Does bathing newborns remove potentially harmful pathogens from the skin?

Early development of the skin microbiome: therapeutic opportunities

As human skin hosts a diverse microbiota in health and disease, there is an emerging consensus that dysregulated interactions between host and microbiome may contribute to chronic inflammatory disease of the skin. Neonatal skin is a unique habitat, structurally similar to the adult but with a different profile of metabolic substrates, environmental stressors, and immune activity. The surface is colonized within moments of birth with a bias toward maternal strains. Initial colonists are outcompeted as environmental exposures increase and host skin matures. Nonetheless, early life microbial acquisitions may have long-lasting effects on health through modulation of host immunity and competitive interactions between bacteria. Microbial ecology and its influence on health have been of interest to dermatologists for >50 years, and an explosion of recent interest in the microbiome has prompted ongoing investigations of several microbial therapeutics for dermatological disease. In this review, we consider how recent insight into the host and microbial factors driving development of the skin microbiome in early life offers new opportunities for therapeutic intervention. IMPACT: Advancement in understanding molecular mechanisms of bacterial competition opens new avenues of investigation into dermatological disease. Primary development of the skin microbiome is determined by immunological features of the cutaneous habitat. Understanding coordinated microbial and immunological development in the pediatric patient requires a multidisciplinary synthesis of primary literature.

Variation in Newborn Skincare Policies Across United States Maternity Hospitals

OBJECTIVE

Newborn skincare influences levels of beneficial factors from vernix and vaginal secretions but also the emergence of potential skin pathogens. However, evidence-based national guidelines for newborn skincare do not exist, and actual hospital practices for newborn skincare have not been described. In this study, we test the hypothesis that US maternity hospitals follow differing policies with regard to newborn skincare.

METHODS

A 16-question survey querying skin care practices was distributed to nursery medical directors at the 109 US hospital members of the Better Outcomes through Research for Newborns network. Data from free text responses were coded by 2 study personnel. Survey responses were analyzed by using descriptive statistics and compared by region of the United States.

RESULTS

Delaying the first newborn bath by at least 6 hours is a practice followed by 87% of US hospitals surveyed. Discharging newborns without a bath was reported in 10% of hospitals and was more common for newborns born in nonacademic centers and on the West Coast. Procedures and products used for newborn skincare varied significantly. Parental education on tub immersion and soap use was also inconsistent and potentially contradictory between providers. Evidence cited by hospitals in forming their policies is scant.

CONCLUSION

In this study, we identify similar and strikingly different newborn skincare policies across a national network of US maternity hospitals. Research is needed to identify effects of differing skincare routines on skin integrity, infection rates, and childhood health outcomes to improve the evidence base for the care of newborn skin.

Recommendation for hygiene and topical in neonatology from the French Neonatal Society

We sought to establish guidelines for hygiene care in newborns based on a systematic review of the literature and grading of evidence using the Groupe de Réflexion et d'Evaluation de l'Environement des Nouveau-nés (GREEN) methodology. We examined 45 articles and 4 reports from safety agencies. These studies recommend a tub bath (rather than a sponge bath) for full-term infants and a swaddle bath for preterm newborns. They also recommend against daily cleansing of preterm infants. The literature emphasized that hygiene care must consider the clinical state of the newborn, including the level of awareness and behavioral responses. Hospitalized newborns treated with topical agents may also experience high exposure to potentially harmful excipients of interest. Caregivers should therefore be aware of the excipients present in the different products they use. In high-resource countries, the available data do not support the use of protective topical agents for preterm infants.Conclusions: We recommend individualization of hygiene care for newborns. There is increasing concern regarding the safety of excipients in topical agents that are used in neonatology. A multidisciplinary approach should be used to identify an approach that requires lower levels of excipients and alternative excipients. What is known: • Hygiene care is one of the most basic and widespread types of care received by healthy and sick newborns worldwide. • There is no current guideline on hygiene for preterm or hospitalized term newborn. What is new: • The French Group of Reflection and Evaluation of the environment of Newborns (GREEN) provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' behavioral responses to hygiene care, exposition to excipients of interest, and the potential risk of protective topical agents in a preterm infant. provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' possible behavioral responses to hygiene care, exposition to excipients of interest and the potential risk of protective topical agents in a preterm infant.

Skin care for healthy babies at term: A systematic review of the evidence

OBJECTIVES

to identify what skin practices are important for the protection of baby skin in healthy term babies (0-6 months) and generate evidence-based conclusions to inform health professionals and parents.

DESIGN

eleven databases were searched for all empirical quantitative and qualitative research published between 2000-2015 which explored baby skin care for bathing and cleansing, nappy care, hair and scalp care, management of dry skin or baby massage, for healthy term babies up to 6 months old. Papers not published in English were excluded. A total of 3062 papers were identified. Pairs of reviewers assessed all citations and extracted data independently. There were 26 included papers: 16 RCTs, 3 non-randomised experimental studies, 1 mixed-methods study and 6 qualitative studies. Primary and secondary outcome measures were analysed using meta-analysis or narrative descriptive statistics. Synthesis of qualitative data was not possible due to disparity of the evidence.

FINDINGS

from the small numbers of studies with comparable data, there was no evidence of any significant differences between tested wash products and water or tested baby wipes and water. There was some evidence to suggest that daily use of full-body emollient therapy may help to reduce the risk of atopic eczema in high risk babies with a genetic predisposition to eczema; however, the use of olive oil or sunflower oil for baby dry skin may adversely affect skin barrier function. There was no evidence about hair/scalp care or baby massage. Qualitative research indicates that parents and health professionals believe that water alone is best.

KEY CONCLUSIONS

meta-analysis was restricted due to the lack of consistency of study outcome measures. Although there is considerable RCT evidence comparing the use of specific products against water alone, or another product, for bathing, cleansing and nappy care, the power of this evidence is reduced due to inconsistency of outcome measures in terms of outcome, treatment site or time-point. The development of a core outcome measure set is advocated for trials assessing skin care practices.

IMPLICATIONS FOR PRACTICE

this review offers health professionals best evidence available on which to base their advice. Of those studies with comparative outcomes, the evidence indicates no difference between the specific products tested and water alone; offering parents a choice in their baby skin care regimen. Protocol available: http://www.crd.york.ac.uk/PROSPEROFILES/28054_PROTOCOL_20151009.pdf.

The Skin as a Route of Allergen Exposure: Part II. Allergens and Role of the Microbiome and Environmental Exposures

PURPOSE OF REVIEW

This second part of the article aims to highlight recent contributions in the literature that enhance our understanding of the cutaneous immune response to allergen.

RECENT FINDINGS

Several properties of allergens facilitate barrier disruption and cutaneous sensitization. There is a strong epidemiologic relationship between the microbiome, both the gut and skin, and atopic dermatitis (AD). The mechanisms connecting these two entities remain enigmatic; however, recent murine models show that commensal skin bacteria play an active role in supporting skin barrier homeostasis and defense against microbial penetration. Likewise, the association between the lack of colonization with Staph species and AD development suggests a potentially functional role for these organisms in regulating the skin barrier and response to environmental allergens. In undisrupted skin, evidence suggests that the cutaneous route may promote allergen tolerance. Properties of environmental allergens and commensal bacteria add to the complex landscape of skin immunity. Further investigation is needed to elucidate how these properties regulate the cutaneous immune response to allergen.

Bathing and Beyond: Current Bathing Controversies for Newborn Infants

BACKGROUND

Bathing the newborn infant is controversial, ranging from how and when to give the newborn their first bath, whether to bathe newborns at all in the initial days of life, and how to approach bathing the hospitalized premature and full-term infant in the neonatal intensive care unit (NICU).

PURPOSE

To review relevant literature about bathing newborn infants, as well as examine the controversies about bathing NICU patients including the use of daily chlorhexidine gluconate (CHG) baths.

FINDINGS

Despite studies showing that temperature can be maintained when the first bath was at 1 hour after delivery, there are benefits from delaying the bath including improved breastfeeding. Tub or immersion bathing improves temperature, and is less stressful. It is not necessary to bathe infants every day, and premature infants can be bathed as little as every 4 days without an increase in skin colonization. No differences have been reported in skin parameters such as pH, transepidermal water loss, and stratum corneum hydration whether the first and subsequent baths are given using water alone or water and a mild baby cleanser. Concerns about systemic absorption suggests caution about widespread practice of daily CHG bathing in the NICU until it is known whether CHG crosses the blood-brain barrier, particularly in premature infants.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Research regarding bathing practices for NICU patients should be evidence-based whenever possible, such as the benefits of immersion bathing. More evidence about the risks and benefits of daily CHG bathing is needed before this practice is widely disseminated.

Two methods of cord care in high-risk newborns: their effects on hydration, temperature, pH, and floras of the cord area

This randomized clinical study explored the effects of two cord care methods on hydration, temperature, pH, and floras at the cord area in high-risk newborns. One group used the water method; and the other group used the alcohol method. Seventy-two newborns, including premature newborns, in the neonatal intensive care unit (NICU) of a university-affiliated hospital in South Korea were enrolled from August 2011 to May 2012. Hydration, temperature, pH, and floras were measured daily until the cords fell off. The results showed no difference between the groups in hydration, temperature, pH, and the colonization of floras, but cord detachment in the alcohol group took 2 days longer (12.8 [5.7] days) than in the water group (10.9 [4.1] days). Our findings suggest that the clean-and-dry method of cord care, which uses water, could be sufficient, possibly even better than alcohol in maintaining the physiologic surface milieu of the cord area with less chance of infection and manipulation in NICUs with optimal infection control.

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.

Host defense proteins on the surface of neonatal skin: implications for innate immunity

OBJECTIVES

To compare the spectrum, concentration, and activity of host defense proteins (HDPs) on the skin surface of newborns and adults, to assess variation in HDP concentrations in different anatomic regions in newborns, and to examine alteration in HDP concentrations with care practices.

STUDY DESIGN

Proteins recovered from tape discs applied to stratum corneum of 25 term newborns (forehead and posterior trunk) and 20 adults (forehead) were analyzed by Western analysis for 5 HDPs and for muramidase activity. Protein concentrations were compared in samples obtained after delivery, after the first bath, and at 24 hours of age.

RESULTS

Total protein was 2.8-fold higher in adults compared with newborns. Lysozyme and lactoferrin were detected in all samples. In contrast to total protein, lysozyme concentrations and muramidase activity were 5-fold higher in newborns relative to adults and were not altered after bathing. Lysozyme concentrations were significantly higher over the trunk compared with the forehead in newborns.

CONCLUSIONS

The newborn skin surface is replete with prototypical HDPs, lysozyme, and lactoferrin. Bathing does not significantly diminish concentrations. These factors are likely to contribute importantly to the newborn infants' defense against invasive bacterial infections.

The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial

AIM

To elucidate the impact of bathing on the prevalence of hypothermia among newborn babies exposed to the skin-to-skin (STS) care technique before and after bathing.

METHODS

Non-asphyxiated newborns after vaginal delivery (n = 249) in a Ugandan referral hospital were consecutively enrolled and randomized either to bathing at 60 min postpartum (n = 126) or no bathing (n = 123). All mothers practised skin-to-skin care of their newborns. Four rectal and tympanic registrations of newborn temperatures were carried out in both groups directly after drying at birth, and at 60, 70 and 90 min postpartum.

RESULTS

Bathing of newborns in the first hour after delivery resulted in a significantly increased prevalence of hypothermia, defined as temperature <36.5 degrees C, at 70 and at 90 min postpartum despite the use of warmed water and the application of the STS method. There was no neonatal mortality. Aside from the bathing procedure, no background factor potentially predisposing the newborns to hypothermia was identified.

CONCLUSION

Bathing newborn babies shortly after birth increased the risk of hypothermia despite the use of warm water and STS care for thermal protection of the newborn.

Skin care in the well term newborn: two systematic reviews

BACKGROUND

Awareness is increasing that the use of some commercial products on the premature neonatal skin may be beneficial, whereas the use of others may be harmful. The World Health Organization developed general postnatal care guidelines and the Association of Women's Health, Obstetric and Neonatal Nurses published specific evidence-based guidance relating to neonatal skin care. No systematic reviews on the topic have focused on the term newborn. The objective of this review was to determine, for the well term baby, if the use of soaps or detergents in bath water is associated with the development of dry, cracked, or flaking skin in the perinatal period, and short- and long-term consequences of the use of emollients, lotions, or moisturizers for dry skin.

METHODS

We conducted a structured systematic review of prospective studies involving term newborns.

RESULTS

No relevant studies were located.

CONCLUSIONS

No prospective studies of research in skin care involving the term newborn were found. Some recommendations for skin care may balance risk and benefit for the compromised infant, but this balance may be different for the healthy term newborn. Clinical practitioners should be aware that outcomes related to the use of soaps, detergents, emollients, and lotions on the term neonatal skin have not been formally investigated. Systematic reviews that yield no formal results provide insights into unresearched areas of practice, and should be reported to highlight these deficits, and to avoid duplication of effort by future investigators.

Effect of bathing on skin flora of preterm newborns

OBJECTIVE

To assess the effect of bathing with water only or with mild pH neutral soap and water on skin flora of preterm newborns.

METHOD

Randomized blinded clinical trial that enrolled 73 preterm newborns whose gestational age was between 28 and 35 weeks and birth weight between 800 and 1800 g. At the age of 3 days the infants were randomly assigned to a group that was given daily baths either with water only, or with soap and water for 7 or more days. Antibiotic treatment delayed onset of the trial in some preterm infants. On the final day of bathing axillary bacterial cultures were obtained before and 30 minutes after bathing.

RESULTS

At the time of axillary culturing, the mean age of the newborns was 19 days. Coagulase-negative Staphylococcus was the most prevalent microorganism in both groups. No significant difference was found in the count of microorganism colonies between both groups. The comparison of the number of bacterial colonies between the time before and after bath, carried out by repeated-measures ANOVA showed a significant difference over time in the two groups, without a significant difference between the two groups.

CONCLUSIONS

Bathing preterm newborns with water only or with soap and water produces similar effects on skin colonization of a preterm neonate. Both are effective to decrease the number of colonies of Gram-positive and Gram-negative bacteria.

Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial

BACKGROUND

Despite the widespread household use of cleaning and personal hygiene products containing antibacterial ingredients, their effects on the incidence of infectious disease symptoms have not been studied.

OBJECTIVE

To evaluate the effect of antibacterial cleaning and handwashing products for consumers on the occurrence of infectious disease symptoms in households.

DESIGN

Randomized, double-blind clinical trial.

SETTING

Northern Manhattan inner-city neighborhood, New York.

PARTICIPANTS

238 primarily Hispanic households (1178 persons) that included at least one preschool-age child.

INTERVENTIONS

Households were randomly assigned to use either antibacterial or nonantibacterial products for general cleaning, laundry, and handwashing. All products were commercially available, but the packaging was blinded and the products were provided free to participants.

MEASUREMENTS

Hygiene practices and infectious disease symptoms were monitored by weekly telephone calls, monthly home visits, and quarterly interviews for 48 weeks.

RESULTS

Symptoms were primarily respiratory: During 26.2% (717 of 2736) of household-months, 23.3% (640 of 2737) of household-months, and 10.2% (278 of 2737) of household-months, one or more members of the household had a runny nose, cough, or sore throat, respectively. Fever was present during 11% (301 of 2737) of household-months, vomiting was present in 2.2% (61 of 2737), diarrhea was present in 2.5% (69 of 2737), and boils or conjunctivitis were present in 0.77% (21 of 2737). Differences between intervention and control groups were not significant for any symptoms (all unadjusted and adjusted relative risks included 1.0) or for numbers of symptoms (overall incidence density ratio, 0.96 [95% CI, 0.82 to 1.12]).

CONCLUSIONS

The tested antibacterial products did not reduce the risk for symptoms of viral infectious diseases in households that included essentially healthy persons. This does not preclude the potential contribution of these products to reducing symptoms of bacterial diseases in the home.

The Effect of Bather and Location of First Bath on Maintaining Thermal Stability in Newborns

OBJECTIVE

To compare thermal stability during the first bath of newborns bathed by maternal-child nurses in a newborn nursery with thermal stability of newborns bathed by parents at the maternal bedside.

DESIGN

A randomized clinical controlled trial.

SETTING

A tertiary care hospital in western Canada.

PARTICIPANTS

Participants (N = 111) were full-term newborns born vaginally.

INTERVENTIONS

The experimental treatment was the parent bathing the newborn under nursing supervision at the bedside in the first few hours of birth; the standard treatment was a nurse bathing the newborn in an admission nursery.

MAIN OUTCOME MEASURES

The main outcome measure was newborn heat loss occurring from bathing as assessed by changes in aural temperatures, which were taken before, during, and following bathing.

RESULTS

There was no difference in temperature change between newborns bathed by a nurse and those bathed by a parent (F = 0.595, df = 1, p = .442). A return to normal thermal ranges takes approximately an hour.

CONCLUSION

Heat loss experienced by newborns during bathing is significant and is not associated with who bathes the newborn or where the bath takes place.