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Module 4. The prevention, treatment and management of nappy rash in newborns and infants
Abstract
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.
... Therefore, it is essential that vernix is not removed at birth. 1,2,3 The skin is the largest organ of the body and contributes to the body's defence mechanisms. It acts as a barrier to bacteria, balances water and electrolytes, and stores fat to help regulate body temperature. ...
... It is important to dry the area gently and thoroughly afterwards. 1 Around a third of all babies and toddlers wearing nappies will suffer from nappy rash, 2 which can be caused by: a baby's skin being in contact with wet or soiled nappies for a long time the nappy not fitting well and rubbing against a baby's skin not cleaning or drying the nappy area effectively or changing the nappy often enough soap, detergent or bubble bath alcohol-based baby wipes a fungal infection a baby recently taking antibiotics. ...
... If the area looks infected, it is important to seek medical attention for treatment. 1,2,4 A nappy cream can be applied to the skin as a treatment for nappy rash or as a preventative measure. While this is not supported by evidence it is suggested as the best expert recommendation. ...
The physiology of a newborn baby’s skin is delicate, and it is important to understand how the skin develops in the first few weeks of life and how to care for their sensitive skin. Therefore, careful consideration should be taken when deciding what cleansing agents and products to use on a baby’s skin.
The human skin acts as the interface between the individual and the external environment. In many ways, it is the window to the rest of the human body. The skin serves many functions that regulate the body's temperature, assist in the immune defenses, and facilitate fluid and electrolyte regulation. The newborn and infant skin undergoes many changes as it matures. Sometimes, these changes are caused by toxic exposures and result in rashes, dermatitis, or other skin eruptions. Other times, skin thickens and becomes more of a barrier against adverse invasions. The skin is also used as a surface for topical treatments. This article explores the physiology of the newborn's and infant's skin, pathologic conditions as they relate to topical administration of medications, and, finally, the nursing implications of such usage. Copyright © 2001 by W.B. Saunders Company
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.
To assess the association between primary tooth eruption and the manifestation of signs and symptoms of teething in infants.
An 8-month, longitudinal study was conducted with 47 noninstitutionalized infants (ie, receiving care at home) between 5 and 15 months of age in the city of Diamantina, Brazil. The nonrandomized convenience sample was based on the registry of infants in this age range provided by the Diamantina Secretary of Health. Eligible participants were infants with up to 7 erupted incisors and no history of chronic disease or disorders that could cause an increase in the signs and symptoms assessed in the study. Tympanic and axillary temperature readings and clinical oral examinations were performed daily. A daily interview with the mothers was conducted to investigate the occurrence of 13 signs and symptoms associated with teething presented by the infants in the previous 24 hours.
Teething was associated with a rise in tympanic temperature on the day of the eruption (P = .004) and with the occurrence of other signs and symptoms. Readings of maximal tympanic and axillary temperatures were 36.8°C and 36.6°C, respectively. The most frequent signs and symptoms associated with teething were irritability (median: 0.60; P < .001), increased salivation (median: 0.50; P < .001), runny nose (median: 0.50; P < .001), and loss of appetite (median: 0.50; P < .001).
Irritability, increased salivation, runny nose, loss of appetite, diarrhea, rash, and sleep disturbance were associated with primary tooth eruption. Results of this study support the concept that the occurrence of severe signs and symptoms, such as fever, could not be attributed to teething.
Functional differences between infant and adult skin may be attributed to putative differences in skin microstructure. The purpose of this study was to examine infant skin microstructure in vivo and to compare it with that of adult skin. The lower thigh area of 20 healthy mothers (ages 25-43) and their biological children (ages 3-24 months) was examined using in vivo noninvasive methods including fluorescence spectroscopy, video microscopy, and confocal laser scanning microscopy. Stratum corneum and supra-papillary epidermal thickness as well as cell size in the granular layer were assessed from the confocal images. Adhesive tapes were used to remove corneocytes from the outer-most layer of stratum corneum and their size was computed using image analysis. Surface features showed differences in glyph density and surface area. Infant stratum corneum was found to be 30% and infant epidermis 20% thinner than in adults. Infant corneocytes were found to be 20% and granular cells 10% smaller than adult corneocytes indicating a more rapid cell turnover in infants. This observation was confirmed by fluorescence spectroscopy. Dermal papillae density and size distribution also differed. Surprisingly, a distinct direct structural relationship between the stratum corneum morphology and the dermal papillae was observed exclusively in infant skin. A change in reflected signal intensity at approximately 100 mum indicating the transition between papillary and reticular dermis was evident only in adult skin. We demonstrate in vivo qualitative and quantitative differences in morphology between infant and adult skin. These differences in skin microstructure may help explain some of the reported functional differences.
Skin water barrier development begins in utero and is believed to be complete by week 34 of gestational age. The goal of this investigation was to assess the dynamic transport and distribution of water of the stratum corneum of infants and compare it to those of adults. The interaction of water with the stratum corneum was assessed by measuring capacitance, transepidermal water loss (TEWL), rates of absorption-desorption as well as Raman spectra as a function of depth (a total of 124 infants (3-12 months) and 104 adults (14-73 years)). The results show that capacitance, TEWL, and absorption-desorption rates had larger values consistently for infant stratum corneum throughout the first year of life and showed greater variation than those of adults. The Raman spectra analyzed for water and for the components of natural moisturizing factor (NMF) showed the distribution of water to be higher and have a steeper gradient in infants than in adults; the concentration of NMF was significantly lower in infants. The results suggest that although the stratum corneum of infants may appear intact shortly after birth (<1 month), the way it stores and transports water becomes adult-like only after the first year of life.
Nappy rash is a general definition used to describe a range of inflammatory reactions of the skin in the nappy area, often it is a mild condition that affects most babies at some time. There appear to be key times when infants become more prone to nappy rash. This article describes these trigger points from a parents prospective and provides skin care advice to help manage and treat the condition.
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.
Nappy rash is generally a mild condition that affects most infants at some time. Community nurses are very well placed to reassure parents and give advice about managing and preventing this common condition.
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 (Kuller et al, 2001). The baby's nappy has been subject to a remarkable number of improvements since the first disposables appeared on the market; from the first use of super absorbent polymers, through to the large scale use of refastenable tape and the incorporation of petrolatum-based ointment transfer systems, to the introduction of the first breathable nappies.
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.
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.
Maintaining the health of a newborn's skin is an essential part of infant care and the choice of nappies and hygienic nappy-care plays 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 soil and urine. There are factors common to infant care in both home and hospital although it is recognised there are added risks when many infants are cared for together.
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.
Diaper dermatitis is a highly prevalent condition that causes discomfort and stress for patients and frustration for healthcare staff. Diaper technology has evolved to substantially lessen the severity of diaper dermatitis, but additional improvements are needed. Premature infants and incontinent adults are particularly at risk for developing diaper dermatitis and its potential consequences. Contributing factors include overhydration, irritants, friction, increased skin pH, diet, gestational age, antibiotic use, diarrhea and medical condition. Treatments aim to reduce hydration, provide a semipermeable 'layer' to facilitate skin barrier repair, shield the skin from irritants, deactivate specific fecal components and maintain skin surface contact. The published research on the effects of diaper dermatitis treatments is especially sparse. Controlled clinical trials are needed to provide definitive evidence for selection of effective treatments. This article discusses the incidence and etiology of diaper dermatitis in infants and adults. It provides the scientific basis for repair of diaper skin barrier damage and describes recent developments that will be available in the future.
Recommendations vary regarding immediate antimicrobial treatment versus watchful waiting for children younger than 2 years of age with acute otitis media.
We randomly assigned 291 children 6 to 23 months of age, with acute otitis media diagnosed with the use of stringent criteria, to receive amoxicillin-clavulanate or placebo for 10 days. We measured symptomatic response and rates of clinical failure.
Among the children who received amoxicillin-clavulanate, 35% had initial resolution of symptoms by day 2, 61% by day 4, and 80% by day 7; among children who received placebo, 28% had initial resolution of symptoms by day 2, 54% by day 4, and 74% by day 7 (P=0.14 for the overall comparison). For sustained resolution of symptoms, the corresponding values were 20%, 41%, and 67% with amoxicillin-clavulanate, as compared with 14%, 36%, and 53% with placebo (P=0.04 for the overall comparison). Mean symptom scores over the first 7 days were lower for the children treated with amoxicillin-clavulanate than for those who received placebo (P=0.02). The rate of clinical failure--defined as the persistence of signs of acute infection on otoscopic examination--was also lower among the children treated with amoxicillin-clavulanate than among those who received placebo: 4% versus 23% at or before the visit on day 4 or 5 (P<0.001) and 16% versus 51% at or before the visit on day 10 to 12 (P<0.001). Mastoiditis developed in one child who received placebo. Diarrhea and diaper-area dermatitis were more common among children who received amoxicillin-clavulanate. There were no significant changes in either group in the rates of nasopharyngeal colonization with nonsusceptible Streptococcus pneumoniae.
Among children 6 to 23 months of age with acute otitis media, treatment with amoxicillin-clavulanate for 10 days tended to reduce the time to resolution of symptoms and reduced the overall symptom burden and the rate of persistent signs of acute infection on otoscopic examination. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00377260.).
Multiple skin sites and the gastrointestinal tract of 57 infants with otitis media were cultured quantitatively for Candida albicans before and after antibiotic therapy. Ten days of systemic therapy with amoxicillin was associated with a twofold increase in the recovery of C. albicans from the rectum and skin. Infants who developed diaper dermatitis had a significant increase in the number of C. albicans organisms recovered from these sites. We conclude that the use of amoxicillin increases the risk for developing diaper dermatitis.
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 strength of the association between diaper dermatitis and measurements of skin wetness and skin pH was evaluated by statistical analysis of four diaper trials involving 1601 infants. Although the strength of the association between skin wetness and diaper dermatitis was greater than that between skin pH and diaper dermatitis, increases in wetness and pH were both significantly associated with elevated mean grades for diaper dermatitis. The skin environment least likely to be associated with diaper dermatitis is one in which increases in both skin wetness and skin pH are minimized.
This article reviews side-effects of fragrance materials present in cosmetics with emphasis on clinical aspects: epidemiology, types of adverse reactions, clinical picture, diagnostic procedures, and the sensitizers. Considering the ubiquitous occurrence of fragrance materials, the risk of side-effects is small. In absolute numbers, however, fragrance allergy is common, affecting approximately 1% of the general population. Although a detailed profile of patients sensitized to fragrances needs to be elucidated, common features of contact allergy are: axillary dermatitis, dermatitis of the face (including the eyelids) and neck, well-circumscribed patches in areas of "dabbing-on" perfumes (wrists, behind the ears) and (aggravation of) hand eczema. Depending on the degree of sensitivity, the severity of dermatitis may range from mild to severe with dissemination and even erythroderma. Airborne or "connubial" contact dermatitis should always be suspected. Other less frequent adverse reactions to fragrances are photocontact dermatitis, immediate contact reactions and pigmentary changes. The fragrance mix, although very useful for the detection of sensitive patients, both causes false-positive and false-negative reactions, and detects only 70% of perfume-allergic patients. Therefore, future research should be directed at increasing the sensitivity and the specificity of the mix. Relevance is said to be established in 50-65% of positive reactions, but accurate criteria are needed. Suggestions are made for large-scale investigation of several fragrances on the basis of literature data and frequency of use in cosmetics. The literature on adverse reactions to balsam of Peru (an indicator for fragrance sensitivity), essential oils (which currently appear to be used more in aromatherapy than in perfumery) and on fragrances used as flavours and spices in foods and beverages is not discussed in detail, but pertinent side-effects data are tabulated and relevant literature is provided.
Reports in the literature suggest that the permeability of a wound dressing to water transport is an important variable in the healing of superficial wounds. Factors that influence skin hydration during barrier repair, therefore, are important in the optimization of wound treatments. In this study, the effects of semipermeable films on human skin following a standardized wound (tape stripping) were evaluated using measurements of transepidermal water loss (TEWL), skin hydration, rate of moisture accumulation, and erythema. Wounds treated with semipermeable films underwent more rapid barrier recovery than either unoccluded wounds or wounds under complete occlusion. Barrier films that produced intermediate levels of skin hydration during recovery produced the highest barrier repair rates. The results support the hypothesis; that semipermeable wound dressings augment barrier repair and skin quality by providing an optimized water vapor gradient during the wound healing process. The choice of wound dressing is discussed within the larger context of the design of vapor-permeable fabrics (smart materials) and the new fields of corneotherapy and comfort science.
The importance of the stratum corneum and its barrier function for infants, especially for newborns, is clinically evident. Research regarding the maturation of the stratum corneum in neonates, i.e. when full barrier function is obtained, has produced varying results. Based on transepidermal water loss and percutaneous absorption studies, term infants seem to possess stratum corneum with adult barrier properties. Additionally, postnatal life is thought to accelerate stratum corneum maturation, so that even preterm infants have barrier function similar to term infants at 2-3 weeks of gestational age. However, a look at other parameters, such as skin thickness, skin pH and stratum corneum hydration, shows that neonatal skin is always adjusting to the extrauterine environment in contrast to the steady state of adult skin. This suggests that barrier stabilization may be dependent on achieving a balance between different parameters. However, it is still in question, which parameters, what balance and what timing. This paper provides an up-to-date overview on the neonatal skin barrier based on the review of current literature.
Irritant diaper dermatitis (IDD) is a form of contact dermatitis occurring in the diaper area as a consequence of disruption of the barrier function of the skin through prolonged contact with faeces and urine. Despite advances in diaper technology, it is a condition that still occurs regularly in young children. To combat this, barrier preparations can be used to protect the skin by coating the surface of the skin and/or by supplying lipids that can penetrate the intercellular spaces of the stratum corneum. In this review, the pathophysiology of IDD is outlined and its prevention and treatment are discussed, with particular reference to the role of emollients.
Atopic dermatitis (AD) is a multifactorial, chronic inflammatory skin disorder in which genetic mutations and cutaneous hyperreactivity to environmental stimuli play a causative role. Genetic mutations alone might not be enough to cause clinical manifestations of AD, and this review will propose a new perspective on the importance of epidermal barrier dysfunction in genetically predisposed individuals, predisposing them to the harmful effects of environmental agents. The skin barrier is known to be damaged in patients with AD, both in acute eczematous lesions and also in clinically unaffected skin. Skin barrier function can be impaired first by a genetic predisposition to produce increased levels of stratum corneum chymotryptic enzyme. This protease enzyme causes premature breakdown of corneodesmosomes, leading to impairment of the epidermal barrier. The addition of environmental interactions, such as washing with soap and detergents, or long-term application of topical corticosteroids can further increase production of stratum corneum chymotryptic enzyme and impair epidermal barrier function. The epidermal barrier can also be damaged by exogenous proteases from house dust mites and Staphylococcus aureus. One or more of these factors in combination might lead to a defective barrier, thereby increasing the risk of allergen penetration and succeeding inflammatory reaction, thus contributing to exacerbations of this disease.