Mouth Care Neonatal Clinical Guideline - V1.0 February 2021

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Mouth Care Neonatal Clinical Guideline

                V1.0

            February 2021
Summary

                           Mouth Care Procedure

               Perform hand hygiene and wear clean gloves

     Assessment of mouth should be done during daily cares using the
      assessment tool. (Unless score=0, mouth care should be given)

    Gather articles required for mouth care (cotton tip applicator, gauze,
                   colostrum, sterile water and paper bag)

   Use clean gauze dipped in sterile water to clean lips and a cotton bud
   dipped in 0.1ml of colostrum to apply over lips and to coat a thin layer
                       over buccal cavity and tongue

                Discard all used items including excess milk

   Document mouth care in intensive care charts, daily feeds/ care record
                          and badger checklist

                       Mouth Care Neonatal Clinical Guideline V1.0
                                     Page 2 of 10
1. Aim/Purpose of this Guideline
     Oral hygiene is an integral part of total care. Babies in the neonatal unit are
     more susceptible to nosocomial infections as majority of them are premature.
     Colostrum is rich in immune agents that can stimulate oropharyngeal associated
     lymphoid tissue. When colostrum is placed directly into the oral mucosa it can
     be systemically absorbed and help protect vulnerable infants against infections.

Data Protection Act 2018 (General Data Protection Regulation – GDPR)
Legislation
The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to
process personal and sensitive data. The legal basis for processing must be identified
and documented before the processing begins. In many cases we may need consent;
this must be explicit, informed and documented. We cannot rely on opt out, it must be
opt in.
DPA18 is applicable to all staff; this includes those working as contractors and providers
of services.
For more information about your obligations under the DPA18 please see the
Information Use Framework Policy or contact the Information Governance Team
rch-tr.infogov@nhs.net

2. The Guidance
     The aim of this document is to outline the advantages of, and provide guidance
     on the use of colostrum in mouth care.

     This policy applies to all staff that care for babies admitted to neonatal unit.

     Oxford dictionary definitions are:

      Colostrum– The first secretion from mammary glands after giving birth, rich in
       antibodies.
      Breastmilk– Milk produced by a woman’s breasts after child birth as food for
       her child

     2.1. Roles and responsibilities
          Health professionals have responsibilities for development, management
          and implementation of this guideline as detailed below.

          2.1.1.   Role of managers
                   The neonatal ward manager is responsible for ensuring monitoring
                   and compliance standards are met as specified in the guideline.

          2.1.2.   Role of individual staff
                   All neonatal staff members are responsible for practising in
                   accordance with this neonatal guidance document at all times while
                   employed in this trust.

                          Mouth Care Neonatal Clinical Guideline V1.0
                                        Page 3 of 10
2.2. Standards and practice

    2.2.1.   The fundamental objective of providing mouth care is to maintain
             the oral mucosa, gums, buccal cavity and lips in good condition. It
             will also benefit the neonate by:

              Keeping the oral mucosa moist, soft and intact, thereby reducing
               oral and systemic infections.
              Keep lips soft, moist and intact.
              Removal of debris without damage to mucosa.
              Prevent oral colonisation of gram negative flora
              Freshen the mouth and increase the general wellbeing.
              In a sick preterm neonate it also benefits by:
               o Providing positive oral experience for the neonate.
               o Early sensory development of taste and smell.
               o Odour and taste of colostrum provides a soothing effect and
                  decreases cortisol levels.
               o Neonate can gain from the advantageous constituents of
                  maternal breast milk as it gets absorbed through the oral
                  mucosa.
               o Reaffirms mum the importance of her milk as it is a unique
                  contribution from mums to the treatment of their sick baby.

    2.2.2.   Factors that compromise the oral wellbeing of neonates include:
              Intubated neonates, surgical babies nursed in prone and babies
               with jaw abnormalities such as micronathia provides restricted
               access to oral mucosa causing difficulty in performing oral
               hygiene and thus mucosal deterioration
              Hyperthermia can cause dry mouth and coated tongue.
              Antibiotics can alter the mouth’s natural flora and increase the
               risk of opportunistic infection such as oral thrush.
              Some medications and oxygen therapy can cause dry mouth.

    2.2.3.   Procedure for mouth care
              Mouth care should be provided along with the daily cares and
               the frequency depends on the individual needs of the babies
               based on assessment. It should at least be provided once during
               the 12 hour shift.
              Gather the articles required for mouth care prior to initiation of
               daily care(cotton tip applicator, gauze, colostrum, sterile water
               and paper bag)
              Colostrum 0.2 – 0.3 ml should be drawn up in a syringe and
               labelled properly. It should be used in increments of not more
               than 0.1 ml to minimize risk of aspiration. Whenever available
               freshly expressed colostrum should always be the first choice for
               mouth care. Formula milk should not be used for mouth care.
              Perform hand hygiene and wear clean gloves. Suction the oral
               cavity if there are excess secretions or pooling of saliva.
              Dip clean gauze in sterile water and clean the lips. Discard it in
               the paper bag. Never re-dip a used swab.

                   Mouth Care Neonatal Clinical Guideline V1.0
                                 Page 4 of 10
 Dip a cotton bud in 0.1 ml of colostrum and apply over the lips. If
                        the oral cavity permits roll a thin layer of colostrum over the gum
                        line, buccal cavity and tongue.
                       Discard all used items including any excess milk. Sterile water to
                        be labelled for 24 hours and kept in the baby’s drawer.
                       Document the mouth care in intensive care charts, daily
                        feed/cares record and badger checklist.

           2.2.4.     Oral assessment
                       Assessment of the oral cavity should be done each time mouth
                        care is provided and should involve observation of
                       Lips and corners of mouth – should be smooth, pink and moist
                        with no signs of dryness, cracks, ulceration and bleeding.
                       Tongue – should be pink, moist and with a shiny appearance of
                        papillae. There should be no cracking, splitting, presence of oral
                        candida, redness and ulceration.
                       Saliva – should be thin and watery.
                       Mucous membranes – should be pink and moist. Check for
                        ulceration or candida.

                                      Assessment of mouth
                                  Undertaken at each mouth care
                 (Score written on chart where mouth care indicated and care plan)
                    Lips               Observation             0=smooth, pink, moist
                                                             1=coated, dry or cracked
                                                             2=ulceration or bleeding
                 Tongue                Observation             0=pink, moist papillae
                                                             1=coated/shiny + >/4suction)

           Consistency of oral              Observation                      0=Clear and clean
              secretions                                                     1=Thin and mucoid
                                                                           2=thick and discoloured
*Adapted from Jiggins M, Talibot J(1999) mouth care in PICU, pediatric nursing Dec/Jan11;(10):23-26

     2.3. Implementation
          This policy is to be communicated to all health care staff that have any
          contact with the neonates and families.

           Neonatal team members have the responsibility of supporting all parents to
           be confident in providing mouth care.

           All new staffs will be orientated to the policy on initiation of neonatal duty.
           Information will be given to the paediatrics team as well to support
           appropriate mouth care.

                             Mouth Care Neonatal Clinical Guideline V1.0
                                           Page 5 of 10
3. Monitoring compliance and effectiveness
Element to be     Compliance with policy
monitored
Lead              Neonatal Guidelines Lead- Chris Bell; Neonatal Consultant
Tool              Adherence to guidelines will be monitored as part of the ongoing
                  audit process on a Word or Excel template
Frequency         As dictated by audit findings

Reporting         Neonatal Audit and Guidelines Meeting
arrangements
Acting on         Neonatal Medical and Nursing teams
recommendations
and Lead(s)
Change in         Required changes to practice will be identified and actioned within
practice and      3 months, immediately if required. A lead member of the team will
lessons to be     be identified to take each change forward where appropriate.
shared            Lessons will be shared with all the relevant staff/stakeholders

4. Equality and Diversity
    4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
         service Equality and Diversity statement which can be found in the 'Equality,
         Inclusion & Human Rights Policy' or the Equality and Diversity website.

    4.2. Equality Impact Assessment

         The Initial Equality Impact Assessment Screening Form is at Appendix 2.

                        Mouth Care Neonatal Clinical Guideline V1.0
                                      Page 6 of 10
Appendix 1. Governance Information
Document Title                        Mouth Care Neonatal Clinical Guideline V1.0

This document replaces (exact
                                      New
title of previous version):
Date Issued/Approved:                 January 2021

Date Valid From:                      February 2021

Date Valid To:                        February 2024

Directorate / Department
                                      Lekshmi Balakrishnan; Neonatal Staff Nurse
responsible (author/owner):

Contact details:                      01872 252667

                                      Guidance on appropriate mouth care for neonatal
Brief summary of contents
                                      inpatients

Suggested Keywords:                   Mouth care, neonatal
                                            RCHT                 CFT             KCCG
Target Audience
                                             
Executive Director responsible
                                      Medical Director
for Policy:
Approval route for consultation
                                      Neonatal Guidelines team
and ratification:

General Manager confirming
                                      Mary Baulch
approval processes
Name of Governance Lead
confirming approval by specialty
                                      Caroline Amukusana
and care group management
meetings
Links to key external standards       No
Related Documents:                    None required
Training Need Identified?             No
Publication Location (refer to
Policy on Policies – Approvals        Internet & Intranet             Intranet Only
and Ratification):
Document Library Folder/Sub
                                      Clinical/ Neonatal
Folder

                        Mouth Care Neonatal Clinical Guideline V1.0
                                      Page 7 of 10
Version Control Table

             Version                                                     Changes Made by
   Date                                 Summary of Changes                (Name and Job
               No
                                                                              Title)
                                                                         Lekshmi
 September
             V1.0       Initial issue                                    Balakrishnan;
 2020
                                                                         Neonatal Staff Nurse

All or part of this document can be released under the Freedom of Information
                                   Act 2000

     This document is to be retained for 10 years from the date of expiry.
             This document is only valid on the day of printing

                             Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
 Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
               express permission of the author or their Line Manager.

                           Mouth Care Neonatal Clinical Guideline V1.0
                                         Page 8 of 10
Appendix 2. Equality Impact Assessment

               Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Mouth Care Neonatal Clinical Guideline V1.0
Directorate and service area:                   Is this a new or existing Policy?
Neonatal                                        New
Name of individual/group completing EIA         Contact details:
Neonatal Guidelines Group                       01872 252667
 1. Policy Aim
 Who is the
 strategy / policy /    The aim of this document is to outline the advantages of,
 proposal / service     and provide guidance on the use of colostrum in mouth care.
 function aimed at?

2. Policy Objectives
                         As above

3. Policy Intended
Outcomes
                        To improve the well-being of patients by offering the appropriate
                        management of patients

4. How will
you measure             Audit/Multidisciplinary team weekly discussion/incidents/risk
the outcome?            management

5. Who is intended
to benefit from the      Patients and staff
policy?
6a). Who did you                                       Local          External
                        Workforce      Patients                                     Other
consult with?                                          groups         organisations
                        x

b). Please list any      Please record specific names of groups:
groups who have
been consulted                  Neonatal Guidelines Group
about this procedure.
c). What was the
outcome of the
consultation?
                        Approved- 16th September 2020

                            Mouth Care Neonatal Clinical Guideline V1.0
                                          Page 9 of 10
7. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
                          Yes No        Unsure           Rationale for Assessment / Existing Evidence
Characteristic
 Age
                                   X
 Sex (male, female
 non-binary, asexual               X
 etc.)

 Gender
 reassignment                      X

 Race/ethnic                                           Any information provided should be in an
 communities                                         accessible format for the family’s needs – i.e.
 /groups                           X
                                                   available in different languages if required/access
                                                               to an interpreter if required
 Disability
 (learning disability,                               Those families with any identified additional
 physical disability,                               needs will be referred for additional support as
 sensory impairment,                                   appropriate- i.e. to the Liaison team or for
                                   X
 mental health                                                  specialised equipment.
 problems and some                                 Written information will be provided in a format to
 long term health                                  meet the family’s needs e.g. easy read, audio etc
 conditions)
 Religion/
 other beliefs                     X

 Marriage and civil
 partnership                       X

 Pregnancy and
 maternity                         X

 Sexual orientation
 (bisexual, gay,                   X
 heterosexual, lesbian)
 If all characteristics are ticked ‘no’, and this is not a major working or service
 change, you can end the assessment here as long as you have a robust rationale
 in place.
         I am confident that section 2 of this EIA does not need completing as there are no highlighted
         risks of negative impact occurring because of this policy.

Name of person confirming result of initial
                                                        Neonatal Guidelines Group
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis

For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead debby.lewis@nhs.net

                                Mouth Care Neonatal Clinical Guideline V1.0
                                             Page 10 of 10
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