Infant skin care
Key learning points:
uUnderstand the unique needs of newborn skin
uCurrent evidence and opinion on best practice in infant skin care
uThe role of the health visitor to advise and support new parents to make informed
Skin care and how to prevent irritations, rashes and
infections will be a signiﬁcant concern for new
parents. Health visitors can play an important role
in offering advice and support. To do this they must
have a good knowledge and understanding of the
anatomy and physiology of skin in general, and
know the dif ferences between the skin of an infant
and that of an adult. It is also vitally important that this advice and
support is based on the best available evidence.
There are important differences between the infant and adult
skin. The skin of a newborn is well developed to cope with
extra-uterine life, but there are some differences to that of an
adult. For example, an infant’s skin is more delicate and therefore
more prone to irritant and allergic reactions.1
The key differences are described by Steen and Macdonald1
Stratum corneum (epidermis) is thinner in infants.
Protective lipid ﬁlm is similar to that of an adult at birth, but
changes after a few weeks.
Secretion of sebum diminishes to be replaced by lipids of
Ratio of skin surface to body weight is highest at birth and
declines progressively during infancy.
A newborn’s skin will undergo a number of changes during the
ﬁrst month of life as it adapts to an extra-uterine environment.
During this time period the epidermis and dermis is further
developed and there is a noticeable change in the baby’s skin pH
surface and desquamation of the skin.2
CLEANSING AND MOISTURISING A BABY’S SKIN
Over the last two decades, concerns have been voiced regarding
the possible effects of bathing and using cleansers such as soaps,
baby wash products and baby wipes.3-7 Therefore, this article is
based on the opinion of exper ts in the ﬁeld and recent research
A baby does not routinely have to be bathed every day,8
although some parents will have a preference to do so and many
will bathe their baby in the evening with the aim of rela xing and
settling their baby for the night.1 It has been reported that there are
no adverse effects in bathing a healthy full-term baby with a body
temperature above 36.5oC.9 However, a study involving the
bathing of premature babies reported adverse physiological and
behavioural effects and therefore routine bathing was not
The use of a pH neutral cleanser and emollient application that
is specially designed for a baby skin has been reported to have a
good safety proﬁle.11 However, a ﬁne balance between the
cleansing of an infant’s skin and the preservation of its
homeostatic properties is required. Cleansers need to be
extremely mild in their properties to prevent excessive removal of
lipids from the stratum corneum, as these are essential to the
In addition, it has been highlighted that the chemical composi-
tion of water needs to be taken into consideration.12 Water rich in
calcium salts is more likely to be an irritant to an infant’s skin.
Being reared in a geographical area where hard water is supplied
may increase the potential risk of skin irritation.
The National Institute of Health and Care Excellence (NICE)
guidelines on postnatal care did not identify any research studies
that speciﬁcally addressed general care of the skin of a full-term
infant.13 Therefore, a grade D good practice point (GPP) was made
on the experience of the guide development group (GDG). In view
of the lack of research evidence, they recommended that parents
should be advised that cleansing agents should not be added to a
Nursing in Practice: Healt h Visito r Supple ment May/June 2013
‘Water rich in calcium salts is
more likely to be an irritant to
an infant’s skin’
Dr Mary Steen
Professor of Midwifery
Faculty of Health & Social Care
University of Chester
HEALTH VISITOR SuppLEmEnT
www.nursinginpractice.comNursing in Practice: Health Visitor Supplement May/June 201324
baby’s bath water nor should lotions or medicated wipes be used.
However, should a cleansing agent be needed, a ‘mild non-per-
fumed soap’ can be suggested.
Due to a lack of research evidence to conﬁrm or refute whether
a cleansing agent should be added to an infant’s bath water or not
and also whether baby wipes are safe to use, two research studies
have recently been under taken by Lavender et al.14 -15 The research-
ers compared Johnson’s Baby Top-to-Toe wash against plain bath
water on 307 newborn babies over a four-week period and found
washing newborn babies in a speciﬁc baby wash was just as safe
as using water alone in terms of maintaining healthy skin. The
study found no difference in transepidermal water loss ( TEWL),
which indicates the amount of water that escapes from the skin.
This research also repor ted that skin hydration was better in the
wash agent group when compared to the water only group at the
two-week time measurement point. The second study investigated
whether Johnson’s Baby Extra Sensitive Wipes were safe to use
and found these to be equivalent to the use of water and cotton
wool in terms of skin hydration. Mothers taking par t in this study
also reported nappy rash as being higher in the water and cotton
wool group. These studies provide the strongest evidence to date.
Health visitors can advise parents on the basis of this recent
evidence, to support them to make informed choices.
Parents should be advised to never use cleansing products that
are speciﬁcally manufactured for adults, as many of these are not
pH neutral and will not be mild enough for a sensitive baby’s skin.
There is recent evidence to conﬁrm that a baby wash product
was safe to use and does not appear to affect an infant’s skin
barrier integrity, and that baby wipes were also safe to use. It is
therefore sensible to use cleansers that have been specially
designed for a baby’s skin, are pH neutral and very mild to avoid
irritant dermatitis and allergic dermatitis.
Ultimately, choices on how best to care for an infant’s skin will
be made by parents who will consider the best available evidence
and exper t opinion in order to make their decision on their personal
preferences and beliefs.
1. Steen M, Macdonald S. A revi ew of baby skin care. Midwives Online
RCM, Aug/S ept 2008. Availa ble at: www.rcm.org.uk /magazin es/
2. Hoegar PH, Enzmann CC. Ski n physiology of the neonate and yo ung
infant: a prospective stud y of functiona l skin parameters during early
infancy. Pediatric Dermatology 2002;19(3):256-62.
3. Tupper RA, Pinnagoda J, Coenraads PJ, Nater JP. Evaluation of
detergent induced irr itant skin re actions by visu al scoring an d
transepidermal water loss measurement. Dermatologic Clinics
199 0;8 (1):3 3-5.
4. Gfatter R, Hackl P, Braun F. Effects of soap and deterg ents on skin
surface pH, stratum cor neum hydration and fat content in i nfants.
Dermatology 1997;19 5:258 -62 .
5. Lund C, Kulle r J, Lane A, Loft JW, Raines DA. Neon atal skin care: the
scientiﬁc basis for practice. JOGNN 1999;28(3):241-54.
6. Darmstadt GL, Mao-Q iang M, Chi E, Saha S K, Ziboh VA, Black RE,
Santosha m M, Elias PM. Impact of topical oils o n the skin barr ier:
possible implications for neonatal health in developing countries. Acta
7. Trotter S. Care of the newborn: propos ed new guidelines. British
Journal of Midwifer y 2004;12(3):152-7.
8. Lund C, Kulle r J, Lane A, Lott JW, Raines D, Thomas K. Neonatal skin
care: evaluation of the AWHONN/NANN research-based practice
project o n knowledge a nd skin care practices. JOGNN 2 00 1;
9. Penny-Mac Gillivray TA. Newborn’s ﬁrst bath: when? Journal of
Obstetri cs and Gynecology: Neonatal Nursing 19 96 ;25: 48 1-7.
10. Peters KL. Bathing premature infants: physiologic al and behavioural
consequences. American Journal of Critical Care 1998;7(9):90-100.
11. Hopkin s J. Essentials of n ewborn skin c are. British Journal of Midwi fery
2 0 0 4 ;1 2( 5 ) : 3 14 - 7.
12. Mc Nally NJ, Williams HG, Philips D R, Smaillman-Raynor M, Lewi s S,
Venn A, Britton J. Atopic eczema and domestic water hardness. Lancet
13. National Institu te for Health and Clinical Exc ellence. Post natal care:
routine p ostnatal care fo r women and thei r babies. London: NICE;
2006. Available at: www.nice.org.uk/nicemedia/pdf/CG037fullguideline.
14. Lavender T, Bedwell C, Roberts SA, Har t A, Turner MA, Carter LA,
Cork MJ. Randomized, Controlled Trial Evaluating a Baby Wash
Product on Skin Barrier Function in He althy, Term Neonates. Journal of
Obstetri c, Gynecologic, & Neonatal Nu rsing 2013 ;42:2 03–14 .
15. Lavender T, Furber C, Campb ell M, Victor S, Roberts I, Bedwell C, Cork
MJ. Effect on skin hydratio n of using baby wip es to clean the na pkin
area of newborn babies: assessor-blinded randomised controlled
equivalence trial. BMC Pediatrics 2012;12:59.
‘A ﬁne balance between
the cleansing of an infant’s
skin and the preservation of
its homeostatic properties is
HEALTH VISITOR SuppLEmEnT