WHO CLEANS YOUR OCTOPUS? AN OBSERVATION OF CLEANING BEHAVIOURS AND BACTERIAL COLONISATION OF TOYS IN A NEONATAL UNIT.

Editor,

Toys remain a fixture of neonatal intensive care units despite being proven reservoirs of nosocomial microbes.1 A survey of 13 neonatal units in the UK2 identified variation in procurement and cleaning procedures and testing for fomites. Washing toys is proven to reduce the bacterial load of potential pathogens.3 However there remains variation between units, regarding who has responsibility for cleaning toys, and what the interval between washes should be.

Toys within neonatal units have recently received a significant boon in press coverage. A movement originating from Aarhus, Denmark has seen knitted octopodes become an increasing fixture in neonatal units, with hospitals worldwide issuing public appeals for their procurement via social media. Despite emotive stories about the benefits of such woollen crustaceans there remains a paucity of published data proving they help regulate infant breathing, or reducing heart rate as is oft claimed anecdotally. Whilst the physiological benefits of toys in the neonatal setting are yet to be corroborated or refuted by robust testing, they are unlikely to disappear from units. Toys are often preferred by parents, they humanise an otherwise intensely clinical environment. Their presence allows parents to provide a touch of the child friendly environment, similar to that enjoyed on maternity and paediatric wards alike.

In a 13 bed neonatal unit, we tested all toys for colonization and observed for cleaning behaviours. No prompting was given to the parents to procure, remove or clean toys. Parents were free to supply, remove or take any toy for cleaning as they deemed fit, representing no change in established clinical practice. Toys that were removed for cleaning and returned by the parents were recorded.

During testing the operator washed their hands with the 7 step technique and donned sterile gloves before removing the toy, swabbing the entire surface with a moistened sterile swab and replacing the toy. The same procedure was repeated on day 3, day 7 and day 14 of the toy's sojourn in the neonatal unit.

The anonymised swabs were cultured on plates of MacConkey agar and Columbia blood agar. Results were not communicated from the lab until after the study period.

Figure 1 displays the prevalence of those micro-organisms cultured.

Figure 1.

NICU Toy swabbing audit 2018

The positive culture rate of the toys was 72-82%. The predominant organisms in the first week were Coagulase-negative Staphylococcus (CoNS) and Micrococcus species, (skin commensals). The predominant Gram-negative organism was Acinetobacter Iwoffii (an environmental organism). Group B Streptococcus was found on one toy, Escherichia coli on 2 toys. Pseudomonas pudita was cultured from a toy on day 14. Pseudomonas has gained notoriety in neonatal circles as recent outbreaks were associated with mortality in this population.4

Of the 28 toys enrolled into this study none were removed for cleaning and thereafter returned by the parents during the 3 month study period. A policy which depends on parents washing toys frequently under their own volition e.g. as suggested by octopusforapremie.com, was unsuccessful. After 7 days failure to do so seemingly increases the risk of colonisation by Gram-negative organisms including pseudomonas.

Yours sincerely

Dr Michael McGowan (Consultant Paediatrician),

Dr Peter Yew (Consultant Microbiologist),

Dr Ryan Graydon (Senior Biomedical Scientist),

Doris Wilson (Advanced Neonatal Nurse Practitioner),

Claire Boyce (Advanced Neonatal Nurse Practitioner),

Dr Nivedita (Nita) Saxena (Consultant Paediatrician) Ulster Hospital, Dundonald.