To minimize infant stress and pain during diapering • Educate parents /health professions to assess infant cues related to stress and pain 1,2 3 • Provide pain-prevention techniques such as non-nutritive sucking, kangaroo care, facilitated tucking, and nesting of bedding4-10 • Provide state & motor support during potentially stressful events4,11 Stress and pain experienced by premature infants in the NICU can alter the normal course of pain expressed in toddlers and preschoolers and lead to long-term emotional, behavioral and learning disabilities. 12-14 12 1. Coughlin M, et al. J Adv Nurs. 2009;65:2239-48; 2. American Academy of Pediatrics, Canadian Paediatric Society. Pediatrics. 2000;105:454-61; 3. Karl DJ, et al. MCN Am J Matern Child Nurs. 2006;31:257-62; 4. Comaru T, Miura E. J Perinatol. 2009;29:504-7; 5. Dodds E. Paediatr Nurs. 2003;15:18-21; 6. Gardner SL, et al. Pain and pain relief. In: Gardner SL, Carter BS, Hines ME, Hernández JA, eds. Merenstein & Gardner’s Handbook of Neonatal Intensive Care. 8th ed. St. Louis, MO: Elsevier; 2016; 7. Gibbins S, et al. Expert Opin Pharmacother. 2003;4:475-83; 8. Johnston CC, et al. Biol Neonate.1999;76:120-4; 9. Stevens B, et al. Cochrane Database Syst Rev. 2013 Jan 31;1:CD001069; 10. Ward-Larson C, et al. MCN Am J Matern Child Nurs. 2004;29:151-6; 11. Sizun J, et al. J Pain. 2002;3:446-50; 12; American Academy of Pediatrics. Pediatrics. 2006;118:2231-41; 13. Grunau RV, et al. Pain. 1994;58:341-6; 14. Grunau RV, et al. Pain. 1994;56:353-9.
- 13. Champion Sleep/Protected Sleep To promote sleep: • Encourage Kangaroo care, skin-to-skin contact, gentle healing touch1-6 • Employ strategies to facilitate sleep cycle (e.g sleep assessment tools, cycled lighting) 7,8 • Expose infants to music therapy, singing, biological maternal sounds9,10 • Use diapers with wetness indicators to avoid unnecessary disruptions7,8 Adequate sleep for infants is connected to immune function enhancement, reduction in stress, cortical development and optimal neuromaturation. Sleep is also needed for linear growth and increased weight, as well as increased growth hormone.8,11-13 1. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal skin care, evidence-based clinical guidelines, 3rd ed. Washington, DC: AWHONN; 2014; 2. Counts JL, et al. Clin Pediatr (Phila). 2014;53(suppl 9):10S-13S; 3. Heimall LM, et al.. Maternal Child Nursing. 2013;17:10-6; 4. Helmes CT, et al. Clin Pediatr (Phila). 2014;53(suppl 9):14S-16S; 5. Odio M, Thaman L. Pediatr Dermatol. 2014;31(suppl 1):9-14; 6. Shin HT. Pediatr Clin N Am. 2014;61:367-82; 7. Stamatas GN, et al. Pediatr Dermatol. 2010;27:125-31; 8. Clark-Greuel JN, et al. Clin Pediatr (Phila). 2014;53(suppl 9):23S-26S; 9. Lund CH, et al. J Obstet Gynecol Neonatal Nurs. 2001;30:30-40; 10. Blume-Peytavi U, et al. Pediatr Dermatol. 2014;31:413-29. 13
- 14. Confidence and Closeness – Family-Integrated Care To promote family-integrated care during diapering: • Integrate and involve family in all aspects of infant caregiving1 • Support parents in their new role as “confident caregivers” 2 • Encourage parents to incorporate developmentally appropriate care measures2 • Model use of the diaper change as an opportunity to engage with the infant3,4 • Share the importance of proper positioning and handling during diapering5,6 Healthcare professionals should, when possible, reserve intentional care measures for families to implement with their infant6 14 1. Craig JW, et al. J Perinatol. 2015;35(Suppl 1):S5-S8; 2. Cong X, et al. J Pain. 2012;13:636-45; 3. Coughlin M, et al. J Adv Nurs. 2009;65:2239-48; 4. Karl DJ, et al. MCN Am J Matern Child Nurs. 2006;31:257-62; 5. Lyngstad LT, et alEarly Hum Dev. 2014;90:169-72; 6. Sizun J, et al. J Pain. 2002;3:446-50; 7. McGrath JM. Family: essential partner in care. In: Kenner CM, Lott JD, eds. Comprehensive Neonatal Care: An Interdisciplinary Approach. 4th ed. St. Louis, MO: Saunders Elsevier; 2007.
- 16. Thank you!
Hinweis der Redaktion
- Welcome, everyone. I am thrilled to be here today and share this exciting resource that will contribute to well being of preterm and term babies and their families Only 2nd presentation of material – previously CAPWHN
- Barb: Before we start we want to mention that Huggies is a proud sponsor of the No Baby Unhugged program in Canada, which is dedicated to helping babies get the hugs they need through our products and hugging programs in hospitals. In addition, to thank you for your participation in this presentation, Huggies will be donating a days worth of diapers to the Food Banks of Canada for each of you attending today.
- Last year, Kimberly Clark and Huggies brand convened the Huggies Nursing Advisory Council. This incredible group of professionals brings expert perspective in areas of neonatal and perinatal nursing and education, as well as an occupational therapy, and also includes insights from the NICU parent experience. While the Council covers a broad range of expertise, they all share a passion for helping babies thrive – which is also what drives our team at Huggies. As the Council met, they took a new look at diapering from their across their areas of expertise, and together discovered an unseized opportunity for nurses to integrate, model and educate parents and other caregivers about the importance of developmental care, in addition to skin care, within the act of diapering. The result, Every Change Matters: A Guide to Developmental Diapering Care, is the first review to consider diapering care within such a comprehensive approach—including skin care, physical development, sensory elements and bonding.
- Sharon - Introductions: comments on background and why she is happy to be part of KC nursing council
- In your personal life or professional life…..How many of you have changed a diaper (show of hands) How many of you have changed 100 diapers (show of hands) How many of you have changed 500 diapers (show of hands) RTN –so we have a group of experienced diaperers – when you get to those kinds of numbers, and for nurses it can be several dozen a shift – diapering can be a routine repetitive task RTN – But… However, the Huggies® Nursing Advisory Council believes diapering provides an extraordinary opportunity for nurses and other healthcare professionals to support the neonate’s psychological and physiological development. Beyond this, diapering is seen as a key time for healthcare professionals, parents and other caregivers to create a strong connection with the infant through regular and attentive interactions, which help foster growth and neurodevelopment. result, Every Change Matters*: A Diapering Guide to Developmental Care is the first review to consider diapering within the context of developmental care and discuss comprehensive diapering care—including skin care, physical development, sensory elements and bonding—based on a review of current literature.
- the literature deals with diaper dermatitis and baby wipes- Not surprisingly to any of you as skin care concerns are common and a fairly concrete research topic – easily fits with a fundable RCT HOWEVER it was important to note that the literature also labeled diapering as a source of pain and stress in preterm and to some extent in term babies A gap in the literature was clear – we needed to know more about this pain and stress factor and how we could improve care in this area This was like a red flag to the council
- ANIMATED (RTN = return key to bring up next statement) AWHONN 2013 3rd ED – lots of excellent information Sharon only – tangent re staff nurse research re alcohol and cord care RTN Delving further
- Formatted the results of the literature review into 2 documents A referenced manuscript to support the suggestions A quick practical guide of 5 key points to remember 5 areas of developmental care - psychological, neurobiological, and psycho-emotional domains.- aligned them with activities during diapering Targets healthcare professionals, parents and other caregivers to merge skin and developmental care into 1 package Goal is to make all 5 something done at each diaper change to underpins basic healing and wellness for babies HENCE THE NAME ….EVERY CHANGE MATTERS Made the words all start with C – easy to remember List areas – will discuss in some detail
- ANIMATED (RTN = return key to bring up next statement) Incorporates key areas of safety, hygiene and stimulus management First 2 bullets are very familiar to you SAFETY ie Hand on baby – avoid falls etc HYGIENE Washing hands before and after – disposing of the diaper What is this practicing mindfulness = paying attention to infant cues – infant centered care Touch and sound are two of the first sensory systems to develop and we can use that as a positive experiences for fetus and baby (response to touch at 8 wks post conception)- importantly for all the administrators in the audience it is a no cost intervention. Over 600 scientific papers Touch stimulates tactile nerve endings leading to release of endorphins and serotonin- a happy feeling Aside depending on audience – years ago we used to give patients a back rub every night before bed and talk to them – same effect – now we just give them a pill Music therapy and gentle voice sounds associated with sucking and feeding, O2 saturation and heart rate - compare that to beeping monitors and alarms Remember all the publicity about memories of music heard by the fetus and recalls as an adult – a powerful early strategy RTN bolded statement
- As we move into winter we are all concerned with skin care issues – the snow outside is good reminder. May not work for Palm Springs So whatever we think about regarding skin care similar principles apply to the newborn and the preterm infant . Clean and check for dryness is the same thing we do for our faces. You all know that premature infants have a poor epidermal barrier at birth with few cornified layers, making it especially susceptible to irritants that can lead to diaper dermatitis. Important to check diaper area at each change to spot early potential for diaper dermatitis Polymers – want to wick away urine so the skin is not lying in a wet environment Change – hard for low SES due to costs – cloth even expensive with water, soap, and difficulty getting to a Laundromat Wipes –maintain acid mantle thus pH important (takes 9 wks to develop in preterm) no perfumes; preservatives must be gentle soap and water may not clear all the feces and some soaps have a high pH which limits development of the acid mantle Fascinating to look on the web to get the pH of different soaps Diaper free time is great Fit – decrease friction .
- ANIMATED (RTN = return key to bring up next statement) routine caregiving linked to physiological markers of stress in preterm ie cerebral bld flow fluctuations and brain pathway changes so minimize stress and pain during the diaper change Want to improve particularly preterm self regulation using containment, postural support and non nutritive sucking. Watch facial expression, body position For example we know extension is a sign of stress so moving the baby’s arms back to a midline tucked position and supporting the motor system will reduce pain and stress Blankets around a baby to form a nest is also helpful For a term baby the kangaroo care and non nutritive sucking are helpful By caregivers modelling these behaviors, parents wil learn these cues, they’ll know when to intervene and interact with the baby, and when to let the baby rest and recover their own control. These parents will feel so powerful when they realize they are not just changing a diaper but providing comfort and improving RTN – bolded statement .
- very important for enhancing core functions in the immune system, reducing stress, and supporting cortical development and optimal neuromaturation. Some days after a set of nights or on call times we are all reminded of the importance of sleep – think of how much more important that is to newborns. To facilitate sleep we need to think about decreasing noxious stimulation and increasing positive experiences such as music therapy, singing, biological maternal sounds to facilitate sleep. Recording a mother’s voice or a parent voice make reduce stress for the baby – maternal hrt beat that baby has been listening to for many months may be reassuring – recording of a dishwasher similar to maternal hrt rate- kangaroo care will also promote listening to the maternal heart rate Lighting is important – blankets over the isolette Noise indicators in the unit Using diapers with wetness indicators to avoid unnecessary disruptions is another way we can try to bundle care so we don’t unnecessarily interrupt sleep. Helping baby sleep helps mother sleep = breastfeeding RTN – bolded statement Protecting sleep should be a unit-wide practice—the health care team and family need to be on the same page and try to promote systems and care plans that will facilitate sleep practices, whether that’s environmentally through decreasing noise and bright lights or with clustering cares to allow for longer periods of sleep. Skin-to-skin holding provides the best, deepest sleep experience for the infant, so the better we can promote Kangaroo care, especially as it relates to educating parents, the better we’ll be able to promote protection of the sleep environment.
- involving family in all aspects of infant caregiving and supporting parents and other caregivers in their new role. As Health professionals, you are key figures in parent’s new journey. You have the opportunity to dramatically impact and redirect their sense of confusion, feelings of helplessness and negative thought processes to help parents bond with babies and become confident caregivers and advocates for them. While you see the medical equipment, and the bright lights and monitors of a L&D, nursery or NICU most parents are seeing it for the first time, and we struggle to see past the all of it to their babies. This is a barrier to bonding that some health professionals do not appreciate. Diaper changes are often one of the first activities parents do with their babies, Parents are terrified with diapering a new baby – heard all the stories about being laughed at when it falls off – intimidated by the slick nurse who does the diapering in record time and it is perfect – by helping parents understand all the aspects of diapering gives them a greater appreciation of what they can do for baby beside have a good looking diaper. The NICU is even worse – Suggestion of giving them a sticker – I changed my baby’s diaper For parents with babies in the NICU, participating in the care of their baby can be an important coping mechanism and boost their self-confidence as a parent. WAIT for the parent to be there to do things Healthcare professionals should, when possible, reserve intentional care measures for families to provide for their infant. As nurses, changing diapers can start to feel really routine for us, but for the parent it’s an opportunity to have a profound connection with their baby. Placing an emphasis on incorporating parents in these everyday tasks is critical for their connection with their infant. As a nurse who has spent a lot of time with high risk antenatal women who then become parents of babies in our NICU, I have seen that changing his diaper for the first time was a powerful, emotionally charged event. Moms were terrified that they might hurt their baby. him, A nurse can gently and calmly coach as carefully maneuvering multiple pieces of medical equipment and use extreme care with his delicate skin. It’s important to keep in mind how much your support and your encouragement mean to NICU parents. And of course, this moment also serves as the time when we, as healthcare professionals, can emphasize and educate parents and other caregivers about the elements of developmentally appropriate care that can make a significant difference – helping them to see that every change matters.
- Research Just before going to ?- want to identify the educational resources available based on this work – there is a hard copy of the manuscript with all the references included – there is also a quick reference guide you could think about using for staff educations as a parent resource. Also to mention this is being piloted as several hospitals in the USA and at McMaster in Hamilton – describe – awaiting results Prompts for audience if needed In your experience, do you think nurses and healthcare professionals are aware of the developmental impact diapering has on infants? What role does mindfulness play here? ]How easy or hard is it to implement these recommendations? How would you encourage nurses to incorporate Every Change Matters within their existing workflow? I’m interested to hear from you how Every Change Matters may help parents in interacting with their infant? In your opinion, are parents aware of the developmental impact diapering has on infants?
- Barb: Are there any questions? Thank you again for joining us today—we hope you are interested in what you’ve heard about Every Change Matters, and are considering bringing this back to implement in your unit. As you leave, we invite you to pick up a copy of the Every Change Matters manuscript, quick-reference guide and poster. If you have any additional questions, myself and Sharon will be available at the front of the room. Thank you, and have a great rest of your day!