Midwives online: Aug/Sept 2008
This paper will describe a brief overview of the skin and its functions, compare the skin of a full term newborn baby to that of adult skin and will then discuss the current evidence and opinions of experts to support best practice for baby skin care. This information will then assist the authors to develop a list of good practice guidelines for midwives to use to inform and support parents in making a choice as to what they think is best for their newborn baby.
Baby skin care
A baby’s needs are normally interpreted by its parents. Parents will learn very quickly to respond to their baby’s cues and want to provide the best care they can. Assessing the skin integrity, skin care and how to prevent irritations, rashes and infections will be a high priority. Many new parents will be influenced by their family members and peers on how to care for their baby’s skin, and will also have their own beliefs and preferences with regards to how to cleanse and protect it. Midwives however, can play an important role in offering information, advice and support to new parents to enable them to make an informed decision. To do this, midwives must have a good knowledge-base of the anatomy and physiology of skin in general, have in-depth knowledge of the differences between the skin of a full term newborn baby and that of an adult and be very aware of any evidence to support the benefits and risks of different baby skin care products that are widely available in the UK.
The purpose of this review is to explore and discuss the best available evidence and expert opinions on caring for a baby’s skin to enable the authors to develop some guidelines for midwives to refer to when guiding new parents.
Firstly, a search of the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews and the National Research Register was undertaken to identify any trials or systematic reviews that had investigated the use of baby skincare products, procedures or policies. No trials or systematic reviews were registered by the Cochrane databases, but one ongoing study and two systematic reviews were registered by the National Research Register.
Secondly, a further search of empirical articles using MEDLINE, CINAHL, and EMBASE was undertaken. The search period was limited from January 1996 to November 2007 and thesaurus terms and key words: ‘baby’, ‘babies’, ‘infant’, ‘skin’ and ‘care’ were used. The number of articles identified were 550 on CINAHL, EMBASE sourced 109, MEDLINE uncovered 293. Combining the key words reduced the number of relevant articles to 22 on CINAHL, 79 on EMBASE, and 33 on MEDLINE. In addition, a search of the Maternity and Infant Care database using the key words ‘infant’ and ‘skin care’ produced a further 21 records.
In jointly deciding whether the article described a study or a systematic review of evidence on the use of baby skincare products, both authors reviewed the abstracts. Procedures or polices relating to the full-term newborn were to be included in this review. Two randomised controlled trials were identified, but on review of the full publication one of these was excluded, as it was not published in the English language. One publication discussed the undertaking of two systematic reviews, another reported the findings from a postal survey and another publication discussed a large prospective study that investigated the effectiveness of clinical guidelines (see Table 1). The references given in these relevant articles were further examined. During the hand search, the World Health Organization’s (WHO) general postnatal care guidelines (World Health Organization, 2003) and the recent National Institute for Health and Clinical Excellence (NICE) guidelines on postnatal care (National Institute for Health and Clinical Excellence, 2006) were identified.
In addition, from the abstracts, 16 relevant articles were identified by the authors that either discussed an overview of the skin and its functions, compared the skin of a full-term newborn baby to that of adult skin or highlighted experts’ opinions to support best practice on baby skin care. These were critically analysed and will be referred to in this review.
Anatomy and physiology of the skin
The skin is the largest organ of the human body and has a variety of functions (Darmstadt and Dinulos, 2000). It is the body’s first line of defence providing a protective barrier against infection and environmental toxins. It has pigmentation or melanin provided by melanocytes, which absorb some of the potentially dangerous ultraviolet radiation in sunlight. It also has an important role to play in protecting the internal organs, in insulation and thermoregulation of the body. It discharges electrolytes and prevents excessive fluid loss and synthesises vitamins D and B (Lund et al, 1999). The skin also provides tactile perception and is instrumental in the initial bonding attachment phase between a mother and her baby (Marbut and Loan, 1996).
Basic structure of the skin
The skin consists of three layers:
Epidermis (outer layer)
§ Keratinocytes and dendritic cells
Dermis (underlying connective tissue)
§ Capillary loops and nerve endings
§ Hair follicles, glands nerves, blood vessels
§ Thickest part of dermis.
Hypodermis or subcutaneous layer (basement membrane)
§ Cushion of fat
Newborn and adult skin
There are important differences between the newborn and adult skin. The skin of a term baby is well developed to cope with extra-uterine life. However, there are some differences when comparing it to that of an adult – a baby’s skin is more delicate and therefore, more prone to irritant and allergic reactions (Holbrook, 1982; Kuller et al, 2002).
The key differences are that the:
Stratum corneum (epidermis) is thinner
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 baby’s skin will undergo a number of changes during the first month of life as it adapts from a uterine environment to that of an extra-uterine environment. During this 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 (Hoeger and Enzmann, 2002).
Cleansing and moisturising a baby's skin
Parents need to decide what method of skin care and frequency is best suited to them and their baby. A baby does not routinely have to be bathed every day (Lund et al, 2001), although some parents will have a preference to do so and many will bathe their baby in the evening with the aim of relaxing and settling their baby for the night.
Following birth, many parents expect and request that their babies are bathed to remove any vernix caseosa, blood, meconium and cellular debris. Much of this, however, can be gently removed by the midwife with a soft clean towel very shortly after birth. The amount of vernix caseosa on full-term babies can vary and postmature babies have a tendency to have very little and this is usually seen in the skin folds. It has been recommended that the vernix caseosa is not removed immediately after birth as there is limited evidence to support the benefit of this practice (Gelmetti, 2001).
Conversely, it has been reported that there are no adverse effects to bathing a healthy full-term baby with a body temperature above 36.5oC (MacGillivray, 1996). However, a study involving premature babies reported adverse physiological and behavioural effects when bathed, so routine bathing was therefore not recommended (Peters, 1998). Subsequently, research focusing on the skin of neonates has to consider whether the studies involved pre-term, full-term or both as evidence from either cannot be easily generalised to the other.
The two systematic reviews identified asked two important research questions. The first was: ‘Is the use of soaps or detergents in bath water for the well term newborn associated with the development of dry, cracked, or flaking skin in the perinatal period?’ The second was: ‘What is the effect of using emollients, lotions, or moisturisers for dry, cracked or flaking skin for well term babies in the perinatal period on skin integrity and pathology in the first postnatal year?’ The reviewers found no studies that answered these questions and highlighted that the use of soaps, detergents, emollients and lotions on the full-term baby’s skin have not been formally investigated (Walker et al, 2005a).
Nevertheless, a few recommendations have been put forward to guide parents and midwives on methods of cleansing a baby’s skin. Following a local audit that reported a reduction in the incidence of erythema neonaturum when evidence-based guidelines were introduced, bathing a baby in water only has been recommended for the first two to four weeks of life and the use of creams and lotions for dry skin should be avoided as it appears to be a natural phenomenon (Trotter, 2004). However, the use of a pH neutral cleanser and emollient application that is specially designed for use with a baby from birth has also been reported to have a good safety profile (Hopkins, 2004).
It has been suggested that if bathing is limited to two or three times a week, the risk of skin irritation, absorption of chemicals and skin surface pH changes is reduced (Kuller et al, 2002). Alternating water-only baths with baths using cleansers has also been recommended in the clinical guidelines produced by the American Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) (Lund et al, 2001). The guidelines were based on evidence provided by two studies that involved pre-term infants and addressed ten aspects of neonatal skin care (Nopper et al, 1996; Lane and Drost, 1993). A large prospective study was undertaken to evaluate these guidelines in daily clinical practice and measure the effect these had on neonatal skin care practices. The AWHONN study observed pre- and post-skin conditions of 2820 babies from zero to 28 days with twice-weekly assessment of the newborn skin and daily care practices at 51 sites in the US. Clinical assessors were prepared and educated to increase their knowledge base and awareness of neonatal skin practices in order to undertake the assessments. The assessment tool of the Neonatal Skin Condition Score (NSCS), which ranges from a score of three (best condition) to a score of nine (worst condition) based on dryness, erythema and skin breakdown was used to assess the babies’ skin condition. It was reported that after implementation of the clinical guidelines, skin condition was improved in both pre-term and full-term babies. However, the guidelines were based on evidence of pre-term infants and the majority of the babies included in this study were therefore pre-term with only 356 babies categorised as full term. This has to be taken into consideration and further research carried out in the UK involving full-term babies may confirm or refute this evidence provided by this US study.
It has been reported that washing the skin alone does not remove all the impurities on the surface layer (Gelmetti, 2001). This is due to some of the substances being water rather than fat soluble. Mild cleansers will emulsify the fat-soluble substances into fine droplets that can then be removed by water. These cleansers act by suppressing the surface tension that allows fatty substances to remain on the skin surface. Care must be taken not to suppress the surface tension too much as this would increase the risk of causing unnecessary trauma to the skin surface. A fine balance is necessary between cleansing of the newborn skin and the preservation of its homeostatic properties. Cleansers need to be extremely mild in their properties to prevent excessive removal of lipids from the stratum corneum, which are essential to the surface ecosystem. 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. It is therefore sensible to use cleansers that have been specially designed for a baby’s skin, be pH neutral and very mild to avoid irritant dermatitis and allergic dermatitis. There are many different types of cleansing products available (Hopkins, 2004).
Midwives and parents need to be aware of the different types and what properties these have. At present, there is a lack of both studies and evidence to support either a water-only policy or using a very mild pH neutral cleanser remains inconclusive. The NICE (2006) Guidelines on postnatal care did not identify any research studies that specifically addressed general care of the skin of a full-term infant. 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 cleaning agent should not be added to a baby’s bath water nor should lotions or medicated wipes be used. However, should a cleansing agent be needed a ‘mild non-perfumed soap’ can be suggested.
Following publication of these guidelines (National Institute for Health and Clinical Excellence, 2006), a community-based placebo-controlled clustered randomised trial has been undertaken in southern Nepal. This trial reported that cleansing newborn skin (one time) with baby wipes that contained 0.25% chlorhexidine may reduce neonatal mortality in low birthweight babies and in areas where hygiene practices are poor (Tielsch et al, 2007). Some 17530 babies were enrolled with 8650 of these being randomised to the treatment group and 8880 to a placebo group. Babies were either cleansed with the chlorhexidine baby wipes or a placebo solution as soon as possible after birth (median 5.8 hours). The main primary outcome was an all cause mortality rate at 28 days post-delivery. The researcher reported that when an intention-to-treat (ITT) analysis was performed, there was no statistical significant findings when the baby wipes were used. However, an 11% lower neonatal mortality rate was reported when considering low birthweight babies (<2500g), but this did not reach statistical significance. Further research is needed to investigate whether more than a one-time application may be of benefit or not. See Table 1 for a summary of the evidence provided by the limited studies found during this review.
Guidelines on bathing
Immersion bathing may be beneficial from a developmental perspective and it has been recommended that this method should be used when the baby is sufficiently stable and usually after the cord has detached (Kuller et al, 2002). Midwives will be required to offer advice and demonstrate how this method should be undertaken to give mothers/parents confidence to do so.
When bathing a newborn baby, the bath water should not exceed body temperature of 37oC (Gelmetti, 2001). Mothers/parents are advised to have the water in the range of 34oC to 36oC. Bath thermometers are available to purchase, but as a natural guide, placing the elbow or wrist in the water to see if it feels comfortable can test the temperature. The room should be warm in the range of 24oC to 27oC and free from drafts. Usually a bathing demonstration is given to new mothers/parents and the importance of cleansing their baby’s face and head and gently drying these prior to their baby’s body being immersed in the bath water is stressed to reduce the risk of unnecessary body temperature heat loss. In addition, when their baby is immersed in the bath water the superficial layers of the skin are hydrated; these layers then become thicker with a reduction in cellular cohesion. Over-hydrated skin is more fragile and the risk of any friction to cause damage is increased (Gfatter et al, 1997). A bath, therefore should be of a short duration and it has been recommended that it should not be longer than five minutes (Trotter, 2004; Gelmetti, 2001).
There are many different products available for mothers/parents to purchase and many of these are used in maternity units. A postal survey sent to 29 maternity units in the north-west of England reported that a total of six different types of bathing and cleansing products and ten different products to treat dry skin were stocked and used on newborn babies. In addition, 17 different products were recommended by midwives to treat dry skin (Walker et al, 2005b). There is some evidence that baby care products should be not used on preterm babies (Lund et al, 2001). This evidence, however, cannot be easily generalised to full-term babies and it appears that there is limited evidence to support either the benefits or risks of these products on such babies. The researchers recommended further research and a large prospective study to be undertaken on full-term babies with a follow-up study.
Since the early 1990s, concerns have been raised concerning the possible effects of bathing and using cleansers such as soaps, detergents and baby wipes (Tupker et al, 1990; Gfatter et al, 1997; Lund et al, 1999; Darmstadt et al, 2002; Trotter, 2004). In general, there seems to be two schools of thought in the UK and therefore no consensus as to the best method of cleansing and moisturising a newborn baby has been reached. Trotter (2004) argues that water alone should only be used for cleansing for the first two to four weeks of life and then pH neutral cleansing products may be used and bases her argument on the physiology of the baby’s skin structure immediately after birth. The other school of thought is that it is safe to use mild, pH neutral products that have been specifically prepared for a baby’s skin from birth (Hopkin, 2004).
Interestingly, McNally et al (1998) highlighted that the chemical composition of water needs to be taken into consideration and suggested that water rich in calcium salts is more likely to be an irritant to a baby’s skin. Therefore, babies being reared in a geographical area where there is hard water supplied in the UK may be potentially more at risk when compared to an area where soft water is supplied.
When reviewing the literature, there appears to be no standardised skin care policy or guidelines in the UK and this may be due to the two conflicting views, but also the apparent lack of research studies available to support best practice as identified by NICE in 2006 and two systematic reviews and a postal survey (Walker et al, 2005a; Walker et al, 2005b).
Nevertheless, in the US a very detailed review was undertaken by the AWHONN and this led to them publishing clinical practice guidelines (Lund et al, 2001). They concluded that no baby care products should be used on preterm babies but that pH neutral cleansing and moisturising products are safe and effective for full-term infants.
The recent large randomised controlled trial undertaken in South Nepal demonstrated some possible benefits of the use of medicated wipes, but recommended further research (Tielsch et al, 2007).
Due to the limited evidence to support best practice for baby skin care, expert opinion is often then sought. This review found the majority of relevant articles to be opinion based. The reviewers have critically analysed the available evidence and explored opinions to develop a list of good practice guidelines to assist midwives to discuss and guide parents to make choices as to what they think is best for their baby based on current evidence and expert opinion (see Table 2).
Table 2. Good practice guidelines
Good practice guidelines for baby skin care
Explore what the mother’s/parents’ views and experience of baby skin care
Ensure that mother/parent understands the physiology of the baby’s skin and is aware that this is different to adult skin
Respect mother’s/parents’ personal preferences and beliefs
Discuss with the mother/parents the available evidence to provide guidance on how best to cleanse and care for the baby’s skin
Demonstrate and support a mother/parent in undertaking cleansing procedures.
Cleansing the skin
Following birth vernix, blood, meconium and cellular debris can be gently removed with a soft clean towel
It is important to consider the frequency and duration of bathing
Premature baby should not be routinely bathed
A full-term baby with a body temperature above 36.5oC may be bathed
A full-term baby does not routinely have to be bathed every day
Limit bathing to two or three times a week
Preparing a warm environment, room temperature between 24oC to 27oC and
free from draughts is necessary before removing baby’s clothes
Duration of a bath should be short – no longer than five minutes
Bath water should not exceed body temperature 37oC. Ideally, bath water should range from 34oC to 36oC
Use a bath thermometer to measure temperature of water
Place a wrist in the water as a natural guideline to feel the bath temperature
Ensuring that the principles of thermoregulation are used – have a warm towel and clothing prepared for the baby’s exit from the bath
Bathing a baby in water only for first two to four weeks has been recommended
A pH neutral cleanser specially designed for use for a baby from birth has a good safety profile
pH neutral mild cleansers will emulsify fat-soluble substances that can then be removed by water
Use the recommended amount of pH neutral cleanser
Alternating water-only baths with baths using cleansers have been recommended
Never use cleansers that have been specifically manufactured for adults.
The use of creams and emollient applicants should be avoided during first two to four weeks of life
Emollients specially designed for baby have been reported to have a good safety profile
Never use any creams, lotions and emollients that have been specifically manufactured for adults.
There is a lack of research studies investigating the use of baby skincare products, policies or procedures. There are also no standardised skincare policies or guidelines developed in the UK. This may be due to limited evidence available as highlighted during this review and that there appears to be no consensus at present, as to whether to use water alone for the first two to four weeks of life or to use cleansers and moisturisers that are very mild and pH neutral.
However, there is some agreement that the ideal cleanser and moisturisers should be very mild and pH neutral. It is also recommended that potential irritating or sensitising substances, not essential for hygienic purposes, should be absent from baby cleansers and moisturisers. Further research, however, is needed to support the benefits or risks of these two views. In the meantime, good practice guidelines should be available for all midwives to enable them to provide guidance and support to parents on how to care for their baby’s skin (see Table 2).
Ultimately, choices on how best to care for a baby’s skin will be made by parents who will consider the best available evidence and expert opinion in order to make their decision on their personal preferences and beliefs.
Darmstadt GL, Mao-Qiang M, Chi E, Saha SK, Ziboh VA, Black RE, Santosham M, Elias PM. (2002) Impact of topical oils on the skin barrier: possible implications for neonatal health in developing countries. Acta Paediatr 91: 546-54.
Darmstadt GL, Dinulos JG. (2000) Neonatal skin care. Pediatr Dermatol 47: 757-83.
Gfatter R, Hackl P, Braun F. (1997) Effects of soap and detergents on skin surface pH, stratum corneum hydration and fat content in infants. Dermatology 195: 258-62.
Hoegar PH, Enzmann CC. (2002) Skin physiology of the neonate and young infant: a prospective study of functional skin parameters during early infancy. Pediatric Dermatology 19(3): 256-62.
Holbrook KA. (1982) A histological comparison of infant and adult skin: In: Maibach HI, Boisits EK. (Eds.). Neonatal skin: structure and function. Marcel Dekker: New York: 3-31.
Hopkins J. (2004) Essentials of newborn skin care. British Journal of Midwifery 12(5): 314-7.
Kuller J, Lund C, Lourdes BN. (2002) Neonatal integumentary system. Clinical Education Series Ross Pediatrics: Ross Products Division: Abbott Laboratories: US.
Lane AT, Drost SS. (1993) Effects of repeated application of emollient cream to premature neonates’ skin. Pediatrics 92: 415-9.
Lund C, Kuller J, Lane A, Lott JW, Raines D, Thomas K. (2001) Neonatal skin care: evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. JOGNN 30(1): 30-40.
Lund C, Osborne JW, Kuller J, Lane AT, Lott JW. (2001) Neonatal skin care: Clinical outcomes of the AWHONN/NANN evidence-based clinical practice guidelines. JOGNN 30(1): 41-51.
Lund C, Kuller J, Lane A, Loft JW, Raines DA. (1999) Neonatal skin care: the scientific basis for practice. JOGNN 28(3): 241-54.
Marbut KK, Loan LA. (1996) Newborn hygiene: to bathe or not to bathe. Mother Baby Journal 1(6): 25-30.
McNally NJ, Williams HG, Philips DR, Smaillman-Raynor M, Lewis S, Venn A, Britton J. (1998). Atopic eczema and domestic water hardness. Lancet 352(9127): 527-31.
National Institute for Health and Clinical Excellence. (2006) Postnatal care: routine postnatal care for women and their babies. See: www.nice.org.uk/nicemedia/pdf/CG037fullguideline.pdf (accessed 3 July 2008).
Nopper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ, Lane AT. (1996) Topical ointment therapy benefits premature infants. Journal of Pediatrics 128: 660-9.
Penny-MacGillivray TA. (1996) Newborn’s first bath: when? Journal of Obstetrics and Gynecology: Neonatal Nursing 25: 481-7.
Peters KL. (1998) Bathing premature infants: physiological and behavioural consequences. American Journal of Critical Care 7(9): 90-100.
Tielsch JM, Darmstadt GL, Mullany LC, Khatry SK, Katz J, LeClerq SC, Shrestha S, Adhikari R. (2007) Impact of newborn skin-cleansing with chlorhexidine on neonatal mortality in Southern Nepal: a community-based, cluster-randomised trial. Pediatrics 119(2): 330-40.
Tierno Jr, Philip M. (2006) How to protect your baby against harmful germs: In: Ettus S. (Ed.). The experts’ guide to the baby years. Clarkson Potter: New York.
Trotter S. (2004a) Care of the newborn: proposed new guidelines. British Journal of Midwifery 12(3): 152-7.
Trotter S. (2004b). Audit following the introduction of evidence-based guidelines for skincare and cord care (unpublished report). NHS Ayrshire and Arran: Kilmarnock.
Tupper RA, Pinnagoda J, Coenraads PJ, Nater JP. (1990) Evaluation of detergent induced irritant skin reactions by visual scoring and transepidermal water loss measurement. Dermatologic Clinics 8(1): 33-5.
Walker L, Downe S, Gomez L. (2005a) Skin care in the well term newborn: two systematic reviews. Birth 32(3): 224-8.
Walker L, Downe S, Gomez L. (2005b) A survey of soap and skin care product provision for well term neonates. British Journal of Midwifery 13(2): 768, 770-3.