Design and Evaluation of Clothing

for the Neonate

Mari E. Bergen
Linda Capjack
Linda G. McConnan
Elizabeth Richards

Abstract
Every day, countless premature babies begin their lives weeks or even months too early. Because of being born
at an early gestational age, the diminutive size of the neonate, coupled with medical problems, creates some unique
clothing needs. Hospitals often have difficulty meeting these clothing needs due to budget constraints and general
unavailability of the miniature sized and specially adapted clothing. This research used the functional design
process as the conceptual framework to design and evaluate clothing for the premature infant in the intensive care
setting. Six design criteria were identified from which specifications were developed and their interrelationships
explored through an interaction matrix. Prototype garments were evaluated by caregivers in the neonatal intensive
care setting in two hospitals. Results indicate that there is a definite need for clothing in a range of sizes with
special adaptations for the premature infant in the intensive care setting.
Key Words: neonate, clothing, functional design process

those whose body weight is more than three kilograms. In

Introduction addition, clothing for the neonate, adapted for use in the
neonatal intensive care unit is virtually nonexistent.
The purpose of this study was to develop garments for
Every day, countless premature babies, or neonates, the premature infant in the intensive care setting. The
begin their lives weeks or even months too early. Because research followed a functional design process that incorpo-
of being bom at an earlier stage in their gestational develop- rated an extensive literature search, user-group interviews,
ment, the birth weight of the neonate is often precariously anthropometric analysis, market analysis, and development
low, sometimes one-fifth to one-sixth the size of normal of criteria for design specifications. Finally an evaluation
newborns (Bendel, 1992). Their diminutive size, frequently of the prototype design was done by the caregivers.
coupled with medical problems, creates some unique cloth- The objectives of this study were to:
ing needs. Hospitals often have difficulty meeting these 1. develop specifications for a prototype garment for the
clothing needs due to budget constraints and the general premature neonate;
unavailability of the miniature sized and specially adapted 2. analyze specifications obtained and from this, develop a
clothing. Clothing for newborn babies is often donated to garment that would fit the premature infant and allow
hospital neonatal units by volunteer organizations and the access for the medical procedures performed in the neo-
public at large. Soliciting enough clothing to meet the natal intensive care unit;
demand is difficult enough, but finding it in the proper sizes 3. evaluate the prototype garment developed for the prema-
is an even bigger problem as few manufacturers address the ture infant in the neonatal intensive care setting on the
needs of the premature neonate (Bendel, 1992). &dquo;You can’tt basis of specifications developed.
go out and buy clothing that small ... The smallest ’new-
born’-size clothing is simply too big&dquo; (Bendel, 1992, p. 17).
Infant clothing is generally designed for full-term infants or
Related Literature

Author’s Addresses: Mari E. Bergen, Linda Capjack, Elizabeth Thermal Regulation

Richards, Department of Human Ecology, University of Alberta, The body mass of the newborn infant is a crucial factor
Edmonton, Alberta T6G 2M8, and Linda G. McConnan, Children’s
Health Centre of Northern Alberta, 1700 College Plaza, 8215 - 112 related to morbidity rates. The larger infant is able to main-
Street, Edmonton, Alberta T6G 2C8. tain core body temperature by generating heat more effi-

Downloaded from ctr.sagepub.com at The University of Iowa Libraries on June 15, 2015 225
ciently and having more fatty insulation than the premature (Brooten, 1992). With the incubator, the naked infant loses
infant. Philip (1987) writes that most term newborn babies the most heat by radiation to the cool inner walls but
(42 weeks gestation) can adapt to the average environmen- experiences decreased loss due to convection. In addition
tal temperatures (18 to 20°C) provided they are clothed and to the use of radiant warmer beds and forced air incubators,
wrapped in blankets. Lubchenco (1976) notes that the pre- Noerr (1984) notes that other methods to reduce heat loss
term infant is handicapped in his/her ability to maintain a include the application of clothing and the use of heat
normal body temperature. Heat loss is often greater than shields. Noerr also mentions that it is critical to be able to
that of a term infant due to the large surface to mass ratio reach the neonate quickly for emergency procedures such
and the limited ability to produce heat. Infants younger as intubation or the placement of chest tubes.
than 28 weeks gestation are at risk of heat loss through
evaporation. The infant’s skin at this gestational age is only Movement Analysis
two to three cells thick and contains little keratin, which Through observation of the premature infant in the
makes it prone to transepidermal water loss (leakage of neonatal intensive care unit, it was noted that the pre-term
fluid and subsequent evaporation). In addition, an infant of infant generally showed fewer body movements than full-
24 weeks gestation has 0.7% of body weight composed of term infants (L. McConnan, personal communication, Au-
fat, while a full-term infant has 11.3% of body weight gust, 1993). In contrast, however, Gaiter (1985) could find
composed of fat (Brooten, 1992). This larger percentage of no significant difference in the amount of movement be-
fat in the full-term infant provides increased insulation. tween term and pre-term infants during the acute phase of
The ultimate goal for the neonate is to maintain a neutral their illness. The premature infant and the critically ill full-
thermal environment (McConnan, 1992). This means that term infant tend to exhibit less muscle tone and lie in the
there is a balance between heat production and heat loss and extended (open) position as opposed to the flexed (fetal)
the temperature of the body core is therefore maintained. position for the full-term, well infant (Philip, 1987).
Skin temperature is maintained at between 36-36.5°C while
axillary temperature is maintained at 36.5-37.5°C. Tem- Anthropometric Analysis -

perature imbalance can result in hypothermia or Anthropometric measurements of the average total
hyperthermia and increased metabolic demands and oxy- body length (distance from the vertex of the head to the
gen requirements (Noerr, 1984). soles of the feet) of pre-term infants was found to be 35
Strothers (in Moffat & Hackel, 1985) reports reducing centimetres for a 27 week gestational age infant (Merlob,
the heat loss from an infant by as much as 25% by insulat- Sivan, & Reisner, 1984). Merlob, Sivan and Reisner give
ing the head only through the use of a gamgee tissue-lined values for the average arm length at 27 weeks gestational
cap. Moffat and Hackel note that this benefit is not surpris- age as 14 cm, lower limb as 12 cm, torso length as 13,
ing since the head accounts for about 21 % of the body while the chest circumference is 20 cm. Weight for a 27
surface area. They also mention a special cap and bunting week gestational age infant could vary between 750 and
that is available from Minnesota Mining and Manufactur- 2200 grams (Philip, 1987).
ing Co., 1983, which combines a semipermeable inner liner
with an effective thermal insulation. No evaluations were Pacification
found on this clothing system, but Moffat and Hackel sug- Catlett and Holditch-Davis (1990) note that distress in
gest that the bunting system would only be suitable for well the acutely ill premature infants can be reduced by using
babies as it limited access to the body trunk. pacification techniques to calm the infant and promote
The positive consequences of maintaining premature sleep. They suggest that the use of swaddling and non-
infants in a neutral thermal environment have been well nutritive sucking are quite effective. Since premature in-
documented. Buetow and Klein (1964) state that there is a fants generally become irritable with overstimulation, they
reduced mortality rate with a neutral thermal environment, can be soothed by the warmth and security of swaddling.
particularly with infants having a birth weight between Catlett and Holditch-Davis mention that although swad-
1250 and 1500 grams. In addition to reducing mortality dling of premature infants has not been studied in-depth,
rate, there is increased growth, both weight and length, if swaddling of normal full-term infants has been shown to
the premature infant is kept in a neutral thermal environ- reduce crying and increase sleep time. They suggest that
ment (Glass, Silverman, & Sinclair, 1968; Brooten, 1992). this intervention is also likely to benefit the acutely ill
Core temperature changes of as little as 0.5°C can nega- premature infant. The use of specially designed clothing
tively affect the neonate’s ability to cope with metabolic could also be used to reduce overstimulation and could
demands (Baumgart, 1991). pacify the premature infant.
Philip (1987) states that full term babies are better able None of the literature reviewed mentions the impor-
to modify their body temperature due to increased muscular tance of clothing for producing a feeling of well-being and/
activity. In addition, the full-term infant adopts a more or security in the neonate. Clothing designed specifically
flexed (fetal) position which minimizes the surface area for the smaller infant in the intensive care setting could
from which heat is lost (Philip). The premature infant tends provide a micro-environment to reduce heat loss, meet the
to lie in a more extended (open) position, making him/her medical procedure requirements of the intensive care unit,
prone to heat loss. and provide a sense of well-being and security in the infant.
Thermoregulation remains an important component of Parents also express a more positive feeling toward their
pre-term infant care, with the two most common approaches infants who look more &dquo;normal&dquo; in clothing (S. Jaines-
being through the use of incubators and radiant warmers Kelly, personal communication, March, 1993).

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 The functional design process gives continuity to design-
Design Process ing and moves the designer beyond the intuitive stage to look
for solutions. It is an externalized, systematic approach to
clothing design. Details of the process applicable to this
The need for clothing for special purposes, such as research are outlined in Figure 1. The need for specialized
sports activities, industrial use, energy conservation, and clothing for the neonate was identified by the director of the
medical use, is a growing field (DeJonge, 1984). DeJonge neonatal intensive care unit at a large urban hospital.
suggests that the design process must be objectified so that
the resulting design meets specific needs. The creative Interviews and Observations
process must be combined with strategy control so that all Through interviews with the directors of the neonatal
aspects of the problem are clearly defined and the problem intensive care units at two large urban hospitals, it was
being explored is approached from a holistic, creative and learned that all infant clothing used at the hospitals is
effective perspective. The functional design process takes donated by individuals and volunteer organizations. The
the designer step-by-step through the exploration of the factory-made clothing received is generally too large for
initial idea to the evaluation of the final design. the premature infant. Some hand-knitted garments are

Figure 1. The functional apparel design process.

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227
small enough, but there are not enough of these garments to personnel to attend to the problem. The garment should
meet the hospitals’ needs. Ideally, the clothing should therefore allow for easy donning and doffing with a
address some or all of the following concerns: minimum of intricate closures. The garment should also
1. Comfort - Comfort criteria identified for this project are allow access for the insertion of tubes, splints or other
seam type, fabric type, fit, and warmth. The skin of the medical procedures.
newborn infant is quite thin and fragile and subject to 5. Aesthetics - Parents often want their infants to look like
skin shear (abrasion of the top layer of skin). Bulky full-term &dquo;normal&dquo; infants. They like the infant dressed
seams could create a problem for the sensitive skin of the in colors appropriate to his/her sex. Garish colors and
neonate, particularly in areas where there is extensive designs suitable for older children are undesirable for the
movement or where the infant might lie on the seams. tiny premature infant. Blue or yellow garments can make
The fabric should be soft and non-abrasive. For a gar- an oxygen deficient or jaundiced infant appear more ill,
ment to be comfortable, it should not be too large or too thus creating more anxiety for the parents. The fabric
small on the neonate. The garment should provide warmth should have a non-abrasive texture and a soft hand.
and prevent loss of body heat. 6. Production - It was felt that the garment must be easy to
2. Safety - Since the premature infant is often attached to produce, perhaps by volunteer groups, and low in cost if
various medical apparati, the garment should have no the hospital was to purchase it from a manufacturer.
strings that could become wrapped around tubes or wires.
The movement of the infant might cause the apparatus to Design Specifications and Interaction Matrix
become dislodged, or garment strings could entangle Based on discussions with caregivers and observations
around the infant causing discomfort or endangering its in the neonatal intensive care units, an interaction matrix of
life. There should be no metal fasteners on the garment design specifications developed (Table 1). The inter-
was
which could become overheated during medical proce- action matrix was used to illustrate: specifications that
dures such as exposure to heat lamps. were in direct conflict with each other (0); specifications
3. Adjustability - Many pre-term infants have severe medi- that required accommodation to be in the same design (1);
cal problems that are not related to size. They may and specifications that created no conflict (2). Five pairs of
require operations on the chest or back. The garment specifications were identified as being in direct conflict.
would need to allow easy access to this area and accom- The first specification under comfort &dquo;not irritate the skin&dquo;
modate additional bandages or shunts. conflicted with number five &dquo;front or back opening&dquo;. It was
4. Accessibility - The additional medical problems of the felt that any extra seaming or bulk would be irritating to the
neonate might cause emergency situations where the premature infant’s fragile skin. The second specification
infant may have to be undressed rapidly to allow medical &dquo;minimal bulky seams&dquo; was also in direct conflict with

Table 1. Interaction matrix of garment specifcations for neonate garment.

*0 = Conflict; 1 =
Accommodation; 2 = No Conflict

228 Downloaded from ctr.sagepub.com at The University of Iowa Libraries on June 15, 2015
design specification number five since the opening would
add extra bulk and seaming. The same conflict existed with
design specification number eight &dquo;access for procedures&dquo;.
Any extra openings would create bulk and extra seaming.
Two other direct conflicts were identified: one between
specification number five &dquo;front or back opening&dquo; and num-
ber nine &dquo;look like normal clothing&dquo;; and the final one
between number six &dquo;adjustable width in chest&dquo; and num-
ber nine as well. Normal infant clothing seldom has a back
opening and it seldom has an adjustable chest width.
Although, other pairs of specifications did not directly
conflict, they did indicate a need for accommodation in the
design. One such area is between specification number
three &dquo;safe closures&dquo; and number five &dquo;front or back open-
ing&dquo;. Caregivers in the neonatal intensive care unit had
identified a need for a front or back opening in the garment,
but it could not have a metal closure due to the use of heat
lamps on the baby, nor could it have ties due to the danger
of entanglement in equipment or around the baby. Several
other specifications conflicted with production specifica-
tions number eleven and twelve. Complexity of production
as well as cost would increase with each additional feature
added to the garment.

Market Analysis .

A market analysis of suitable garments for the prema-

ture infant revealed a limited selection - all targeted at the
2270-2700 gram/50 cm. infant. This suggested weight is
only slightly smaller than that of the full-term infant. Most
garments were a sleeper style with metal snaps or a zipper
closure at the midline. Fabrics varied from blends of cotton
and polyester knits to 100% cotton in a variety of pastel
colors and small prints. Several pattern books were checked
for clothing patterns for the premature infant. The smallest
size found was for a 2350 gram/51 cm. infant. It was the
typical sleeper style as well.
Prototype Development
Prototype development focused on six design criteria
developed through interviews and observations: comfort,
safety, adjustability, accessibility, aesthetics, and produc-
tion. To test the six parameters on the garment’s accept-
ability, two garments were developed. Size specifications
for the prototype garments were based on the measure- Figure 3. Short garment for the neonate.
ments for an infant of 27 weeks gestational age (Merlob,
Sivan, & Reisner, 1984). This age was chosen as infants
bom after this gestational age have a higher survival rate
than those bom earlier. allow for rapid access to the infant in emergency situa-
One of the garments was a full length (35 cm.) bag tions, as well as adjustability for width. No string or metal,
design with fold-over closures at the ends of the sleeves closures were included. Access to the diaper area was
and bottom for warmth (Figure 2). The other was a short through the fold over closure at the bottom or the open
version of the same design, ending 22 cm. from the shoul- bottom in the short version.
der Figure 3). Both garments had a minimum number of To keep the garment light in weight and soft against
seams, placed in areas where they would minimize irrita- the baby’s skin, a polyester tricot (220 grams/meterz) with a
tion of the skin. A kimono style garment with no shoulder brushed inner surface was chosen. A knit fabric was chosen
seams was developed. To reduce seaming, fold-over clo- for its inherent stretch and comfort properties. The fabric was
sures for the bottom and sleeves were cut in one with the warm, easy care (machine wash and dry), inexpensive ($1.99
body. To avoid bulk at the midline, a zig zag asymmetric Canadian/meter), readily available and easy to work. Prior
closure, designed to be worn either to the front or the to adoption of the garments for institutional use, further
back, was included. Velcrol tape (2 cm. wide by 3 cm. testing would need to be done on the fabric to meet sleepwear
long) was used to hold the zig zag closure in place and to flammability requirements for each specific country.

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 A small overall print fabric on a white background was (n = 12 - not all respondents reported the baby’s length)
chosen for unisex garments. Other colors or prints might be The gestational age ranged from 27 to 34 weeks (42 weeks
suitable, but colors such as blue and yellow, which would is full-term), with the mean of 32.4 (n = 21).
accentuate the illness of jaundiced and oxygen deficient
infants, should be avoided. The fabric was pre-washed
before cutting out the garments. Raw edges of the front/ Table 2. Size and age range for neonates.
back, lower edge of sleeve and bottom edge of garment
opening were serged through a single layer (Stitch type 512
Mock Safety Stitch, United States Federal Standard 751a)
using a spun polyester thread. A spun polyester thread was
chosen for its fineness, strength and elasticity.
To retain the shape of the neckline, a polyester knit
ribbing was attached. The ribbing was stitched to the wrong
side of the garment and then folded over to the right side of
the garment and top stitched in place. The underarm and
side seams were serged (Stitch type 512 Mock Safety
Stitch, United States Federal Standard 751a) with wrong Evaluation Criteria Based on Comfort
sides together including the fold over closures at the ends of Comfort criteria evaluated were fit or garment size,
the sleeves and bottom in the seam. By having the seam seam type and placement, fabric type and use of fold-over
allowances on the outside of the garment, the comfort closures on the sleeves and bottom (Figure 4). When asked
issues associated with abrasiveness of seams was addressed. if the garment was suitable for a &dquo;preemie&dquo;, 82% of re-
Although a coverstitch or flat lock stitch would have been spondents were positive. There was some disagreement
flatter, it was not used as the fabric was very light weight over whether this was the most useful size as 45% thought
and stitches would still be exposed to the inner garment and it was and 22% thought it was not, while 33% were unable
the infant’s body. to decide if this was the most useful size. With the varia-
tion in sizes of the babies in the neonatal intensive care unit
Evaluation of the Prototype Garments at the time of this study, these results are not surprising.
Evaluation criteria for the prototype garments were Many caregivers commented that they would like to see a
based on the six design criteria developed through inter- variety of sizes both larger and smaller within the prema-
views and observations: comfort, safety, adjustability, ac- ture infant range.
cessibility, aesthetics, and production. Twenty long and Almost all of the respondents (96%) liked the seams
sewn to the outside and felt that this would prevent skin
twenty short prototype garments were produced. Ten of
each were sent to two neonatal intensive care units for irritation. When assessing if the fabric was soft enough for
evaluation. A nineteen question, two-page questionnaire the baby’s skin, 86% of the responses were positive. When
was included with the garments to test the evaluation asked if they thought the fold-over sleeve provided extra
criteria for the design developed. The questionnaire was warmth, 50% agreed, 10% disagreed, 36% neither agreed
reviewed by the faculty Human Ethics Review Committee. nor disagreed, and 4% had no response. A few caregivers
The hospitals did not require an additional ethical review. commented on the sleeve design and felt it could be wider
A covering letter explained the research project, outlined to accommodate an intravenous tube and arm board or
the design features incorporated in the garment and asked splint pad. Others liked the fold-over sleeve as it prevented
that caregivers (nurses working in the neonatal intensive the baby from scratching itself or from pulling out tubes
care units) try the garment on an infant they were caring for inserted in other parts of the body. One caregiver com-
and then fill out the questionnaire with their comments. mented that babies like sucking on their hands and the fold-
Caregivers were asked to rate the garment using a five-point over sleeve prevented this. As mentioned in the literature

Likert-type scale ranging from strongly agree to strongly review, Catlett and Holditch-Davis (1990) found that non-
disagree on the different design criteria. Extra comments nutritive sucking may reduce distress in acutely ill prema-
were encouraged under the questions for each criteria. ture infants. Having the foldover sleeve cover the hand is
optional with the design of the sleeve and caregivers could
assess which way to use it.
For those that evaluated the long garment with the
Results fold-over bottom (n = 15), 67% agreed that this feature
would provide extra warmth. Extra comments about the
fold-over bottom included that the &dquo;preemies&dquo; liked to be
Differentcaregivers evaluated 22 garments on 21 ba- tucked in or swaddled, and this feature accomplished that.
bies. One caregiver evaluated both a long and a short It provided the appearance of being secure and comfort-
garment on one baby. It was not specified how long the able. Another respondent felt the fold-over bottom was
garments were to remain on the baby before evaluating it as inconvenient when checking the diaper. For babies with a
this was not integral to the study. The garments were longer body length, there was a problem with the length of
assessed on babies ranging in weight from 780 - 2,000 the longer garment and the fold over bottom did not stay
grams (Table 2), with mean of 1579 grams (n 21). The = closed. A Velcro4l closure or a partially sewn lower edge
length ranged from 26 to 47 cm., with the mean of 38.9 cm. would alleviate this problem. The garment could also be

230 Downloaded from ctr.sagepub.com at The University of Iowa Libraries on June 15, 2015
 Figure 4. Evaluation based on comfort criteria.

made slightly longer. The long prototype garment was longer average body length (38.9 cm.) than that suggested
designed for a slightly shorter average body length than by Merlob, Sivan, and Reisner (1984) in the anthropometric
was found in this study. The babies in this evaluation had a analysis (35 cm.).

Figure 5. Evaluation based on accessibility, adjustability, and safety criteria.

Downloaded from ctr.sagepub.com at The University of Iowa Libraries on June 15, 2015 231
Evaluation Criteria Based on nous tube and splint pads. Of the 22 respondents, 18 felt

Accessibility, Adjustability and Safety that being able to use the garment with the closure to the
The criteria of accessibility and adjustability were front or back would be useful, although some noted that it
evaluated by examining the closure systems, the ease of would be worn mainly to the front. Several respondents
donning and doffing the garment, as well as the location of said that it was easier to reach the baby’s arm for blood
the openings (Figure 5). In evaluating the VelcroO closures pressure monitoring through a front closure. One caregiver
and their location, 82% felt that they were appropriately noted that very ill and tiny infants are often kept naked as
located, while 95% agreed that they worked well for this they do not tolerate handling well and rapid access is
garment and did allow for some adjustability. The collec- needed for medical procedures.
tion of lint in the Velcrol closures was mentioned as a
possible problem with repeated laundering. Garments were Evaluation Criteria Based on
not evaluated for durability in repeated laundering at this Aesthetics and Production
point; however, this would need to be done before adop- Ninety one percent of the respondents either agreed or
tion by an institution.
The abrasiveness of the Velcro4l closures against the
strongly agreed that the garments looked like normal infant
clothing (Figure 6). Almost all of the respondents (86%)
baby’s skin was identified as a possible problem, especially felt that seams sewn to the outside were acceptable and the
if the child were to lie on the closures. A few mentioned
that the closures should be smaller (2 cm. by 3 cm. on two style was pleasing. When asked if they would like this
locations along the front of the garment evaluated) and type of garment supplied to the neonatal intensive care
should be in four locations instead of two. The smaller unit, responses were all affirmative for both the long and
short garments. A few respondents mentioned that with
circular VelcroO closures could be used, but adjustability of
the suggested modifications, both garments would be ex-
the front or back opening would then be sacrificed. Grad-
ing patterns to more sizes, however, would alleviate the tremely useful. Some noted that the long garment was
need for adjustability. especially beneficial for the stable premature infant. For
For ease of donning and doffing, 64% agreed that the the more critical infants, some respondents felt the shorter
garment was easy to put on and take off. Suggestions for garment would be more serviceable.
Production costs were not assessed in this study. The
improvement included leaving the entire front of the gar-
ment open and adding additional Velcroll closures to hold researchers, however, felt that the seaming was minimal,
it in place; however, this option may make the garment too the fabric was reasonably priced, and the assembly was
stiff. In addition, suggestions were made for making the relatively simple with a serger, therefore, it was felt that
sleeve wider to allow the caregiver to reach in to pull the production costs would be low and the garments could
arm through as well as to allow for insertion of an intrave- easily be produced by volunteer groups or a manufacturer.

Figure 6. Evaluation based on aesthetics criteria.

232 Downloaded from ctr.sagepub.com at The University of Iowa Libraries on June 15, 2015
 the premature infant? A more difficult, but important,
Conclusions assessment needs to be done on the premature infant on
the effect of wearing clothing on its well-being, comfort,
and contentedness.
The functional design process provided a conceptual
framework for the design and evaluation of clothing for the
neonate in the intensive care setting. It provided an oppor-
tunity to identify the problem and explore the design situa- References
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