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What does current evidence advocate as best practice in skin care for the healthy term infant?
Abstract
Caring for newborn babies’ skin is a subject about which parents frequently seek advice from health visitors. An increase in incidences of eczema and other dry skin conditions (Simpson et al, 2009) means it is vital that the advice given is based on current evidence that will promote skin integrity from the beginning of extrauterine life. This article reviews the current evidence available to support bathing practices and the advice regarding applying oils to an infant's skin. It also considers advice on using moisturisers and emollients and the importance of being able to demonstrate correct application of these products to maximise benefits and reduce symptoms when dry skin conditions develop.
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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.
Unlabelled:
Topical therapy to enhance skin barrier function may be a simple, low-cost, effective strategy to improve outcome of preterm infants with a developmentally compromised epidermal barrier, as lipid constituents of topical products may act as a mechanical barrier and augment synthesis of barrier lipids. Natural oils are applied topically as part of a traditional oil massage to neonates in many developing countries. We sought to identify inexpensive, safe, vegetable oils available in developing countries that improved epidermal barrier function. The impact of oils on mouse epidermal barrier function (rate of transepidermal water loss over time following acute barrier disruption by tape-stripping) and ultrastructure was determined. A single application of sunflower seed oil significantly accelerated skin barrier recovery within 1 h; the effect was sustained 5 h after application. In contrast, the other vegetable oils tested (mustard, olive and soybean oils) all significantly delayed recovery of barrier function compared with control- or Aquaphor-treated skin. Twice-daily applications of mustard oil for 7 d resulted in sustained delay of barrier recovery. Moreover, adverse ultrastructural changes were seen under transmission electron microscopy in keratin intermediate filament, mitochondrial, nuclear, and nuclear envelope structure following a single application of mustard oil.
Conclusion:
Our data suggest that topical application of linoleate-enriched oil such as sunflower seed oil might enhance skin barrier function and improve outcome in neonates with compromised barrier function. Mustard oil, used routinely in newborn care throughout South Asia, has toxic effects on the epidermal barrier that warrant further investigation.
The maintenance of good skin in newborns is important to enable the skin to protect the body from infection and other toxins. This article examines the evidence around the products and information which is available to parents and health professionals in order to provide optimum care for infants. The lack of research to guide policies and protocols for care of the skin hinders the provision of evidence-based care (Steen, 2008). Parents need to be informed about how to cleanse their infant's skin, and how to prevent and treat nappy rash and other common skin problems in newborns.
Throughout infancy, skin differs from that of an adult in structure, function, and composition and has water-handling properties that are markedly distinct. Although competent to prevent dehydration, immature skin barrier function leaves infants especially vulnerable to the environment with potential for development of skin irritations elicited, for example, by contact with allergens or exposure to harsh climatic conditions. To this is added a relatively high risk for the development of the inflammatory disease atopic dermatitis. Specially formulated moisturizers are thus needed that respect the specific properties of infant skin and protect it by enhancing the barrier properties without interfering with the natural development.
Olive oil is commonly recommended by health professionals to new parents for use in the prevention and treatment of the term baby's dry skin, and for baby massage. There is no evidence to support this practice. The use of olive oil may be harmful to skin, affecting skin barrier function. This effect may be a contributory factor in the prevalence of childhood conditions such as atopic eczema. This paper discusses a national online audit of UK maternity hospitals (n = 67) and neonatal units (n = 33) performed between November 2010 and January 2011. Our findings confirm that oil use on babies' skin is common practice. As the direct cost to the NHS for treatment of atopic eczema is high, it is imperative that further research in this area is performed, preferably in the form of a randomized controlled trial. Health professionals will then be in a position to provide accurate information to parents with regard to oil in baby skin care regimens.
This article reviews current advances in the understanding of eczema, a common chronic inflammatory and itchy skin condition where there are subtle defects in the protein structure and function of the skin barrier. Parent and carer education in management and use of treatments is key and, as most children develop eczema under the age of 4 years, health visitors are well placed to help and support families with education and practical demonstrations about the use of emollients and topical corticosteroids. Food allergy in young children with moderate or severe atopic eczema should be considered in the presence of faltering growth and gastrointestinal symptoms.
Atopic eczema is a chronic inflammatory, dry skin condition characterised by an itchy red rash (National Institute for Health and Clinical Excellence, 2007). The role of the health visitor is important in supporting parents who have children with atopic eczema, as they are often the first health professional to see the infant's skin and hear about the concerns of the parent. Emollients are effective when treating and managing atopic eczema, and topical corticosteroids are effective for the management of acute flare-up as they can relieve symptoms of itching and treat inflammation. However, it is also important to consider trigger factors such as food allergens. Giving parents information on trigger factors and how to manage these will empower them to gain control of their infant or child's atopic eczema.
Caring for neonatal skin is a key area where parents will seek advice from midwives and health professionals. It is important therefore to have an understanding of the composition of neonatal skin and differences to adult skin that make it more delicate. An overview of current research into bathing, cleansing of the nappy area and the cord area is provided. Health professionals need to provide guidance and yet it important not to raise anxiety levels in parents with too many rules about what is right and what is not, particularly as there is room for further evidence in this field.
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.
Skin care practices involving the application of products to the skin are common. This article focuses on these aspects of infant skin care, the importance of skin barrier function and how the use of products and therapies applied to the skin can affect skin‑barrier function. It also challenges current practice and tradition, and highlights the evolving body of research into practice and tradition.
Natural oils are advocated and used throughout the world as part of neonatal skin care, but there is an absence of evidence to support this practice. The goal of the current study was to ascertain the effect of olive oil and sunflower seed oil on the biophysical properties of the skin. Nineteen adult volunteers with and without a history of atopic dermatitis were recruited into two randomized forearm-controlled mechanistic studies. The first cohort applied six drops of olive oil to one forearm twice daily for 5 weeks. The second cohort applied six drops of olive oil to one forearm and six drops of sunflower seed oil to the other twice daily for 4 weeks. The effect of the treatments was evaluated by determining stratum corneum integrity and cohesion, intercorneocyte cohesion, moisturization, skin-surface pH, and erythema. Topical application of olive oil for 4 weeks caused a significant reduction in stratum corneum integrity and induced mild erythema in volunteers with and without a history of atopic dermatitis. Sunflower seed oil preserved stratum corneum integrity, did not cause erythema, and improved hydration in the same volunteers. In contrast to sunflower seed oil, topical treatment with olive oil significantly damages the skin barrier, and therefore has the potential to promote the development of, and exacerbate existing, atopic dermatitis. The use of olive oil for the treatment of dry skin and infant massage should therefore be discouraged. These findings challenge the unfounded belief that all natural oils are beneficial for the skin and highlight the need for further research.
In recent years, there have been continuing efforts to understand the effects of baby skin care routines and products on the healthy development of baby skin. Such efforts aim ultimately to determine the best infant skin care practices. The pediatric and dermatologic communities have not reached consensus on what constitutes an appropriate cleansing practice. In the United States, guidelines for neonatal skin care have been developed, propagated, and implemented. The accumulated knowledge has promoted evidence-based clinical practices and, therefore, may help to improve clinical outcomes, although these guidelines primarily cover the care of preterm newborns and the treatment of those with other health problems. High-level, long-term clinical evidence of the effective and safe cleansing of healthy, full-term newborns and infants is scarce. This review presents a comprehensive analysis of the scientific literature on baby skin development, cleansing practices, and related products (for healthy newborns and babies) since 1970. The evidence drawn from the reviewed literature can be summarized as follows: Bathing immersed in water seems generally superior to washing alone. Bathing or washing with synthetic detergents (syndets) or mild liquid baby cleansers seems comparable with or even superior to water alone. Nevertheless, larger randomized clinical trials with age-defined cohorts of babies as well as more-defined parameters are required to identify optimal practices and products for skin cleansing of healthy infants. These parameters may include standardized skin function parameters such as transepidermal water loss, stratum corneum hydration, skin surface pH, and sebum production. Clinical skin scores such as the Neonatal Skin Condition Score may be employed as outcome measures.
Please cite this paper as: Functional skin adaptation in infancy – almost complete but not fully competent. Experimental Dermatology 2010; 19: 483–492.
Abstract: Early postnatal life is a period of active functional reorganization and cutaneous physiological adaptation to the extrauterine environment. Skin as the outermost organ of mammalians is endowed of multiple functions such as protection, secretion, absorption and thermoregulation. Birth stimulates the epidermal barrier maturation and the skin surface acidification especially in premature infants. In full-term infants the developed stratum corneum accomplishes competent barrier function, in contrast to prematures. Complete barrier maturation in preterm infants is fulfilled by 2–4 weeks of the postnatal life. However, in preterms with 23–25 weeks gestational age this process takes longer. Versatile regulatory mechanisms, namely skin surface acidity, calcium ion gradient and nuclear hormone receptors/ligands are interrelated in the complex postnatal newborn adaptation. The skin of newborns is adjusting quickly to the challenging environmental conditions of the postpartum. However, certain functions, for example, microcirculation, continue to develop even beyond the neonatal period, that is, up to the age of 14–17 weeks. Different environmental factors (for instance, dry and cold climate, diapers and cosmetic care procedures) influence the postnatal development of skin functional parameters such as stratum corneum hydration and the permeability barrier especially in premature infants. The aim of this article is to summarize the current knowledge on skin physiology in newborn and infants with a practical approach and to discuss the possible clinical consequences. This review offers the readership a critical and practical overview of skin physiology in newborns and infants. It emphasizes possible new research fields in neonatal and infantile skin physiology.
Development of the skin barrier continues up to 12 months after birth; therefore, care must be taken when cleansing and bathing infants' skin. Available guidelines for skin care in newborns are, however, limited. In 2007, the 1st European Round Table meeting on 'Best Practice for Infant Cleansing' was held, at which a panel of expert dermatologists and paediatricians from across Europe aimed to provide a consensus on infant bathing and cleansing.
Based on discussions at the meeting and a comprehensive literature review, the panel developed a series of recommendations relating to several aspects of infant skin care, including initial and routine bathing, safety while bathing, and post-bathing procedures. The panel also focused on the use of liquid cleansers in bathing, particularly relating to the benefits of liquid cleansers over water alone, and the criteria that should be used when choosing an appropriate liquid cleanser for infants. Alkaline soaps have numerous disadvantages compared with liquid cleansers, with effects on skin pH and lipid content, as well as causing skin drying and irritation. Liquid cleansers used in newborns should have documented evidence of their mildness on skin and eyes, and those containing an emollient may have further benefits. Finally, the panel discussed seasonal differences in skin care, and issues relating to infants at high risk of atopic dermatitis. The panel further discussed the need of clinical studies to investigate the impact of liquid cleansers on skin physiology parameters on newborns' and infants' skin.
Bathing is generally superior to washing, provided basic safety procedures are followed, and has psychological benefits for the infant and parents. When bathing infants with a liquid cleanser, a mild one not altering the normal pH of the skin surface or causing irritation to skin or eyes should be chosen.
Breakdown of the skin barrier is the first event in the development of atopic eczema (atopic dermatitis). Research over the past five years has indicated that this arises as a result of the interaction of environmental agents such as soap and other detergents with the products of changes in several genes. These genetic changes predispose to the breakdown of the skin barrier, which allows the penetration of allergens, triggering a flare of atopic eczema. This new understanding of how breakdown of the skin barrier is the first event in the development of atopic eczema provides a rationale for a renaissance in the use of a complete emollient therapy regimen in atopic eczema and related skin barrier breakdown diseases, such as asteatotic eczema and irritant contact dermatitis.
The prevalence of eczema, particularly in younger children, increased substantially over the second half of the 20th century. Analysis of primary healthcare data-sets offers the possibility to advance understanding about the changing epidemiology of eczema.
To investigate recent trends in the recorded incidence, lifetime prevalence, prescribing and consulting behaviour of patients with eczema in England.
QRESEARCH is one of the world's largest national aggregated health databases containing the records of over nine million patients. We extracted data on all patients with a recorded diagnosis of eczema and calculated annual age-sex standardized incidence and lifetime period prevalence rates for each year from 2001-2005. We also analysed the consulting behaviour of these patients when compared with the rest of the QRESEARCH database population. The number of eczema prescriptions issued to people in England was also estimated.
The age-sex standardized incidence of eczema was 9.58 per 1000 person-years in 2001 and increased to 13.58 per 1000 patients in 2005 (p<0.001). By 2005, eczema affected an estimated 5,773,700 (95% confidence intervals [CI] 5,754,100-5,793,400) individuals in England, who, on average, consulted a general practitioner 4.02 (95% CI 4.01-4.03) times a year. During the study period, the number of eczema related prescriptions increased by 56.6% (95% CI 56.6-56.7), so by 2005 an estimated 13,690,300 (95% CI 13,643,200-13,737,600) prescriptions were issued.
Recorded incidence and lifetime prevalence of eczema in England continue to increase. Similar increases have also been observed in the estimated number of eczema prescriptions issued to the English population.
The epidermal permeability barrier appears to be regulated primarily by the lamellar arrangement of lipid bilayers between coneocytes of the stratum corneum and presents a significant barrier to the transdermal delivery of drugs. The aim of the present study was to investigate the effects of oleic acid on the ultrastructure of stratum corneum lipids in rat skin. Wistar rats were treated topically with 10% oleic acid/propylene glycol for 2 h, the structure of stratum corneum was examined by electron microscopy using osmium tetroxide or ruthenium tetroxide postfixation, and the epidermal barrier function was evaluated in a lanthanum tracer study. Ultrastructural examination revealed that there was a marked alteration in the stratum corneum and the tracer penetrated into the intercellular spaces of the stratum corneum after application of oleic acid. These results suggest that ruthenium tetroxide postfixation is a powerful tool for the study of the stratum corneum lipid structure. Oleic acid might increase the epidermal permeability through a mechanism involving the perturbation of stratum corneum lipid bilayers and lacunae formation to enhance transdermal drug delivery.