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Care of the Newborn: Proposed New Guidelines
British Journal of Midwifery
Abstract
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.
... At any age, assess the child and family's normal routine in order to incorporate this into care as much as is appropriate within the hospital setting. (Walker et al, 2005b, Blincoe, 2005, Blincoe, 2006aBlincoe, 2006b) as to whether products or water alone should be used, it is generally accepted that cleaning skin with water is as effective as other skin cleansing solutions (Fernandez et al, 2003;Trotter, 2004Trotter, , 2006Trotter, , 2007aTrotter, , 2007bTrotter, , 2008Beale, 2005Stokowski, 2006Trigg and Mohammed, 2006;Johnson and Taylor, 2010) in babies within the first month of life. (Mainstone, 2005, Walker et al, 2005aWalker et al, 2005b;Camm, 2006;Hale, 2007). ...
... There is recent agreement in the current literature that water alone is sufficient for skin cleansing and products are generally avoided ( Fernandez et al, 2003;Trotter, 2004Trotter, , 2006Trotter, , 2007Trotter, a, 2007bTrotter, , 2008Beale, 2005Stokowski, 2006Trigg and Mohammed, 2006;Johnson and Taylor, 2010). However, there are some conditions that require topical application, either as a treatment or to provide a skin barrier so preventing further excoriation. ...
... In addition, recommendations on the proper way to cleanse the diaper area are conflicting. Some professionals consider warm water and cotton balls to be the criterion standard (13,21,22), whereas others recommend disposable baby wipes for cleansing if a clean cloth and water are considered insufficient or are not available (15,20) or for use in general, as wipes are thought to be as good as or better than water-soaked washcloths (16,(23)(24)(25). ...
... Baby wipes as cleansers have become more and more common (24) because they are effective and easy to use, although baby wipe-induced dermatitis in adults has been described (36,37), causing some health professionals to encourage the use of water only (21). ...
Diaper dermatitis (DD) is one of the most common skin conditions in neonates and infants, with a peak between the ages of 9 and 12 months. Appropriate skin care practices that support skin barrier function and protect the buttocks skin from urine and feces are supposed to be effective in the prevention of DD. Despite many recommendations for parents and caregivers on proper diaper skin care, there is no up-to-date synthesis of the available evidence to develop recommendations for DD prevention practice. Therefore we performed a systematic literature review on the efficacy of nonmedical skin care practices on the diapered area of healthy, full-term infants ages 0 to 24 months. We identified 13 studies covering skin care practices such as cleansing, bathing, and application of topical products. DD prevalence and incidence and physiologic skin parameters were used as efficacy parameters. The results of this review indicate that cleansing of the diaper area using baby wipes or water and a washcloth have comparable effects on diapered skin. Bathing with a liquid baby cleanser twice weekly seems comparable with water alone. The application of ointments containing zinc oxide or petrolatum with or without vitamin A seems to have comparable effects on DD severity. There seems to be no information on whether single skin care practices such as cleansing, bathing, and application of topical preparations can prevent DD. High-quality randomized clinical trials are needed to show the effectiveness of skin care practices for controlling and preventing DD.
... The umbilical vessels are still patent for a few days following birth which provides direct access to the bloodstream. The devitalized tissue of the cord stump can be an excellent medium for bacteria, especially if the stump is kept moist or if unclean substances are applied to it [1,5,6,3,7,8,9,10,11]. ...
Aim: This study determined how Nigerian nursing mothers deal with umbilical cord care. Methods: This was a descriptive cross sectional study on 388 Nigerian nursing mothers. Study population was randomly selected using multistage sampling technique. A validated semi-structured questionnaire was performed and data was analyzed using the statistical package for social science (SPSS). Results: Most mothers (380 (97.9%)) cleaned babies' cord. It was 59 (15.2%) mothers who did not clean the cord at every time of changing the diaper. Regarding hand hygiene, only 88 (22.7%) washed their hands with soap. Only 217 (55.9%) cleaned the base of the cord first before the cleaning the surrounding skin. A razor was used to cut the cord in 186 (47.9%). Cord was clamped in 373 (96.1%), and cord clamp was made by tying the cord. A few mothers (131 (22.8%)) used chlorhexidine to the cord disinfaction, while 116 (29.9%) still used herbs. There was a significant Original Research Article Udosen et al.; AJMPCP, 2(2): 1-12, 2019; Article no.AJMPCP.49424 2 relationship between levels of education, income, number of children on cord care practice (P=0.00, 0.00, 0.019). Conclusion: Many women in this area dealt with the cord in their own way and the incidence of chlorhexidine use, which is a recommended disinfection, was very low. Safety cord procedure/disinfection should be urgently educated. The present data may be useful to further making health policy strategy regarding cord hygiene in this area. This data may be also generalizable to any other developing countries.
... 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][4][5][6][7] Therefore, this article is based on the opinion of experts in the field and recent research studies undertaken. ...
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.
... Professional debate has been divided between the use of water only (Trotter, 2004) for skin cleansing in the early weeks and mild pH neutral products manufactured specifically for term newborn skin (Hopkins, 2004). ...
... Lund, Osborne, et al. 2001) evaluated a clinical guideline for optimum neonatal skincare based on best evidence in relation to bathing practices, and use of emollients. Although the sample mainly included preterm infants, the results indicated that bathing in water alone, use of neutral baby cleansing products, and increased use of emollients improved skin condition (Lund et al.) have subsequently been translated into contemporary care of healthy term newborns in the United Kingdom (Trotter, 2004). More recently, Brennan (2010) reinforced the water-only message over concerns that the side effects associated with infant toiletries are not monitored with the United Kingdom (Medicines and Healthcare Products Regulatory Agency, 2007). ...
To explore the complexities of diaper area cleansing reported by women participating in a randomized controlled trial designed to compare optimally formulated baby wipes (Johnson's Baby Skincare fragrance free wipe) with cotton wool and water.
A mixed-method design incorporating quantitative and qualitative methods to explore maternal views and experiences of using baby wipes or cotton wool and water to cleanse their newborn's diaper area over an 8-week period.
Participants were recruited from a large regional maternity hospital in Northern England.
Participants included 280 women and their healthy term newborns; 252 provided 4-week data (90.0%) and 237 provided 8-week data (85.0%).
Data from diaries and structured face-to-face interviews at 4 weeks and telephone interviews at 8 weeks were transcribed and thematically analyzed to identify themes. Quantitative data were compared between randomized groups using descriptive statistics and two-group tests, where appropriate.
Major themes identified highlighted the practical realities of diaper area cleansing, diaper area cleansing and everyday life, and living with the rhetoric that water is best. Baby wipes were perceived as more convenient efficient at cleansing. Some women using cotton wool and water did not cleanse skin after urination alone. Diaper changing was significantly more frequent in the baby wipes group at 4 weeks, but there was no significant difference between the groups at 8 weeks.
Women are faced with a complex environment regarding diaper area cleansing and need clear evidence-based advice and guidance on effective diaper area cleansing.
... Despite the limitations of these studies, all authors concluded that there was good skin tolerance of wipes and no evidence of harm, even when used on dermatitis skin [14]. Conversely, baby wipe-induced dermatitis in adults has also been documented [15,22] causing some health professionals to question the potential harm associated with the use of baby wipes and promote water use only [23]. However, water may not be an innocuous cleansing agent. ...
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.
... Professional debate has been divided between the use of water only (Trotter, 2004) for skin cleansing in the early weeks and mild pH neutral products manufactured specifically for term newborn skin (Hopkins, 2004). ...
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:
In the absence of definitive evidence relating to the use of soaps, detergents and emollients on the skin of the term neonate, we undertook a postal survey in the north west of England to establish the use and distribution of these products. Three surveys (antepartum, intrapartum and postpartum) were sent to all 29 maternity units. Seventy questionnaires were returned (80%). A total of six different bathing and cleansing products and ten products for dry skin were stocked within maternity units for use on neonates. Five were listed as being distributed to women. Seventeen products were recommended by midwives for the treatment of dry skin. Some respondents indicated that they did not always know what was distributed to postnatal women. Four of the units submitted guidelines. One of these was comprehensive. We conclude that, in this particular region, a range of products were used and recommended. In the absence of any definitive evidence in this area, it is important that formal research is undertaken into the potential benefits or harm of these products.
Maintaining the health of a newborn's skin is an essential part of infant care and the choice of both nappies and hygienic nappy care play an important role in achieving this. The critical care points where compromise can occur are identified as the time the infant spends in a wet nappy (leading to mechanical, chemical and microbial trauma), the cleansing routine of the skin at nappy change time, the steps taken to preserve the skin's own defence mechanisms and control of infection through avoiding contamination of clothes, bedding and carers by faeces and urine. The purpose of fitting a nappy to an infant is to reduce the risk of clothes, bedding and carers becoming contaminated with faeces and urine and to help the baby's skin stay healthy by preventing soreness. However, great care needs to be taken to establish a routine to maintain skin health and hygiene whether at home or in a hospital setting.
IntroductionAssessment of the neonatal skinCare of the neonatal skin: a consistent approach to practiceCommon skin lesions in neonateExamination of the jaundiced newbornAssessment of gestational ageConclusion
AcknowledgementsReferences
Overview
This learning module focuses on the aetiology, prevention and treatment of nappy rash in newborns and infants. The module discusses evidence and research on nappy rash, including recommendations for the ideal barrier treatment. It also highlights the role of the health visitor in supporting parents with practical advice in managing nappy rash.
In Jordan, despite being one of the most modern countries in the Middle East, postnatal care services are still under-utilized by rural Jordanian mothers. The purpose of this study is to explore, analyse and critique the postnatal cultural health beliefs, knowledge and practices of rural Jordanian mothers.
a critical ethnographic approach was used to critically investigate the cultural health issues of 13 rural Jordanian postpartum mothers from four rural areas in the Northeast governorate which is characterized rural populated governorate. The findings showed that rural Jordanian mothers depended on the cultural health beliefs and knowledge to perform the postnatal care practices.
most of the rural Jordanian postpartum mothers depended on cultural beliefs and practices as a mode of health seeking behavior, in preference to available government health care services for care of their infants. Thus the rural Jordanian mothers are in need of supportive health educational services to increase their level of health knowledge and enhance the recommended health practices.
It is essential that neonatal skin maintains its integrity and pH balance, in order for it to carry out its pre-programmed duty of creating a protective barrier to ward off infections and to protect its functions of thermoregulation, fat storage, immuno surveillance and prevention of excessive fluid loss. Some argue that if the skin is immediately exposed to chemicals it could disrupt these processes. As a result some believe that infants should be washed with water only for the first month of life, particularly those infants who are born prematurely. While others have found that reducing the frequency of baths, but still using cleansing products can also have a positive effect on neonatal skin. Both schools of thought do however, agree that cleansing products used on neonatal skin should be very mild and pH neutral. As there is not very much conclusive research in this area, it is essential that midwives keep themselves up-to-date with the latest evidence-based research
The fact that there are no national guidelines regarding the routine skin care of newborns, both term and preterm, can prove difficult for the health carer, and calls for there to be more rigorous, research based studies in this area. But there are many tried and tested methods that have developed protocols aimed at keeping an infant's skin as healthy as possible. Not only does it require a good skin care routine but the products used on an infant's skin need to be assessed also. One of the major areas of concern for an infant's skin health is nappy rash. There are many choices of nappy available on the market today, and there have been many research studies into the most appropriate product to use, to ensure an infant's skin is kept as dry as possible. Although there is evidence that disposable nappies fare better than cloth ones, there is no hard evidence that cellulose core based nappies are better than cellulose core with absorbent gelling material nappies.
The skin is the largest organ of the human body, and has the important duty of creating a protective barrier for the neonate, to fight off infections and defend its programmed functions, such as thermoregulation, fat storage, immunosurveillance and the prevention of excessive fluid loss. There is unfortunately little research available defining the best method of ensuring that infant skin is kept at its healthiest, but two schools of thought have developed over the past five years. One argues for a water-only policy in the first month of life, while the other states that cleansing products can be used if kept to a minimum both in frequency and amount. Both however do agree that cleansers used on babies skin should be both mild and pH neutral. Despite such informal guidelines however, skin disturbances are still fairly widespread, particularly nappy rash and cradle cap. Even though it is taken as a given that such occurrences are commonplace in newborns, it is not necessarily the case. More research in this area is definitely needed in order to establish set guidelines for a uniform approach to infant skin care.
It is essesntial that neonatal skin maintains its integrity and pH balance in order for it to carry out its duty of creating a protective barrier to ward off infections, and also to protect its functions of thermoregulation, fat storage, immunosurveillance and prevention of excessive fluid loss. Some have argued that if the skin is immediately exposed to chemicals such as creams and bubble bathe it could disrupt these processes. As a result of this some believe that neonates should be washed with water only for the first month of life, particularly those babies who have been born prematurely. Both schools of thought do agree however that any cleansing products that are used on neonatal skin should be very mild and pH neutral. There is little conclusive research in this area so it would be beneficial if a large scale study were to be carried out to help set guidelines for a uniform approach to neonatal skin care.
Human exposure to potentially toxic environmental chemicals is major concern to our society. Over-the-counter (OTC) skin care products are a potential source of environmental chemical exposure to newborns. A prospective study was undertaken to define existing newborn bathing practices and quantitate environmental chemical exposure from OTC skin care products. One hundred-ninety six mothers of infants discharged from our newborn nursery were asked to respond to a questionnaire concerning newborn bathing practices and OTC skin care product usage. Complete questionnaires were returned by 23% of the mothers. The average newborn had 8 ± 3 (± SEM) skin care products applied with the resultant exposure to 48 ± 18 different environmental chemicals. Forty-seven percent of our respondents used a baby powder. The average one month old was bathed 4 times a week and was shampooed 3 times weekly. Seventy-eight percent of the respondents reported that their newborn had a rash but only 45% of those reporting a rash sought professional medical advice. Thirty-seven percent of the mothers reporting a rash made a change in bathing practice or product selection. In view of our findings, the human newborn is exposed to a large number of environmental chemicals thorough topical OTC preparations. The efficacy, transcutaneous absorption and potential toxicity of these products should be investigated.
Histological development of the epidermis was studied on skin samples from 169 infants (gestation 24-40 weeks, age up to 1 year). Gestation markedly influenced epidermal development. Before 30 weeks, the epidermis is thin, has few cell layers and a poorly formed stratum corneum, but by 34 weeks it has largely matured. Postnatal influence on epidermal development is marked in the preterm infant, so that histologically the epidermis of the most immature infant resembles that of a term infant by 2 weeks of age. These changes in histology exactly parallel the development of the barrier properties of newborn skin.
Diaper dermatitis may result after repeated or prolonged contact of skin with urine and feces. A hairless mouse model was used to elucidate the role of urine in this process. The results of this work suggest that an important function of urine in the etiology of diaper dermatitis is to increase the pH of the diaper environment by breaking down urea in the presence of fecal urease. This rise in pH increases the activities of fecal proteases and lipases, which can damage skin. Urine can also increase the permeability of diapered skin to irritants and can directly irritate skin when exposure is prolonged.
The barrier properties of the skin were examined in 223 studies in 70 newborn infants of 25 to 41 weeks' gestation, aged from 1 hour to 26 days. Percutaneous drug absorption was studied by observing the blanching response to solutions of 1% and 10% phenylephrine applied to a small area of abdominal skin. Skin water loss was measured at the same site using an evaporimeter. Infants of 37 weeks' gestation or more showed little or no drug absorption and had low skin water losses, indicating that their skin is an effective barrier. By contrast, infants of 32 weeks' gestation or less showed marked drug absorption and high skin water losses in the early neonatal period, indicating that their skin is defective as a barrier. Both drug absorption and water loss in these infants fell steadily; by about 2 weeks of age the skin of the most immature infants functioned like that of mature infants. The varying barrier properties can be explained by the poor development of the stratum corneum in the more premature infants at birth and its rapid maturation after birth. The trauma caused to the skin by use of adhesive tape and the fixation of transcutaneous oxygen electrodes resulted in increased drug absorption and water loss from the damaged area.
The prevalence of peanut allergy appears to have increased in recent decades. Other than a family history of peanut allergy and the presence of atopy, there are no known risk factors.
We used data from the Avon Longitudinal Study of Parents and Children, a geographically defined cohort study of 13,971 preschool children, to identify those with a convincing history of peanut allergy and the subgroup that reacted to a double-blind peanut challenge. We first prospectively collected data on the whole cohort and then collected detailed information retrospectively by interview from the parents of children with peanut reactions and of children from two groups of controls (a random sample from the cohort and a group of children whose mothers had a history of eczema and who had had eczema themselves in the first six months of life).
Forty-nine children had a history of peanut allergy; peanut allergy was confirmed by peanut challenge in 23 of 36 children tested. There was no evidence of prenatal sensitization from the maternal diet, and peanut-specific IgE was not detectable in the cord blood. Peanut allergy was independently associated with intake of soy milk or soy formula (odds ratio, 2.6; 95 percent confidence interval, 1.3 to 5.2), rash over joints and skin creases (odds ratio, 2.6; 95 percent confidence interval, 1.4 to 5.0), and oozing, crusted rash (odds ratio, 5.2; 95 percent confidence interval, 2.7 to 10.2). Analysis of interview data showed a significant independent relation of peanut allergy with the use of skin preparations containing peanut oil (odds ratio, 6.8; 95 percent confidence interval, 1.4 to 32.9).
Sensitization to peanut protein may occur in children through the application of peanut oil to inflamed skin. The association with soy protein could arise from cross-sensitization through common epitopes. Confirmation of these risk factors in future studies could lead to new strategies to prevent sensitization in infants who are at risk for subsequent peanut allergy.
Background:
The failure of patients to take medicines in a way that leads to clinical benefit is a major challenge. A consensus has emerged that, on average, compliance sufficient to obtain therapeutic objectives occurs about half the time, with noncompliance contributing to therapeutic failure in the other half. These figures refer to simple oral regimens. There has been little work assessing compliance/concordance with complex treatment regimens for atopic eczema. Asthma schools led by specialist nurses have been shown to improve knowledge, use of therapies and clinical outcome.
Objectives:
To determine the effect of education and demonstration of topical therapies by specialist dermatology nurses on therapy utilization and severity of atopic eczema.
Methods:
Fifty-one children with atopic eczema attending a paediatric dermatology clinic were followed for up to 1 year. At each visit the parent's knowledge about atopic eczema and its treatment and therapy utilization was recorded. The severity of the eczema was recorded using the six area, six sign atopic dermatitis severity score (SASSAD) and parental assessment of itch, sleep disturbance and irritability. At the first visit a specialist dermatology nurse explained and demonstrated how to use all of the topical treatments. This education was repeated at subsequent visits depending on the knowledge of the parent.
Results:
At baseline less than 5% of parents had received/recalled receiving any explanation of the causes of eczema or demonstration of how to apply topical treatments. The eczema was poorly controlled in all children (mean SASSAD 42.9). Of the children, 24% were not being treated with any emollient cream/ointment; the mean use was 54 g weekly. Of the children, 25% were being inappropriately treated with potent or very potent topical steroids. Following repeated education and demonstration of topical therapies by a specialist dermatology nurse, there was an 89% reduction in the severity of the eczema. The main change in therapy utilization was an 800% increase in the use of emollients (to 426 g weekly of emollient cream/ointment) and no overall increase in the use of topical steroids, accounting for potency and quantity used.
Conclusions:
This study reinforces the importance of specialist dermatology nurses in the management of atopic eczema. It also confirms the opinion of patients, patient support groups, dermatologists and best practice guidelines that the most important intervention in the management of atopic eczema is to spend time to listen and explain its causes and demonstrate how to apply topical therapies.
Evolution of skin barrier function in neonates. Doctoral dissertation.University of California
- L B Nonato