The consent of the child and family needs to be sought in all circumstances (see also Ch. 1), and family-centred care needs to be considered an integral aspect of the care of children in any environment (Smith 1999, Kirk et al 2005). Basic hygiene needs are considered fundamental to the child receiving nursing care; however, consent still needs to be sought from the child and family irrespective of the expectation that it may be provided as a basic requirement. Prior to the activity, the nurse needs to negotiate with the child and the family the level of their interaction and participation during the personal care time (Coleman 2003, Corlett & Twycross 2006). Full explanations of what actions are being taken should be given, and these should be reinforced during the interaction.

In general, the preparation and consent of children decreases their anxiety, promotes their cooperation, supports their coping skills and helps them to more fully understand what is happening to them (Wong et al 1999, Mansson & Dykes 2004).

Family inclusion

The child and family need to be fully involved throughout the child’s care and encouraged to be partners in care (Casey 1988, Smith et al 2002, DoH 2004). Education of the child and family and the sharing of information are important areas that are the nurse’s responsibility (NMC 2008a,c). This involves the promotion of partnership and informed consent to develop the empowerment of the child and family in any given situation.

Family/carer presence and their involvement in the child’s care will increase feelings of security, and decrease the anxieties of the child. Encouragement will need to be given to the family to promote their active inclusion in even the most basic of care activities, as often the stress of being a parent of a sick child can reduce the parent’s ability to communicate effectively (Fleitas 2003). Their level of participation needs to be assessed early on, and then reassessed frequently to ensure opportunities are given for their involvement in the child’s care. Nurses need to help find specific ways in which family members can support their child (NMC 2008a).

The child needs to be encouraged to develop their independence and positive feelings of control by being able to choose the desired level of activity and participation (Hallstrom & Elander 2004). The nurse needs to be aware of all aspects of communication, including the use and observation of verbal and non-verbal body language during the activity (Bannister 1997). Active communication may help the nurse, child and family to develop a rapport and provide assessment opportunities (Thomas 1996). Active communication is also combined with the use of play and humour during stressful situations (Wong et al 1999) (see also Ch. 10).

Documentation and safe practice

All care should be documented in the nursing notes, in accordance with the Nursing and Midwifery Council Record-keeping guidance for Nurses and Midwives (NMC 2009). Any changes resulting from assessment and reassessment should be noted and reported.

PREVENTION OF CROSS-INFECTION

Good hygiene represents an important defence against infection. A child’s ability to fight infection will depend on their age, health and immunological status. The overprotection of children from contact with micro-organisms may render them unable to develop a natural immunity, but allowing children to develop preventable illness because of poor hygiene practice and infection control is unacceptable.

Universal precautions to prevent infection should be taken (see also Ch. 4). Hands should be washed thoroughly before and after handling any baby or child, in the home or in hospital (Lawson 2001). When handling any body fluids, and especially before any procedure requiring intimate contact, such as feeding or bathing, the nurse should wear gloves and other protective clothing (e.g. an apron) appropriate to the level of contact.

Hand washing is important for all carers and siblings. It is especially important in hospital due to potential contact with unusual or highly infectious diseases and to prevent cross-infection or spread of disease. Therefore the use of universal precautions and good hand washing techniques are essential to reduce cross-contamination (Lawson 2001, RCN 2004a). Older sibling children should be told to wash their hands after using the toilet, and before and after meals, especially if they want to hold or touch the baby, or share toys. Younger children should be encouraged to wash their hands aided by an adult.

DEVELOPMENTAL NEEDS

• Each child is a unique individual with their own routine, temperament and personality.

• Guidelines of developmental age and ability are helpful but each child must be respected as an individual. This can be acknowledged by calling the child by their name.

• Care and support given should provide the child with encouragement and confidence to retain their level of independence in self-care activities.

• Personal hygiene forms an important element of the healthy child’s normal everyday routine.

These routines and practices should be maintained as much as possible while the child is sick, either in hospital or at home, and details should be recorded in the nursing notes or health records. Keeping to established routine provides comfort and reassurance to the child and family, especially during periods of stress.

GUIDELINES

Before commencing any hygiene task, consider:

• Is the task really necessary? Children who are sick, or babies who are premature, should be left in peace with minimal disturbance unless there is a good reason to do otherwise. The clustering of care may be considered to be of benefit and limit the negative effects of continuous interaction (Young 1996).

• Could any other aspect of care be combined with hygiene needs? Examples include observations of vital signs, topical drug administration and specimen collection.

• Consider family-centred care: Could the parents be involved or undertake the task with supervision, or would they prefer the nurse to do it?

• What can the child do independently? Or what can the child begin to learn to do on their own? If a child is able to learn a basic skill or develop their independence, for example hair brushing, tooth cleaning or dressing, it may encourage a sense of achievement and a feeling that something positive has occurred.

• The developmental stage of the child and the appropriate level of activity and interaction.

• How can you make the experience fun? Can you introduce play or toys into the experience?

• Have you collected all necessary equipment together?

SPECIFIC HYGIENE NEEDS OF THE BABY

Birth is a traumatic, exhausting experience for mother, father and baby. The newborn baby is covered with both a protective substance called vernix caseosa, white grease that protects the skin in utero from the amniotic fluid that surrounds the infant, and blood from the mother. The adaptation of the skin from intrauterine life, where the skin has been surrounded by amniotic fluid, to the predominately dry cool extrauterine life takes about 14 days. At birth, the mean pH of skin is 6.34, which decreases to 4.95 by 4 days as the skin colonises with normal flora. The acidic quality of newborn skin provides a defence against harmful microorganisms (Medves & O’Brien 2001). After birth, excess moisture is wiped away and the infant is placed naked on the mother’s abdomen or breast, covered perhaps by a clean towel to maintain warmth. Positive skin-to-skin contact at this stage can provide an ideal opportunity for the mother, father and child to familiarise themselves and bond. However, babies can lose heat rapidly and therefore specific attention needs to be paid to the ambient temperature in the room (Bailey & Rose 2000, Rudolf & Levene 2006).

A full-term healthy infant may be bathed within a few hours of birth, once the body temperature has stabilised (Trotter 2002). Newborn babies do not get especially dirty, and daily bathing of newborn babies is unnecessary as frequent bathing may disrupt the natural pH of the skin. It may also be unwise if the umbilical cord is still in situ (Skale 1992, Guala et al 2003). For the first 2–4 weeks baths should be carried out using only plain water (NICE 2006) and gauze or muslin cloths for cleansing, then gradually introduce tiny amounts of baby bath product. These should be of a neutral pH, contain minimal dyes and perfumes, and be used only two to three times a week (Trotter 2002).

For any baby, bathing is not only for skin cleansing, but is also a time for contact and interaction. The timing of hygiene activities should be planned for when the baby will enjoy them, when awake and content, however bathing after a feed is to be avoided as this may induce vomiting (Lee & Thompson 2007).

Maintaining a clean environment for the baby is an equally important part of their hygiene care. Newborn babies have very little defence against microorganisms; once the placental transference of immunity has worn off at 3 months, or if breastfeeding has stopped, babies must develop their own defences (Lawson 2001). Likely sources of contaminants are feeds, feeding bottles or pacifiers. If formula feeds are to be used, they must be made up under sterile conditions. Feeding bottles and pacifiers should be sterilised after each use. Weaning foods must be prepared using food hygiene guidance (see also Ch. 39).

Once the child is older and can reach for toys and put them in their mouth (usually at about 3 months), toys should be kept ‘socially’ clean, and sterilising them is not necessary. Reinforcing and teaching hand washing techniques before and after contact with the baby are important for all carers and siblings. For older children this is especially important when sharing the baby’s toys.

The environment around a baby whether at home, in a hospital cubicle or ward, should be clean and as free as possible from excessive build-up of dust and dirt. Once a child is crawling, the floor and other surfaces should be kept ‘socially’ clean. Staff and visitors who have coughs or colds or other infections should not have close contact with a baby.

Any episode of ill health can interrupt the family bonding processes. Hygiene activities can form a useful way for the mother or father and baby to bond. During the activities the contact can give an opportunity for face-to-face contact, touch and ‘talking’. For example, if the newborn baby is in a neonatal intensive care unit, inviting the family to help with these activities can encourage bonding when they can no longer fulfil other caring functions (see also Ch. 5).