Neonatal skin care

Postnatal care and acceptability of emollient therapy in very low birthweight infants in Harare, Zimbabwe: a qualitative analysis

BACKGROUND

Preterm birth (birth before 37 completed weeks of pregnancy) is the leading cause of neonatal and child under-five mortality globally, both of which are highest regionally in sub-Saharan Africa. The skin barrier plays a critical role in neonatal health and increasing evidence supports the use of topical emollient therapy to promote postnatal growth and reduce hospital-acquired infections in preterm infants. The World Health Organization (WHO) currently recommends emollient therapy in preterm or low birthweight infants globally but calls for further research on impacts of emollient use, especially in Africa. Little is known about postnatal skincare practices and the tradition of oil massage across sub-Saharan Africa. Further documentation is necessary to understand the context for future emollient intervention trials.

METHODS

61 semi-structured interviews with mothers who just delivered preterm or term infants and 4 focus group discussions (32 participants) with physician and nurse providers of newborn care were conducted at Sally Mugabe Central Hospital (SMCH), in Harare, Zimbabwe. SMCH is the principal public-sector tertiary care hospital for newborn infants in the northern part of the country. Mothers and healthcare professionals were questioned about newborn care at the hospital, current neonatal skincare and bathing practices, and the community's receptivity to a future emollient therapy clinical trial.

RESULTS

Postnatal skincare is centrally important to Zimbabwean communities and petroleum jelly application is nearly universal. The use of cooking oil and other natural oils on infants is also part of traditional customs. The primary needs and desires of mothers who have just given birth to preterm infants are having greater agency in their children's care and financial support in purchasing prescribed medications while at the hospital. Community receptivity to emollient therapy as a cost-effective treatment is high, particularly if mothers are trained to assist with the intervention.

CONCLUSION

Emollient therapy will likely be well-received by communities in and around Harare because of its accordance with current skincare practices and perceptions; however, cultural norms and the experiences of new mothers who have given birth at a facility highlight challenges and considerations for future clinical trial execution.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05461404.

Neonatal emollient therapy and massage practices in Africa: a scoping review

There have been few reports from Africa on the use and health effects of emollient therapy for newborn infants. We aimed to describe neonatal skin care practices in Africa, and to illuminate opportunities to introduce evidence-based interventions to improve these practices. We conducted a scoping review of the quantitative and qualitative published peer-reviewed and grey literature in English on emollient use in Africa. Outcomes of interest included neonatal skin care practices, with a focus on the application of oils and other products to infant skin, including in association with bathing and massage. We screened 5257 articles and summarised findings from 23 studies-13 qualitative, nine quantitative and one mixed methods-that met our study criteria. Seven studies reported the use of emollients for perceived benefits, including thermal care, treatment for illness, promotion of growth and development, infection reduction, skin condition improvement, spirituality and lubrication to aid massage. Four studies reported the quantitative health impact of skin care product applications, including improvements in skin condition, neurodevelopment and bone growth, as well as a reduction in nosocomial infections. This review highlights opportunities for skin care intervention and future research on neonatal skin care practices in Africa.

Respiratory distress syndrome prediction at birth by optical skin maturity assessment and machine learning models for limited-resource settings: a development and validation study

Background

A handheld optical device was developed to evaluate a newborn's skin maturity by assessing the photobiological properties of the tissue and processing it with other variables to predict early neonatal prognosis related to prematurity. This study assessed the device's ability to predict respiratory distress syndrome (RDS).

Methods

To assess the device's utility we enrolled newborns at childbirth in six urban perinatal centers from two multicenter single-blinded clinical trials. All newborns had inpatient follow-up until 72 h of life. We trained supervised machine learning models with data from 780 newborns in a Brazilian trial and provided external validation with data from 305 low-birth-weight newborns from another trial that assessed Brazilian and Mozambican newborns. The index test measured skin optical reflection with an optical sensor and adjusted acquired values with clinical variables such as birth weight and prenatal corticoid exposition for lung maturity, maternal diabetes, and hypertensive disturbances. The performance of the models was evaluated using intrasample k-parts cross-validation and external validation in an independent sample.

Results

Models adjusting three predictors (skin reflection, birth weight, and antenatal corticoid exposure) or five predictors had a similar performance, including or not maternal diabetes and hypertensive diseases. The best global accuracy was 89.7 (95% CI: 87.4 to 91.8, with a high sensitivity of 85.6% (80.2 to 90.0) and specificity of 91.3% (95% CI: 88.7 to 93.5). The test correctly discriminated RDS newborns in external validation, with 82.3% (95% CI: 77.5 to 86.4) accuracy. Our findings demonstrate a new way to assess a newborn's lung maturity, providing potential opportunities for earlier and more effective care.

Trial registration

RBR-3f5bm5 (online access: http://www.ensaiosclinicos.gov.br/rg/RBR-3f5bm5/), and RBR-33mjf (online access: https://ensaiosclinicos.gov.br/rg/RBR-33rnjf/).

Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India

Purpose

Neonatal skin care practices guided by personal experience and preferences might be substantially different across different hospital settings. The aim of this consensus recommendation is to provide clinical practice guidance to healthcare practitioners on evidence-based neonatal skin care practices from delivery-to-discharge, in hospital settings.

Patients and Methods

A Scientific Advisory Board meeting on "Evidence-based Neonatal Skin Care Practices and Protocols" was held in December 2020 with an expert panel comprising neonatologists, pediatricians, obstetricians and gynecologists and pediatric dermatologist. Comprehensive literature search was performed up to 23 March 2021 using PubMed and Google Scholar to retrieve relevant evidence.

Results

Recommendations were developed on critical aspects of skin care in healthy full-term neonates including cleansing at birth, skin-to-skin care, cord care, diaper area care, initial and routine bathing, cleansers and emollients use, and criteria to choose appropriate skin care products. Recommendations include inclusion of skin assessment in routine neonatal care, first bath timing after cardio-respiratory and thermal stabilization, 6-24 hours after birth; bathing with water alone or adding a mild liquid cleanser could be considered appropriate as it does not impact the developing skin barrier; use of emollients is recommended for neonates with higher risk of development of eczema to maintain and enhance skin barrier function and integrity; and inclusion of skin care advice in neonatal discharge checklist. Importance of rigorous quality control, high-quality clinical trials for assessment of baby products, usage of products that are formulated appropriately for newborns, and full label transparency for baby products were highlighted. The panel identified gaps in literature and discussed the scope for future research.

Conclusion

These recommendations may help to standardize evidence-based skin care for healthy full-term neonates in Indian hospital settings to improve the quality of care that neonates receive in hospital and facilitate improvement in overall neonatal health outcomes.

Perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda: a qualitative study

BACKGROUND

The skin is a major route of infection in the neonatal period, especially in low birthweight (LBW) infants. Appropriate and safe neonatal skin care practices are required to reduce this risk. The perceptions and beliefs of mothers and other caregivers towards various neonatal skin care practices in our setting have been documented. Data from Asia suggests that the application of emollient to the skin of LBW infants can promote growth, reduce serious neonatal infections, and potentially reduce mortality. This is the first study to explore the acceptability of emollients and massage as part of neonatal skin care in a low-resource setting in sub-Saharan Africa (SSA) that is representative of the majority of government health facilities in Uganda and many in SSA.

OBJECTIVE

To explore perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda.

METHODS

We conducted a qualitative study consisting of three focus group discussions (30 participants), eight in-depth interviews with mothers/caregivers of preterm and term neonates and 12 key informant interviews with midwives, doctors and community health workers involved in neonatal care, to explore the perceptions and practices surrounding neonatal skin care and emollient use. Data collected were transcribed and analyzed using thematic content analysis.

RESULTS

Mothers perceived that skin care began in utero. Skincare practices depended on the place of delivery; for deliveries in a health facility the skincare practices were mainly based on the health worker's advice. Vernix caseosa was often washed off due to its perceived undesirability and was attributed to sexual intercourse in the last trimester. Despite their deleterious attributes found in previous studies, petrolatum-based oils, petrolatum-based jellies and talcum baby powders were the most commonly reported items used in neonatal skin care. In our population, there was high acceptability of emollient therapy use; however, neonatal massage was treated with scepticism as mothers feared damaging the vulnerable neonate. Mothers suggested massage and emollient application be undertaken by health workers, if it becomes an intervention.

CONCLUSIONS

In eastern Uganda, the perceptions and beliefs of mothers/caregivers toward neonatal skincare influenced their practices of which some could potentially be beneficial, and others harmful. Emollient use would be easily accepted if adequate sensitisation is conducted and using the gatekeepers such as health workers.

In vitro eye irritation testing models may play pivotal role in effort to pursue mild baby cleansers

In recent years, mild baby cleansers have experienced ever-growing demand from caregivers. In the meantime, formulation developers are in practical need for a method(s) to screen mild formulations. In the present study, we aim to repurpose the HET-CAM and SkinEthic™ models to further classify in vivo nonirritant baby cleansing formulations into mild and less mild categories. Both methods were modified to best describe the samples' irritation potential. The results showed that both models successfully classified the formulations into mild and less mild categories according to our customized criteria. For the HET-CAM, the medians of mean irritation scores (IS) were 3.0 for mild formulations (with 0 ≤ mean IS ≤4.5), and 5.0 for less mild formulations (with mean IS values all equaled 5), respectively. And for the SkinEthic™ model, the median relative viabilities were 69.46% for less mild formulations (with 46.80% ≤ mean relative viability ≤84.76%), and 99.96% for mild formulations (with 90.57% ≤ mean relative viability ≤124.58%). Thirty out of 35 formulations were predicted consistently between the HET-CAM and SkinEthic™ model. Statistical analysis of the agreement between predictions made by the two models demonstrated substantial agreement with a Cohen's kappa coefficient of 0.713 (P < 0.001). We conclude that the HET-CAM and SkinEthic™ models are promising in vitro alternatives for screening mild formulations.

Skincare practices in extremely premature infants: A survey of tertiary neonatal intensive care units from Australia and New Zealand

AIM

To investigate skincare practices in the first 2 weeks of life in extremely premature infants across tertiary neonatal intensive care units (NICUs).

METHODS

A web-based secure survey invite was emailed to the medical directors of tertiary NICUs. The survey included questions on various aspects of skincare practices in the first 2 weeks of life in extremely premature infants (born before 28 weeks gestation). The person most familiar with local skincare practices was asked to complete the survey and only one response per unit was requested. We performed a descriptive analysis.

RESULTS

We received responses from 30 out of 32 NICUs (response rate 93%). Twenty-five NICUs (89%) reported offering resuscitation and intensive care to infants born at ≥23 weeks gestation. All NICUs reported occurrences of skin breakdown, including medical adhesive-related skin injury (30%), abrasion/friction-associated skin injury (46%), perineal skin breakdown (55%), pressure site injury (47%) and diaper dermatitis (60%). A high level of consensus (≥75%) was observed for certain practices, such as the use of polyethylene occlusive plastic wraps at birth and aqueous chlorhexidine solution for sterile procedures, but a low level of consensus (<25%) was observed for many other practices, including the skin risk assessment tool used.

CONCLUSIONS

Skin injuries in extremely premature infants are common and skincare practices vary considerably amongst NICUs. Clinical practice improvement projects and further clinical research will help improve consistency amongst NICUs. Further research is needed to assist the development of evidence-based guidelines and benchmarking for skincare practices in these vulnerable infants.

Characterization of the microbiome in the infant diapered area: Insights from healthy and damaged skin

It has been recognized for nearly a century that human beings are inhabited by a remarkably dense and diverse microbial ecosystem, yet we are only just beginning to understand and appreciate the many roles that these microbes play in human health and development. Establishment of the microbiome begins at birth, but many previous studies on infant skin health have focused on Candida species. Little is known on the full microbial composition across different areas and even less is known on how these communities change during disease/inflammatory states. In this clinical study, infants were recruited during periods of diaper dermatitis (DD) and health to characterize the skin microbiome in these two states. Substantial shifts in the skin microbiome were observed across four sites in the diapered area (genitals, intertriginous, buttocks and perianal), as well as during periods of DD. As DD scores increased, there was a shift in relative abundance that demonstrated higher community percentages of faecal coliforms, such as Enterococcus, and lower percentages of Staphylococcus strains. In high-rash samples, the predominant Staphylococcus species is S aureus, potentially implicating S aureus as a DD aetiological agent. This study provides new information related to the microbiome on infant skin in the diapered area and provides insights into the role of the microbiome in the development of DD.

Neonatal Dermatology: The Normal, the Common, and the Serious

The objective of this review is to help practitioners of neonatal and pediatric medicine become more familiar with diagnosing and managing neonatal skin conditions. This article will discuss normal neonatal skin care and benign and common rashes, as well as some of the serious dermatologic conditions that require specialists for further evaluation and/or treatment.

Neonatal skin assessments and injuries: Nomenclature, workplace culture and clinical opinions-Method triangulation a qualitative study

AIM AND OBJECTIVE

To explore and establish the language, clinical opinions and workplace culture around neonatal skin injury nomenclature. Specifically, what nomenclature is used to describe, define, identity and communicate neonatal skin injuries including (a) terms, (b) locations, (c) associated risks and (d) mechanical forces.

BACKGROUND

Skin injuries are affirmed or denied based on visual assessment with findings reported by language rather than measurements. However, if language or nomenclature is ambiguous, assessments could be misinterpreted effecting healthcare delivery.

DESIGN

Qualitative enquiry including applied discourse analysis and between-method triangulation, within a larger exploratory mixed-methods study.

METHODS

Data were collected over two years from four sources: literature, documents, interviews/focus groups and free text injury assessments. Data analysis included content analysis, selective coding and thematic analysis. The collective data were further explored using discourse analysis and triangulation to achieve collective conclusions about opinions, emotions, feelings, perceptions and workplace cultures. The COREQ checklist provided structure for the reporting of study methods, analysis and findings.

RESULTS

A total of 427 data points were collected from literature, documentation and two clinical data sources. Data convergence revealed that neonatal skin injuries are described by numerous terms with preferences for "injury," "trauma" or "redness." Injuries occur in over 20 anatomical locations and risks for injuries included hospitalisation, specific treatments and prematurity. Essential medical devices, clinical condition, lack of clinician experience and overactive neonates were uniquely associated risks. There was incongruency between sources. The literature and documents empathise pressure as the primary force related to skin injury, while varied forces were identified within interviews, focus groups and free text injury assessments.

CONCLUSIONS

The variety of unique terms, locations and risks for injury indicate the need for updated neonatal skin injury frameworks. If frameworks and policies continue to be created without the empirical knowledge of neonatal clinicians, misrepresentation of neonatal skin injury locations and risk will continue to dominate the literature.

RELEVANCE TO CLINICAL PRACTICE

The recognition and management of neonatal skin injuries are related to language used to describe assessments in the absence of diagnostic confirmation, which has implications for both the neonate and the healthcare team.

Effect of Virgin Coconut Oil Application on the Skin of Preterm Newborns: A Randomized Controlled Trial

BACKGROUND

Preterm constitutes a major part of neonatal mortality, particularly in India. Due to dermal immaturity, preterm neonates are susceptible to various complications like infection, hypothermia, etc. Emollient application is a traditional practice in our subcontinent.

AIMS

To find out the efficacy of coconut oil application for skin maturity, prevention of sepsis, hypothermia and apnea, its effect on long-term neurodevelopment and adverse effect of it, if any.

MATERIAL AND METHODS

A randomized controlled trial was conducted in the rural field practice area of Department of Community Medicine, Burdwan Medical College from March 2014 to August 2018. Preterm born in the study period was divided into Group A (received virgin coconut oil application) and Group B (received body massage without any application). Neonatal skin condition was assessed on 7th, 14th, 21st and 28th day of life. Neurodevelopmental status was assessed on 3rd, 6th and 12th months.

RESULTS

A total of 2294 preterm were included in the study. Groups A and B consisted of 1146 and 1148 preterm infants, consecutively. Mean gestational age of the study population was 31.9 ± 3.4 weeks and 50.4% were male. Mean weight loss in first few days was less in group A but mean weight gain per day was higher in group B. Lesser incidences of hypothermia and apnea, and better skin maturity and neurodevelopmental outcome were noted in group A. No significant adverse effect was noted with coconut oil application.

CONCLUSION

Use of coconut oil helps in dermal maturity and better neurodevelopmental outcome. Further studies are warranted for universal recommendation.

Impact of sunflower seed oil versus mustard seed oil on skin barrier function in newborns: a community-based, cluster-randomized trial

Background

Natural vegetable oils are widely used for newborn massage in many low resource settings. Animal models indicated that sunflower seed oil (SSO) can accelerate skin barrier recovery following damage, while other oils, including mustard oil (MO), may cause further skin barrier damage. The objective was to compare the effects of two SSO and MO used for routine massage on skin integrity in premature and full-term neonates.

Methods

This community-based cluster randomized controlled trial included 995 neonates assigned to full body massage with sunflower seed oil (SSO, intervention) or mustard seed oil (MO, standard practice) from July 2012–May 2014 in Sarlahi, Nepal. Skin integrity measures were evaluated over 28 days, including skin condition (erythema, rash, dryness), skin surface pH, stratum corneum (SC) cohesion/protein concentration, and transepidermal water loss (TEWL). Overall means and rates of change in these skin measures were compared between oil groups using bivariate random-effects models.

Results

500 and 495 live born neonates received repeated massage with MO and SSO, respectively. Skin pH decreased more quickly for SSO than MO in the first week of life, with a difference in mean daily reductions of 0.02 (95% CI: 0.002–0.040). Erythema, rash and dryness increased (worsened) over days 1–14 then decreased by day 28, with no significant oil group differences. TEWL increased over time, with no significant oil group differences. Gestational age did not modify the effect; the slightly faster decrease in skin pH among SSO infants was similar in magnitude between term and preterm infants.

Conclusions

Oil type may contribute to differences in skin integrity when neonates are massaged regularly. The more rapid acid mantle development observed for SSO may be protective for neonates in lower resource settings.

Trial registration

ClinicalTrials.gov (NCT01177111); registered August 6th, 2010.

The effect of tub bathing and sponge bathing on neonatal comfort and physiological parameters in late preterm infants: A randomized controlled trial

BACKGROUND

Increasing comfort and physiological stabilization in preterm infants during neonatal care improves their neurophysiological development. Bathing procedures that support this development and will not expose the newborn to stress should be preferred.

OBJECTIVES

Our study aimed to examine the effectiveness of tub bathing and sponge bathing methods on the physiological parameters (i.e., heart rate, respiration rate, oxygen saturation, body temperature) and comfort of late preterm infants.

DESIGN

Randomized controlled trial. Study is registered at ClinicalTrials.gov NCT03796312.

SETTINGS

The trial was conducted in a neonatal intensive care unit of a university hospital in Antalya, Turkey.

METHODS

Late preterm infants (gestational age between 34 0/7 weeks and 36 6/7 weeks) were randomly assigned by a computer program to either intervention (tub bath) or control group (sponge bath). The physiological parameters and comfort of preterm infants in both groups were evaluated at 10 min before the bath. Infant comfort was reevaluated 10 min after the procedure, while physiological parameters were reevaluated after 15 and 30 min. Preterm infant heart rate, oxygen saturation, respiratory rate, body temperature and comfort behaviors were assessed by two independent evaluators who were blinded to the purpose of the study at different phases across the two bathing protocols. Written consent was obtained from the university and hospital ethics committee where the research was performed, and from the families of the infants participating in the study. SPSS 20.0 and SAS 9.3 were used for data analysis. Data was analyzed by percentage distribution, mean, repeated analysis, variance analysis, Bonferroni analysis as a further analysis and t-test in dependent groups.

RESULTS

Approximately 120 preterm infants completed the protocol (60 in each group). The two groups did not differ in gestational age, sex, weight or other demographic variables (p > 0.05). Tub bathing was more effective in reducing preterm infants' comfort scores (9.47 ± 2.55 vs. 14.85 ± 4.77, p < 0.001) and heart rate than sponge bathing (132.88 ± 12.00 vs. 144.00 ± 17.74, p < 0.05). Preterm infants in the tub bathing group maintained their body temperature better than those in the sponge bathing group (36.75 ± 0.26 vs. 36.59 ± 0.25, p < 0.05). There was no difference in oxygen saturation (98.35 ± 0.88 vs. 97.85 ± 1.36, p = 0.291) or respiratory rate (45.57 ± 5.39 vs. 47.20 ± 5.41, p = 0.472) between the tub and sponge bathing groups.

CONCLUSIONS

Tub bathing is a safer, more pleasurable/comfortable bathing option and is the recommended method for bathing healthy, late preterm infants.

First bathing time of newborn infants after birth: A comparative analysis

PURPOSE

The study was designed as an experimental study to describe the effect of the first bathing time on the body temperature and skin moisture of a newborn after birth.

DESIGN AND METHODS

The study population consisted of term newborns between January and June 2016 in the Istanbul University, Cerrahpaşa Medical Faculty Hospital at Istanbul. The sample group was randomly divided into two groups according to different bathing times. The first group (39 infants) was given a bath 24 hr after birth, and the second group (34 infants) was given a bath 48 hr after birth. The infants in both the groups were dried with the first towel and then wrapped in a second dry towel, and a cap put to prevent hypothermia and to minimize any minor fluid loss. The body temperature and skin moisture level were measured before the bath, after the bath, and 10 min after the bath.

RESULTS

It was determined that the 10th-minute body temperatures of the infants with the first bathing time 48 hr after birth were significantly higher compared with the infants with the first bath time 24 hr after birth (Z = -2.654; p = .008).

PRACTICAL IMPLICATIONS

Postponing of the first bathing time of newborns to 48 hr after birth was effective in preserving the body temperature of the infant. Postponing the bath to the 48th hr improved moisture, which may improve skin integrity and aid with skin development.

Biobehavioral Responses of Preterm Infants to Conventional and Swaddled Tub Baths: A Randomized Crossover Trial

Bathing is a routine care procedure that exposes preterm infants to prolonged handling, which could cause stress and potentially disrupt infants' biobehavioral responses. The aim of this double-blind randomized crossover trial was to compare the preterm infant's body temperature, heart rate (HR), peripheral capillary oxygen saturation (SpO2), salivary cortisol levels, and sleep-wake states during and after swaddled and conventional tub baths. Forty-three infants born at 32 to 36 weeks postmenstrual age, weighing 2225 g or less, were enrolled in the study. Infants were videotaped before and after each type of baths. The time interval between baths ranged from 24 to 72 hours to allow a washout period. Physiological, hormonal, and behavioral responses were collected at baseline and during recovery from baths. No significant differences in the mean body temperature, HR, SpO2, salivary cortisol levels, and sleep-wake states between the bath types were observed in the baseline or recovery responses during the first 20 minutes after bath. Regardless of bath type, salivary cortisol levels showed a nonstatistical significant increase.

Effects of cord blood vitamin D levels on the risk of neonatal sepsis in premature infants

Purpose

Vitamin D plays a key role in immune function. Vitamin D deficiency may play a role in the pathogenesis of infections, and low levels of circulating vitamin D are strongly associated with infectious diseases. In this study, we aimed to evaluate the effects of low vitamin D levels in cord blood on neonatal sepsis in preterm infants.

Methods

One hundred seventeen premature infants with gestational age of <37 weeks were enrolled. In the present study, severe vitamin D deficiency (group 1) was defined as a 25-hydroxyvitamin D (25(OH)D) concentration <5 ng/mL; vitamin D insufficiency (group 2), 25(OH)D concentration ≥5 ng/mL and <15 ng/mL; and vitamin D sufficiency (group 3), 25(OH)D concentration ≥15 ng/mL.

Results

Sixty-three percent of the infants had deficient levels of cord blood vitamin D (group 1), 24% had insufficient levels (group 2), and 13% were found to have sufficient levels (group 3). The rate of neonatal sepsis was higher in group 2 than in groups 1 and 3.

Conclusion

There was no significant relationship between the cord blood vitamin D levels and the risk of neonatal sepsis in premature infants.

Emu oil-based lotion effects on neonatal skin barrier during transition from intrauterine to extrauterine life

Both appropriate hydration and skin surface pH are fundamental in preventing baby skin barrier damage during transition from intrauterine to extrauterine life. However, effects of topical moisturizers on neonatal stratum corneum temperature, pH, hydration, and elasticity have not been scientifically evaluated in vivo. We checked 31 full-term breastfeeding neonates by non-invasive bioengineering method, which is able to evaluate the basal skin barrier (left heel), and assessed at 6±1 hours after birth, and at 1 and 24 hours after emu oil-based topical treatment. The basal skin barrier of right heel (no oil exposure) of each newborn was considered as control. We found that a single application of an emu oil-based lotion was effective in improving heel stratum corneum hydration, which increases both skin pH and elasticity without any effect on temperature. Further studies are needed to confirm long-term beneficial effects of this treatment in a very sensitive patient population.

Skin care practices in newborn nurseries and mother-baby units in Maryland

OBJECTIVE

Skin provides several important homeostatic functions to the developing neonate. However, no consensus guidelines exist in the United States for skin care in the healthy term newborn.

STUDY DESIGN

We performed a study of skin and umbilical cord care (including bathing practices, vernix removal and antiseptic cord application) in newborn nurseries and mother-baby units throughout the state of Maryland to determine practices in a variety of clinical settings and assess if uniformity in skin care exists. These data were then assessed in the context of a review of the current literature.

RESULTS

We received responses from over 90% of nurseries across the state. In our cohort, practices varied widely between institutions and specific populations, and often were not evidence-based or were contrary to best practices discussed in the scientific literature.

CONCLUSION

The frequent departures from evidence that occur regarding the aforementioned practices are likely due to a lack of consensus on these issues as well as limited data on such practices, further highlighting the need for data-driven guidelines on newborn skin care.

Lesions requiring wound management in a central tertiary neonatal intensive care unit

BACKGROUND

Most of the skin disorders that occur in neonatal intensive care units are due in part to the immaturity and vulnerability of the neonatal skin. Various iatrogenic diagnostic and therapeutic procedures are also conducive to iatrogenic damage. This study was to review the neonates admitted to our neonatal intensive care unit who needed wound management, and to assess the most common skin injuries and wounds, and their aetiology.

METHODS

Data were extracted from medical records of neonates who needed wound management in our Neonatal Intensive Care Unit between January 31, 2012 and January 31, 2013. Information about gestational age, sex, birth weight, area of involvement, wound aetiology, and therapy were collected.

RESULTS

Among the 211 neonates observed, wound management was required in 10 cases of diaper dermatitis, 7 epidermal stripping, 6 extravasation injuries, 5 pressure ulcers, 1 surgical wound and infection, 1 thermal burn, and 5 other lesions.

CONCLUSIONS

International guidelines in neonatal wound care practice are not available, and further research concerns are clearly needed. Dressings and antiseptic agents should be chosen with great care for application to neonates, with particular attention to the prevention of adverse events in this sensitive population. Team work among dermatologists, neonatologists and nurses is crucial for the successful treatment of neonates.

Critical assessment of the pH of children's soap

OBJECTIVE

To evaluate the pH value of children's antibacterial soaps and syndets used in children's baths and verify whether there is information regarding pH on the product label.

METHODS

Quantitative, cross-sectional, analytical observational study that included ninety soap samples, both in bar and liquid presentations, as follows: 67 children's soap (group 1), 17 antibacterial soaps (group 2), and 6 syndets (group 3). Each sample had its pH measured after 1% dilution. In addition to descriptive statistics, the Pearson-Yates chi-squared test and Student's t-tests were applied, considering the minimal significance level of 5%. The Wilcoxon-Mann-Whitney test, Fisher's exact test, and the Kruskal-Wallis test were used for inferential statistics.

RESULTS

The pH levels varied considerably between liquid and bar presentations, with lower levels (4.4-7.9) found for the liquids (p<0.05). Syndets showed pH levels close to the ideal (slightly acid) and the antibacterial soaps showed the highest pH levels (up to 11.34) (p<0.05). Only two of the soaps included in the study had information about their pH levels on the product packaging.

CONCLUSIONS

Knowledge of the pH of children's soap by doctors and users is important, considering the great pH variability found in this study. Moreover, liquid soaps, and especially syndets, are the most recommended for the sensitive skin of neonates and infants, in order to guarantee skin barrier efficacy.

Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care

BACKGROUND

European roundtable meeting recommendations on bathing and cleansing of infants were published in 2009; a second meeting was held to update and expand these recommendations in light of new evidence and the continued need to address uncertainty surrounding this aspect of routine care.

METHODS

The previous roundtable recommendations concerning infant cleansing, bathing, and use of liquid cleansers were critically reviewed and updated and the quality of evidence was evaluated using the Grading of Recommendation Assessment, Development and Evaluation system. New recommendations were developed to provide guidance on diaper care and the use of emollients. A series of recommendations was formulated to characterize the attributes of ideal liquid cleansers, wipes, and emollients.

RESULTS

Newborn bathing can be performed without harming the infant, provided basic safety procedures are followed. Water alone or appropriately designed liquid cleansers can be used during bathing without impairing the skin maturation process. The diaper area should be kept clean and dry; from birth, the diaper area may be gently cleansed with cotton balls/squares and water or by using appropriately designed wipes. Appropriately formulated emollients can be used to maintain and enhance skin barrier function. Appropriately formulated baby oils can be applied for physiologic (transitory) skin dryness and in small quantities to the bath. Baby products that are left on should be formulated to buffer and maintain babies' skin surface at approximately pH 5.5, and the formulations and their constituent ingredients should have undergone an extensive program of safety testing. Formulations should be effectively preserved; products containing harsh surfactants, such as sodium lauryl sulfate, should be avoided.

CONCLUSION

Health care professionals can use these recommendations as the basis of their advice to parents.

Topical Oil Application and Trans-Epidermal Water Loss in Preterm Very Low Birth Weight Infants-A Randomized Trial

OBJECTIVE

Topical emollient application reduces trans-epidermal water loss (TEWL) in preterm neonates. Coconut oil used traditionally for infant massage in India has not been evaluated for the same.

PATIENTS AND METHODS

Very low birth weight (VLBW) neonates were randomized at 12 h of age to Oil (n = 37) or Control (n = 37) groups. Oil group neonates received twice-daily coconut oil application without massage, and Control group received standard care. TEWL was measured every 12 h using an evaporimeter till Day 7 when skin swabs were obtained for bacterial growth and skin condition was assessed using a validated score.

RESULTS

Birth weight (g; mean ± SD: 1213 + 214 vs. 1164 + 208, p = 0.31), gestation [week; median (interquartile range): 32 (31-33) vs. 32 (29-33), p = 0.10] and other baseline variables were comparable. TEWL was significantly reduced (g/m(2)/h, mean difference: -6.80, 95% confidence interval: -3.48, -10.15; p < 0.01) with better skin condition and lower bacterial growth in the Oil group (20% vs. 60%, p < 0.01).

CONCLUSION

Coconut oil application reduced TEWL without increasing skin colonization in VLBW neonates.

CLINICAL TRIALS REGISTRATION

NCT01758068.

Overview of dermatologic disorders of neonates in a central regional intensive care unit in Hungary

The immaturity and vulnerability of the skin and epidermal barrier function and the frequent iatrogenic complications following diagnostic and therapeutic procedures are often associated with skin manifestations in infants in neonatal intensive care units (NICUs). The aim of the current study was to investigate dermatologic disorders in neonates in our NICU. A prospective cohort study was conducted in the NICU at the Department of Pediatrics at the University of Szeged between January 2012 and January 2013. All full- and preterm infants hospitalized in the NICU underwent whole-body skin examinations and all dermatologic disorders and treatment modalities were recorded. Eighty-nine dermatologic conditions were detected in 64 of the 211 neonates admitted to the NICU. A wide variety of clinical symptoms accompanied these conditions in these preterm and severely ill full-term infants. A considerable proportion of the disorders that were seen resulted from the immaturity of the skin and various iatrogenic complications. Dermatologic disorders are frequent in neonates requiring intensive care. Prevention, early detection, and optimal treatment of these disorders with modern, standardized skin care management strategies can result in significant improvements in barrier function and in the integrity of the skin, increasing the overall efficacy of neonatal intensive care.

Skin antisepsis in the neonate: what should we use?

PURPOSE OF REVIEW

Neonates in intensive care are more susceptible to sepsis. Infection is commonly acquired via the transcutaneous portal. It is necessary to identify the most effective yet safest topical antiseptics for use in neonates to reduce nosocomial sepsis.

RECENT FINDINGS

Recent national surveys indicate that a wide range of topical antiseptic preparations are used in the neonatal nursery. There are very few comparative studies in neonates and no robust evidence in favour of any particular antiseptic. There are significant safety and potential toxicity issues for neonates with all the commonly used antiseptics, particularly in very small immature babies. There are no convincing roles for routine application of emollient creams on the skin, topical antiseptics on the umbilical stump, or maternal vaginal washes with chlorhexidine for the prevention of neonatal infection.

SUMMARY

Large multicentre trials are needed to determine the optimal antiseptic to use for neonates undergoing intensive care, especially for extremely preterm infants.

The effects of two bathing methods on the time of separation of umbilical cord in term babies in Turkey

Background:

Umbilical cord infection developing subsequent to bacterial colonization is one of the outstanding reasons of newborn mortality and morbidity in underdeveloped and developing countries

Objectives:

This study aimed to evaluate the influence of sponge and tub bathing methods on umbilical cord separation time in full term babies in Turkey.

Patients and Methods:

This quasi-experimental and randomized controlled study was performed on 100 healthy term newborn babies and their mothers. One-hundred full-term babies (51 sponge bathing, 49 tub bathing) born at a state hospital between 14.03.2013 and 18.05.2013 with gestational age of 38-42 weeks, weighing 2500 grams and above and met the selection criteria were included as the study sample. Two booklets were prepared about sponge bathing and tub bathing. Mothers were instructed about sponge bathing and tub bathing, umbilical cord care in prenatal and postnatal periods. The first postnatal visit was performed at the hospital. Home visits and telephone calls were continued until the day of cord separation. Number, percent, mean and standard deviation values, qui-square and Mann-Whitney U tests were used for data assessment.

Results:

The time of separation of umbilical cord in babies who were given sponge bathing (6.1 ± 1.4) was shorter compared to those given tub bathing (8.3 ± 2.5) (P < 0.005).

Conclusions:

Since wetting of umbilical cord during tub bathing delays the separation of umbilical cord, sponge bathing is recommended for newborns until the umbilical cord falls off.

Use of topical petroleum jelly for prevention of sepsis in very low-birthweight infants: a prospective, randomised controlled trial

BACKGROUND

Emollient therapy is used frequently to prevent nosocomial infection in the management of preterm infants, despite a lack of adequate evidence of its efficacy.

OBJECTIVE

To assess the efficacy of prophylactic whole-body application of pure preservative-free topical petroleum jelly on the incidence of nosocomial sepsis in very low-birthweight (VLBW) infants.

STUDY DESIGN

A prospective, randomised controlled trial of the application of topical petroleum jelly was conducted. Infants weighing <1250 g at birth and with a gestational age of ≤32 weeks were included. The intervention group received twice-daily topical therapy of 2 g/kg pure, preservative-free topical petroleum jelly until the completion of 34 weeks of gestation. The control group received no topical petroleum jelly treatment. The primary outcome was the incidence of late-onset sepsis during hospitalisation. Other data collected included the pattern of temperature control, weight changes, fluid requirements, serum bilirubin level, electrolyte imbalance and skin condition.

RESULTS

Thirty-five infants in the intervention group and 39 in the control group were recruited. Birthweight, gestational age, gender and perinatal variables were comparable in the two groups. There was a trend towards an increased incidence of culture-proven nosocomial sepsis in the intervention group - 19 episodes (54%) in the intervention group vs 16 (41%) in the control group, and an increased rate of NEC - 20% in the intervention group vs 8% in the control group. The intervention group had better skin condition throughout their stay and the incubator ambient temperature was lower in the intervention group in the 1st week of life. The fluid balance of the infants in the intervention group was better, as reflected by their mean (SD) shorter time to regain birthweight [12 (5) vs 14 (6) days], and there were fewer episodes of hypernatraemia in the 1st week of life, although none of these reached statistical significance. However, there was a significantly lower mean (SD) level of maximum hyperbilirubinaemia [157 (40) vs 182 (46) mmol/L, P = 0·02) in the intervention group.

CONCLUSION

Although prophylactic topical application of pure, preservative-free petroleum jelly brought substantial improvement of skin condition and temperature control, it was associated with a trend towards an increased rate of nosocomial sepsis.

Tolerance of skin care regimen in healthy, full-term neonates

Purpose

To assess the tolerance of a baby cleanser and lotion (both lightly fragranced) on healthy, full-term neonates.

Materials and methods

Twenty-six infant–mother pairs were enrolled in a 6-week, nonrandomized, controlled-use study that took place in the routine setting of a pediatric clinic and mothers’ homes. During study weeks 1 to 6, neonates were bathed by their mother with water and a test cleanser (JOHNSON’S® HEAD-TO-TOE® Baby Wash). During study weeks 1 to 3, mothers also applied test lotion (JOHNSON’S® Baby Lotion) to the babies’ skin immediately after bathing and one to three times/day on bathing and non-bathing days. During study weeks 4 to 6, no lotion was applied. At baseline and weeks 3 and 6, the infants’ pediatrician or mother or both performed visual skin assessments.

Results

Twenty-three infant–mother pairs completed the study. The mean age of neonates at enrolment was 17.4 days (range, 13–28 days). Pediatrician observations found no clinical signs of irritation, erythema, or dryness with any significant difference in scores of these parameters compared with baseline throughout the study. Assessment of skin softness, smoothness, dryness, and overall skin condition was very good at baseline and remained so with minimal changes throughout the study. Mothers reported improvements versus baseline (P ≤ 0.05) in overall skin appearance, moisturization, softness, and smoothness on the arms and legs at weeks 3 and 6. A total of four (15.4%) subjects experienced adverse events. For three of the subjects, the investigator suspected that the adverse events were unrelated to either of the test products. In one participant, the cause of the adverse event could not be determined.

Conclusion

The use of a lightly fragranced nonstinging baby cleanser, with or without a lightly fragranced baby lotion, was well tolerated by newborns and resulted in observable skin benefits per the pediatricians’ and mothers’ assessment.

Neonatal sepsis due to coagulase-negative staphylococci

Neonates, especially those born prematurely, are at high risk of morbidity and mortality from sepsis. Multiple factors, including prematurity, invasive life-saving medical interventions, and immaturity of the innate immune system, put these infants at greater risk of developing infection. Although advanced neonatal care enables us to save even the most preterm neonates, the very interventions sustaining those who are hospitalized concurrently expose them to serious infections due to common nosocomial pathogens, particularly coagulase-negative staphylococci bacteria (CoNS). Moreover, the health burden from infection in these infants remains unacceptably high despite continuing efforts. In this paper, we review the epidemiology, immunological risk factors, diagnosis, prevention, treatment, and outcomes of neonatal infection due to the predominant neonatal pathogen CoNS.

Nutritional management of the low birth weight/preterm infant in community settings: a perspective from the developing world

Globally, about 20 million infants are born with low birth weight (LBW; <2500 g). Of all LBW infants, approximately 95% are born in developing countries. The greatest incidence of LBW occurs in South-Central Asia; the second greatest is in Africa. The two main reasons for LBW are preterm birth (<37 weeks) and intrauterine growth restriction (IUGR), which are risk factors for increased morbidity and mortality in newborn infants. Maternal nutrition status is one of the most important risk factors for LBW/IUGR. Providing balanced protein energy and multiple micronutrient supplements to pregnant women will reduce incidence of IUGR. Calcium supplementation during pregnancy will reduce the incidence of pre-eclampsia and preterm birth in developing countries. Exclusive breastfeeding is protective for a mother and her infant and has been shown to reduce morbidity and mortality in infancy. Kangaroo mother care for preterm infants will reduce severe morbidity and mortality as well. Community-based intervention packages are among the most effective methods of reducing morbidity and mortality in mothers and children. Future research should focus on improving triage of preterm and IUGR infants. Exclusive breastfeeding should be promoted, and appropriate alternative food supplements should be provided when breastfeeding is not possible.

Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age

Nappy dermatitis is a broad term used to describe an acute inflammatory reaction of the skin in the nappy area because of irritation from urine, faeces, moisture or friction. The prevalence is estimated to be between 7% and 35% in infants. Regular application of a barrier preparation at every nappy change may be a valuable component of nappy dermatitis prevention and/or treatment.

Infection control in United Kingdom neonatal units: variance in practice and the need for an evidence base

Infection prevention is a cornerstone of good neonatal care. There are, however, few research data to support infection control approaches in this population. Through a structured telephone interview we surveyed all neonatal units in the United Kingdom to identify infection control issues, practices and policies. Eighty seven percent of the 198 neonatal units participated. Twenty one units (12.2%) had closed with infection control issues in the last year; 14.1% had current infection control concerns; 81.5% of units decolonised MRSA positive infants, but over 15 regimens were used. Wide variations in hygiene measures were identified; 22.1% of units used theatre scrubs for all staff, 7.6% used aprons and 5.8% required gloves to be worn when entering clinical areas. Only 54% required hand washing and alcohol gel before entry to a patient care area; 11.6% required only the use of alcohol gel.

Although infection control issues are resulting in neonatal unit closures and risks to patients, there are considerable variations in hygiene and screening practices. There is little data to support the safety or efficacy of decolonisation in neonatal populations, but this is widely practised. Research needs to be carried out to evaluate the effectiveness of screening practices and decolonisation in order that a consistent evidence-based approach can be applied.

The infant skin barrier: can we preserve, protect, and enhance the barrier?

Infant skin is different from adult in structure, function, and composition. Despite these differences, the skin barrier is competent at birth in healthy, full-term neonates. The primary focus of this paper is on the developing skin barrier in healthy, full-term neonates and infants. Additionally, a brief discussion of the properties of the skin barrier in premature neonates and infants with abnormal skin conditions (i.e., atopic dermatitis and eczema) is included. As infant skin continues to mature through the first years of life, it is important that skin care products (e.g., cleansers and emollients) are formulated appropriately. Ideally, products that are used on infants should not interfere with skin surface pH or perturb the skin barrier. For cleansers, this can be achieved by choosing the right type of surfactant, by blending surfactants, or by blending hydrophobically-modified polymers (HMPs) with surfactants to increase product mildness. Similarly, choosing the right type of oil for emollients is important. Unlike some vegetable oils, mineral oil is more stable and is not subject to oxidation and hydrolysis. Although emollients can improve the skin barrier, more studies are needed to determine the potential long-term benefits of using emollients on healthy, full-term neonates and infants.

Efficacy of Arnica Echinacea powder in umbilical cord care in a large cohort study

BACKGROUND

Today healthy newborns are discharged after 48 h-72 h of life until umbilical cord (UC) detachment. Complications due to an inappropriate management are: erythema, edema, bleeding, omphalitis and sepsis. Hence the importance of a safe, effective, easy to do, and cheap method.

AIM

This study tests the effects and the efficacy of arnica echinacea powder by evaluating the time of cord detachment and the risk of side effects in a large cohort of newborns.

METHODS

6323 babies were treated with Arnica Echinacea powder twice a day until cord stump detachment. Medications started in hospital ward and continued at home until stump detachment.

RESULTS

The UC stump detachment occurred in 89.09% of newborns during the first 4 days of life. This percentage increase to 96.13% at 6 days.

CONCLUSIONS

Our study demonstrates the efficacy and the safety of arnica echinacea in UC separation. No infections or even bacterial colonizations were found. The use of arnica echinacea reduces hospital costs as a consequence of complications. In addition arnica use is well received by medical staff and parents. In conclusion due to its potential benefits, low cost and feasibility, we recommend the use of arnica echinacea powder as routine procedure in all nurseries.

Wound care in the neonatal intensive care unit

The skin is a vital organ with key protective functions. Infants in the NICU are at risk for skin injury because of developmental immaturity and intensive care treatments. When skin injury occurs, the neonatal nurse is challenged to provide wound care to optimize functional and cosmetic healing. Optimal wound care requires basic knowledge of the mechanisms of injury, physiology of wound healing, host factors affecting wound healing, and wound assessment. This knowledge provides the basis for determining appropriate wound treatment, including dressing selection. Attention to pain issues associated with wound care is difficult because of the infant's developmental stage, but is essential because of the potentially negative life-long impact of pain. The premature infant's propensity for skin stripping limits the selection of appropriate dressing, as does the paucity of research examining wound care products in this population.

Children and newborn skin care and prevention

Neonatal skin suffers a progressive adaptation to the extrauterine environment and special care is needed during this period. This skin is very sensitive, thin and fragile. Immaturity of the epidermal barrier reduces the defense against the excessive proliferation of microbes and makes the skin more vulnerable to trauma and percutaneous drug toxicity. Because of the peculiar characteristics of newborn, infant and children's skin, the use of cosmetic products designed for hygiene and protection requires caution. In order to preserve the integrity of neonatal and child's skin, this article reviewed basic preventive care practices in relation to hygiene, bathing, cleansing agents, topical products and their percutaneous toxicity.

Skin care practices for newborns and infants: review of the clinical evidence for best practices

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.

Effects of the use of semipermeable membranes on fluid loss in low-birth-weight premature newborns

Studies have shown that the application of semipermeable membranes to the skin of premature newborns (NBs) can aid in protecting the skin, reduce disturbances in fluid and electrolyte levels, and decrease neonatal mortality. The aim of this study was to verify the effect of using semipermeable membranes in low-birth-weight preterm newborns (PTNBs). A randomized controlled trial was carried out in the neonatal intensive care unit (NICU) with 42 NBs split evenly into an intervention group (IG), in which semipermeable membranes were used to cover large areas of the skin for the first 7 days of life, and a control group (CG), which received normal care. The variables investigated for the study were weight, hydration status, urinary density, glycemic control, sodium concentration, and daily hydration quota. The following variables displayed significant daily variation: weight, hydration quota, and sodium concentration. Statistically significant individual effects by day and by group were found only for sodium concentration. In the overall analysis of the intersubject effects, sodium concentration, alone, proved to be significant (p = .055). Significant effects by group in relation to the sodium concentration were found, with the IG showing a lower average sodium concentration than the CG. Thus, the use of semipermeable membranes reduced fluid loss in premature NBs in the current study, confirming the findings of previous studies. Guidelines for practice may now be warranted.

Feasibility of long-term continuous EEG monitoring during the first days of life in preterm infants: an automated quantification of the EEG activity

Long-term EEG monitoring (LTM) with several electrodes could be a useful tool for surveillance of the brain during the first critical days of life. This study aimed to assess the feasibility of multichannel LTM for automated analysis of EEG activity from d 1 to 3 using eight electrodes. Premature infants (GA <31 wk; n = 48) were continuously monitored for 3 d. EEG monitoring for a total of 3257 h was successfully performed. Total absolute band power (tABP) was calculated per second. Artifacts were removed visually or by an algorithm removing the highest 5, 10, 15, and 20% tABPs. NS difference was found between the trends of visually edited and 5% mathematically trimmed data. Two groups were compared (24 ≤ GA < 28 wk and 28 ≤ GA < 31 wk) using the median of tABP for all frequency bands per day. The results showed that tABP differed between groups. The changes of tABP d 1-3 were equal in both groups. Automatically assessed LTM confirms that the EEG activity depends on GA. However, it reveals that the early changes (d 1-3) are independent of GA. The study demonstrates the feasibility of multichannel LTM and the possibility of developing automated EEG analyses.