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Infant Skin Care

  • University Of Northumbria Newcastle


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 differences 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. 23
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
cellular origin.
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
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
studies undertaken.
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
surface ecosystem.1
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
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: /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
Paediatr 2002;91:546-54.
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:
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 infants
skin and the preservation of
its homeostatic properties is
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
To examine the hypothesis that the use of a wash product formulated for newborn (<1 month of age) bathing is not inferior (no worse) to bathing with water only. Assessor-blinded, randomized, controlled, noninferiority trial. A teaching hospital in the Northwest of England and in participants’ homes. Three-hundred-and-seven healthy, term infants recruited within 48 hours of birth. We compared bathing with a wash product (n = 159) to bathing with water alone (n = 148). The primary outcome was transepidermal water loss (TEWL) at 14 days postbirth; the predefined difference deemed to be unimportant was 1.2. Secondary outcomes comprised changes in stratum corneum hydration, skin surface pH, clinical observations of the skin, and maternal views. Complete TEWL data were obtained for 242 (78.8%) infants. Wash was noninferior to water alone in terms of TEWL (intention-to-treat analysis: 95% confidence interval [CI] for difference [wash–water, adjusted for family history of eczema, neonate state, and baseline] −1.24, 1.07; per protocol analysis: 95% CI −1.42, 1.09). No significant differences were found in secondary outcomes. We were unable to detect any differences between the newborn wash product and water. These findings provide reassurance to parents who choose to use the test newborn wash product or other technically equivalent cleansers and provide the evidence for health care professionals to support parental choice.
Full-text available
Some national guidelines recommend the use of water alone for napkin cleansing. Yet, there is a readiness, amongst many parents, to use baby wipes. Evidence from randomised controlled trials, of the effect of baby wipes on newborn skin integrity is lacking. We conducted a study to examine the hypothesis that the use of a specifically formulated cleansing wipe on the napkin area of newborn infants (<1 month) has an equivalent effect on skin hydration when compared with using cotton wool and water (usual care). A prospective, assessor-blinded, randomised controlled equivalence trial was conducted during 2010. Healthy, term babies (n=280), recruited within 48 hours of birth, were randomly assigned to have their napkin area cleansed with an alcohol-free baby wipe (140 babies) or cotton wool and water (140 babies). Primary outcome was change in hydration from within 48 hours of birth to 4 weeks post-birth. Secondary outcomes comprised changes in trans-epidermal water loss, skin surface pH and erythema, presence of microbial skin contaminants/irritants at 4 weeks and napkin dermatitis reported by midwife at 4 weeks and mother during the 4 weeks. Complete hydration data were obtained for 254 (90.7 %) babies. Wipes were shown to be equivalent to water and cotton wool in terms of skin hydration (intention-to-treat analysis: wipes 65.4 (SD 12.4) vs. water 63.5 (14.2), p=0.47, 95% CI -2.5 to 4.2; per protocol analysis: wipes 64.6 (12.4) vs. water 63.6 (14.3), p=0.53, 95% CI -2.4 to 4.2). No significant differences were found in the secondary outcomes, except for maternal-reported napkin dermatitis, which was higher in the water group (p=0.025 for complete responses). Baby wipes had an equivalent effect on skin hydration when compared with cotton wool and water. We found no evidence of any adverse effects of using these wipes. These findings offer reassurance to parents who choose to use baby wipes and to health professionals who support their use. Current Controlled Trials ISRCTN86207019.
Full-text available
This article is not available through ChesterRep. This article describes and discusses the findings from a structured review of baby skin care and guidelines based on the best available evidence which was undertaken on behalf of the Royal College of Midwives. Health professionals and parents can download the full article from the RCM URL:
Full-text available
In adults the influence of cleansing preparations on the pH, fat content and hydration of the skin is well documented. Studies in newborn and small infants have not been reported. Our study aimed at examining whether similar effects can be ascertained in infants. Infants without skin disease, aged 2 weeks to 16 months, entered an open, controlled and randomized study. Ten infants each had skin washed with tap water (control group), liquid detergent (pH 5.5), compact detergent (pH 5.5) or alkaline soap (pH 9.5). The pH, fat content and hydration were measured before and 10 min after cleansing. Findings were statistically evaluated by parametric covariance analysis. The skin pH increased from an average of 6.60 after cleansing in all groups. The smallest increase (+0.19) was observed in the control group, the largest (+0.45) after washing with alkaline soap. After treatment with liquid or compact detergent, the increase of the pH was only 0.09 higher than for the control group. In comparison to the compact and liquid detergents, the alkaline soap group had a significantly higher increase in pH. The fat content (mean starting value: 4.34 micrograms/cm2) decreased after washing in all groups; the smallest effect was observed in the control group (decrease of 0.93 micrograms/cm2), the highest for the alkaline soap group (decrease of 4.81 micrograms/cm2). In comparison to the compact and liquid detergents, the alkaline soap group had a higher decrease in fat content. This difference was significant for compact detergents. No statistically significant differences were observed for hydration before versus after washing. Each cleansing agent, even normal tap water, influences the skin surface. The increase of the skin pH irritates the physiological protective 'acid mantle', changes the composition of the cutaneous bacterial flora and the activity of enzymes in the upper epidermis, which have an acid pH optimum. The dissolution of fat from the skin surface may influence the hydration status leading to a dry and squamous skin.
Effective care of newborn skin is based on a thorough understanding of both the physiology and specific environment of infant skin. The essentials of newborn skin care are effective cleansing, effective moisturizing and the maintenance of an effective barrier against external irritants. An evidence-based clinical practice guideline published by the Association of Women's Health, Obstetric and Neonatal Nurses in the USA confirms that modern baby care products for cleansing, moisturizing and barrier protection, which meet the guidelines for being pH neutral and having a good safety profile, are safe and effective for neonatal skin care.
This article questions the potential harm associated with early overuse of skincare manufactured products. There is an undeniable need for standardized guidelines that can be introduced nationally, which will inform and educate. Although predominantly involving skincare and cord care, it is important to remember that anything placed on, in or around the neonate has the capacity to harm. With this in mind, and with no available evidence to support their use, it is no longer appropriate for hospitals to supply free, products that are clearly not relevant to the care of the neonate. These new guidelines will not only simplify and supersede previous advice, but also encompass the role of health promotion. This role, which is central to every midwife, cannot be underestimated. If, as a result of the new guidelines, less babies go on to develop skin conditions, then the savings in treatment alone could be considerable. Not withstanding the emotional and psychological effects of such conditions, this, in the cost-effective climate of today's NHS, must be seen as evidence-based practice at its most effective.
Transepidermal water loss measurements proved to be more accurate and sensitive than visual scoring in discriminating the irritating action of detergents on the skin. Further, the baseline transepidermal water loss might be a reliable indicator of an individual's susceptibility to weak irritants.
To determine the effects of early admission bathing on thermoregulation in newborns. Randomized, comparative study. A regional hospital providing primary and secondary newborn care. One hundred healthy, full-term newborns. Newborns in the investigational group with a minimum rectal temperature of 36.5 degrees C. were bathed after the newborn admission assessment examination was completed (M = 61.15 minutes of age), whereas newborns in the control group were bathed at the standard of 4 hours of age (M = 252.12 minutes of age). Rectal temperatures were measured using a Diatek thermometer. Rectal temperatures were recorded during the newborn admission assessment examination, immediately before bathing, immediately after bathing, 1 hour after bathing, and 2 hours after bathing. No significant differences (p < .05) in rectal temperatures, were found between the groups during the admission assessment examination, before bathing, immediately after bathing, 1 hour after bathing, or 2 hours after bathing. No significant differences were found between the groups in type of delivery, time of birth, gestational age, birth weight, Apgar scores at 1 and 5 minutes, air temperature, apical heart rate, or respiratory rate. Healthy, full-term newborns whose rectal temperatures are greater than 36.5 degrees C can be bathed immediately after the admission assessment examination.
Routine procedures are a large component of the caretaking day for preterm infants. Such procedures can have profound adverse effects on an infant's condition, to the point of disrupting normal growth and development. Despite this evidence, routine procedures are perpetuated in the neonatal ICU. To determine the physiological and behavioral effects of a supposedly beneficial procedure, a sponge bath, on premature infants. The study sample consisted of 14 preterm neonates with no neurological abnormalities at two tertiary neonatal ICUs. The ages of the subjects were 28.1 to 31.8 weeks postconception and 4 to 25 days after birth. The study was a prospective, quasi-experimental, repeated-measures design in which each infant acted as his or her own control. Oxygen delivery, heart rate, oxygen saturation, and behavioral responses were continuously recorded by computer or real-time videotape. Physiological and behavioral parameters were compared across three phases: 10 minutes before a bath (baseline), during a standardized bath, and 10 minutes after the bath. Physiological and behavioral disruptions occurred throughout the bath phase and in many cases beyond that phase. These disruptions included significant increases in heart rate, cardiac oxygen demand, and frequency of behavioral motoric cues. Significant decreases in oxygen saturation also accompanied the bath. Nine infants required increased concentrations of ambient oxygen. A significant association was found between physiological components and the frequency and timing of behavioral motoric cues. The results provide further evidence that routine care is not innocuous to neonates. Routine sponge bathing is not recommended for care of ill premature infants.