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EDITORIAL
Year : 2007  |  Volume : 52  |  Issue : 1  |  Page : 1-4
Newborn skin care revisited


From the Pediatric Dermatology Division, Institute of Child Health, Kolkata, India

Correspondence Address:
Sandipan Dhar
Flat 2A2, Block II, 5, N S C Bose Road, Kolkata - 700 040
India
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DOI: 10.4103/0019-5154.31917

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How to cite this article:
Dhar S. Newborn skin care revisited. Indian J Dermatol 2007;52:1-4

How to cite this URL:
Dhar S. Newborn skin care revisited. Indian J Dermatol [serial online] 2007 [cited 2014 Sep 22];52:1-4. Available from: http://www.e-ijd.org/text.asp?2007/52/1/1/31917


The skin is the first barrier of the newborns to counter various noxious factors/ agents of the environment once the baby comes out of the safe and secured intrauterine life to the external world. I shall discuss the details of various aspects of newborn skin care under different headings.


   Why Special Skin Care for Babies? Top


Baby's protective but delicate cover needs to be kept in a healthy condition and it should be disturbed as little as possible. Topical agents are more rapidly absorbed into infant skin due to deficient intercellular bridges. Besides, greater body surface area to weight ratio than adults also facilitates easy absorption and toxicity of topically applied substances. Infant skin cannot withstand the toxicity of most substances as they make this delicate skin more susceptible to electrolyte imbalance, fluid imbalance and thermal instability. Infant skin is particularly very sensitive to cleansing agents as they contain stronger chemicals and may be drying. Hence the product should be guaranteed of safety for use on babies.

Skin problems pertaining to dryness are common in babies due to inadequacies in the epidermal barrier. The skin irritation potential towards topical applicants is also more. Maintaining skin integrity and preventing exposure to toxic substances in childhood assures healthy skin for several years ahead.


   Care of the Newborn Skin Top


Skin of the newborns performs the most challenging task as it is the outermost cover of the body. Moreover, it is confronted with various factors, viz, temperature changes, friction, microbes; etc of the external world once the baby is born. As the structure and functions of the skin depend on whether a child is born at term or prematurely, skin care is related to gestational age.

At birth, microbial colonization of newborn skin is almost nil. But over a few days, aerobic flora occupies skin at different concentrations at different sites, e.g. mostly over groins, axillae and scalp.[1] Coagulase negative staphylococci ( Staphylococcus epidermidis) are the most commonly found microorganisms. Staphylococcus aureus appears only as contamination, usually from mother or nursing staffs.


   Skin Care at Birth Top


Removal of vernix caseosa

At birth the baby's skin is coated with vernix caseosa, blood, meconium and cellular debris. Vernix caseosa contains both epidermal (triglycerides and cholesterol) and sebaceous (squalene and waxes) fat. Premature infants tend to have less of vernix than term babies and postmature babies have little vernix. There is considerable inter-individual variation in the quality of vernix caseosa.

Washing and bathing

A bath is an ideal means of cleaning an infant completely. A bath in infant should not last for more than five minutes. The bath for more than 5 minutes increases the hydration of skin and, thereby, reduces the threshold for friction. Infants can be bathed immediately after birth irrespective of the falling of the umbilical cord stub. The water should be boiled and the temperature should not be exceeding 37°C for bathing newborns. A solid or liquid cleanser or a syndet can be used to clean baby skin. Bubble bath can also be given but not for too long or too frequently as can it can cause irritation. After bath, infants must be dried thoroughly, particularly over skin creases, groins and axillae.

Napkin changes

Napkin should be changed frequently, at least at each nursing and feeding time. It should be carefully washed in lukewarm water and then rinsed off and dried thoroughly.

The diaper area is specifically vulnerable because it is a closed environment suitable for microorganisms and with frequent wetting, it is more often moist and dry; hence the skin becomes prone to maceration and increases its permeability to other irritants.

The skin here is constantly in contact with strong alkalinizing agents e.g., urine and feces and the pH here is prone to high alkalinity that damages the skin integrity. It is, thus, very important to be well-aware of the need to change nappies and the range of products that are available to prevent any rash or irritation in the nappy area.

Nappy rash can be reasonably prevented by reducing moisture by the frequent changing of nappies. This would reduce contact between urine, feces and the skin. However, this does not seem feasible at most instances. In such cases, using partially occlusive agent like mineral oil on the buttocks can help to form a physiological barrier that minimizes this interface. As far as possible, air exposure should be increased by allowing the child to move around the house bare-bottomed. Plastic pants should be avoided as they reduce the air circulation to the skin. Warm water and soft cotton wool should be used to wipe the nappy area. Feces have a tendency to stick and scrubbing only worsens the status of the delicate skin. Here, the use of an emulsion like baby lotion can ease the removal by reducing the surface tension and cleaning the debris. Skin should then be thoroughly dried each time the diaper is changed by exposing it for a few minutes. The bottom should be wiped from front to back to avoid fecal matter from reaching the genitals. After each wash, powder should be applied in the skin folds to prevent friction due to wetting as well as to avoid candidal colonization due to excess moisture in the area. Soaps should be mild and should be used very rarely if a rash has developed.

In general, the nappies should be made of cotton cloth and should be home laundered with mild detergents. Disposable diapers should be avoided as far as possible. However, some newer diapers allow the moisture to stay away from the baby's bottom. They keep the skin relatively dry and reduce the risk of developing the rash. Nappy pads with cotton padding are more suited.

Scalp

Shampoo helps to remove scales and crust from the scalp (cradle cap). If the first sign of seborrheic dermatitis appears, application of mineral or animal oil limits the spread of lesions.

Nails

Nail should be regularly cut and kept short and clean.

The ears

Cotton swabs soaked in boiled water should be used to clean ears. Special care should be taken not to hurt auditory canals.

Umbilicus

After birth umbilical cord dries out and drops off within five to ten days. Certain products containing eosin or others stains are often used. However, they act more as drying agents rather than as antiseptics.


   Skin Care in the Premature Infant Top


After birth, skin maturation proceeds rapidly in preterm infants.[2] These infants are kept warm and nursed in closed incubators. Environmental conditions in these units are potentially harmful for infant skin, which is subject to scarring.[3] Cosmetically or functionally, significant lesions may be caused by needle marks, central venous catheters, transcutaneous oxygen monitoring, chest drain insertion, extravasation of intravenous fluid or skin stripping due to adhesive tape. To reduce the frequency and severity of skin damage, neonatal staffs need to know that many routine procedures can lead to long-term scarring and atrophy.


   Preventive Measures Top


Disinfection: The most common infective agents causing septicemia are coagulase-negative staphylococci in relation to catheter placement. For prevention, maintain hygiene by hand washing of the staff and parents.[4] Cleaning with chlorhexidine-alcohol and povidone-iodine, two consecutive 10 second cleaning destroys more than a single 10 second wipe.[4]

The incubator: Frequent change of infants' position in the incubator reduces the risk of skin erosion and impending bed sore. Fingers and toes must be kept visible. Catheters or needles should be secured with a transparent tape to allow easy detection of fluid extravasation. Scarring alopecia can develop following pressure ulcer. The occurrence of nonblanchable erythema and disruption of epidermis indicate impending ulcer. The occurrence of scarring alopecia has been reported in infants from pressure necrosis.[5]

Transcutaneous oxygen monitors: Transcutaneous oxygen monitors should not be left in place for more than one hour without surveillance. Non-blanchable erythema has been reported with keeping such electrodes for prolonged period. The use of karaya electrodes has been demonstrated to be effective in cardiorespiratory monitoring with decreased trauma to the neonatal skin.[6] Placement of electrodes on the limbs, especially in very low birth weight infants, can eliminate the need to frequently remove these pads to facilitate auscultation or other assessment of the chest wall.[7]

Minimal use of tape and adhesive: The skin of the premature infants may be damaged by repeated attachment and removal of adhesive tapes to secure electrodes, IV cannulas, drains, etc. Adhesives should be used on small areas of skin and removed gently with warm water soaked gauze and diluted soap, but not alcohol, which may be irritant for baby's skin.[8]

Emollients: Application of emollient is a safe and effective way to decrease neonatal peeling and scaling dermatitis. Vegetable oil (e.g., olive oil), lanolin, petroleum-based ointments applied gently to the skin, reduce scaling and fissuring as well as increase skin hydration.[9]


   Skin Care of the Term Baby and Infant Top


The large number of infant skin-care products available over the counter is at times confusing for the average consumers.[8] These have been the gifts of media and so-called health magazines for the lay people with all rosy advertisements. By and large the principle followed by a doctor should be to advice the parents to go for a product marketed by a multinational company or a company of good repute and stature or a product, which has been in the market for a considerable period of time and thus has stood "the test of time". Several types of products are used; viz. detergents in the forms of soaps are shampoos, antiseptics, emollients, etc.


   Detergents Top


The term 'detergent' designates a substance capable of cleaning the skin, i.e., of removing impurities (dust, grease organic secretions, microorganisms). Washing with water alone does not remove all the impurities on the skin surface. Some are only fat soluble, thus requiring the use of products capable of emulsifying the fatty substance into fine droplets, which can then, be carried away by rinsing. These products are known as surfactants, act by suppressing the surface tension, which allows fatty substances to remain on the skin surface. Detergents act by reducing the surface tension between water and air, creating a foaming effect not directly correlated with the cleaning properties of the product. As a rule, a higher foaming power increases the risk of damage to the skin. Detergents are classified as ionic or non-ionic products. In infants detergents should be used cautiously, followed by a thorough rinsing. Too much removal of lipids from the stratum corneum would eliminate those essential to the surface ecosystem.

Soaps are the products of saponification, i.e., the action of alkali on a fatty substance. In hard water, soaps tend to precipitate.

Syndets or synthetic detergents do not have the theoretical disadvantages of soap but are subject to rapid disintegration. They can produce excessive dryness of skin, if moisturizers are not added to it. Antiseptic soaps are useful in preparation of an operative field, but are unsuitable for daily use with an infant as they can cause irritation to an infant's skin. Moreover, antiseptic soaps remove the commensal organism from the skin surface, thereby, making the skin prone to attack by virulent pathogenic organisms from outside.[9]

Bubble bath products attract the infants and their parents because of its colorings and perfumes and, thereby, mask the risk of prolonging a bath and irritating the genital mucosa.

Most baby shampoos in the market contain anionic surfactant which ensure adequate cleansing. The pH should be close to that of tears and, thereby, won't cause irritation to the eyes. Special ingredients, e.g., selenium sulphide, ketoconazole or zinc pyrithione may be added to the shampoos for seborrheic dermatitis. The basic principles of use of various antiseptics and emollients in term babies and infants are essentially the same as in preterm babies.

Protective creams: These are basically prepared to reduce the risk of irritation, particularly napkin rash, by isolating skin from numerous irritants for baby's skin. The creams contain a fatty phase, an aqueous phase, a surfactant, additives (zinc oxide), scents and preservatives. These creams can paradoxically cause increased occlusion and irritant dermatitis to its ingredient.[10]

Powders: These are useful to absorb moisture during hot and humid weather. They can prevent maceration over the skin folds in infants. However, too much of their use can lead to blockade of sweat-duct pores resulting in miliaria formation.[11]


   Role of Massage Top


The act of touch fulfils the basic need to feel safe, comfortable and loved. Touch is also an intrinsic factor in child development. Touch is proposed to play a role in growth, development and overall well-being. Massage is one of the most beautiful and gentle methods of touch. It is practiced in most countries and has recently been researched extensively in western countries.[12] Indian form of infant massage is appreciated all over the world. It has been seen that massage with oil is more beneficial as compared to massage without oil. It is important to note that the oil used in such a situation ought to be smooth, of optimum viscosity and friction free or else it would lead to abrasions on the skin surface. The oil should be nonocclusive so that it does not block the skin pores and allows the skin to breathe. It ought to be safe and mild to suit the baby's delicate skin and the ingredients should be thoroughly tested for their potential to cause contact sensitivity. Mineral oil is one of the best-known moisturizing ingredients ever found. It spreads easily and has a long lasting tactile effect, making it an extremely efficacious emollient. Omission of low molecular weight hydrocarbons alleviates risks of carcinogenicity while the large particle size renders it incapable of blocking pores making it noncomedogenic.[12]

Babies should be massaged from the tenth day of life and the ritual can easily continue till ten years and over. Benefits of massage are numerous. Appropriate knowledge of correct massage techniques is imperative in order to attain maximum therapeutic benefits from it. Complete head to toe massage should be a daily routine. But massage should be gentle and judicious. Massage given by the mother increases the bondage between the mother and her baby. It helps in the physiological and psychological development of the babies.

 
   References Top

1.Bertone SA, Fisher MC, Mortensen JE. Quantitative skin cultures at potential catheter sites in neonates. Infect control Hosp Epidermal 1994;15:315-8.  Back to cited text no. 1  [PUBMED]    
2.Lane AT. Development and care of the premature infant's skin. Pediatr Dermatol 1987;4:1-5.  Back to cited text no. 2  [PUBMED]    
3.Cartlidge PH, Fox PE, Rutter N. The scars of newborn intensive care. Early Hum Dev 1990;21:1-10.  Back to cited text no. 3      
4.Malathi I, Millar MR, Leeming JP, Hedges A, Marlow N. Skin disinfection in preterm infants. Arch Dis Child 1993;69:312-6.  Back to cited text no. 4      
5.Gresham LA, Esterly NB. Scarring alopecia in neonates as a consequence of hypoxemia hypoperfusion. Arch Dis Child 1993;68:591-3.  Back to cited text no. 5      
6.Scholz D. EKG electrodes and skin irritation. Neonat Network 1984;3:46-7.  Back to cited text no. 6      
7.Malloy MB, Perez-Woods RC. Neonatal skin care: Prevention of skin breakdown. Pediatr Nurs 1991;17:41-8.  Back to cited text no. 7      
8.Cetta F, Lambert GH, Ros SP. Newborn chemical exposure from over the counter skin care products. Clin Pediatr (Phila) 1991;30:286-9.  Back to cited text no. 8      
9.Caputo R, Monti M. Children's skin and cleansing agents. Wien Med Wochenschr Suppl 1990;108:24-5.  Back to cited text no. 9      
10.de Groot AC, Bruynzeel DP, Bos JD, van der Meeren HL, van Joost T, Jagtman BA, et al . The allergens in cosmetics. Arch Dermatol 1988;124:1525-9.  Back to cited text no. 10      
11.Mofenson HC, Greensher J, DiTomasso A, Okun S. Baby powder: The hazard. Pediatrics 1981;68:265-6.  Back to cited text no. 11      
12.Lund C. Newborn skin care. In : Baran R, Maibach HI, editors. Cosmetic Dermatology. Mosby: St Louis; 1994. p. 349-57.  Back to cited text no. 12      



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    Why Special Skin...
    Care of the Newb...
    Skin Care at Birth
    Skin Care in the...
    Preventive Measures
    Skin Care of the...
    Detergents
    Role of Massage
    References

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