Midwifery in 2012

Post-natal Care

been discouraged for a number of years due to its implication in respiratory conditions and cancer,42,43 still using it on their newborn’s skin.1,29

evidence exists that women are Aqueous cream, long regarded

found that the cream adversely affected the skin barrier function of individuals with known atopic dermatitis.

as the standard, economic and readily available cream safe for use on newborn skin has also recently come under criticism. The study by Danby et al.44

Currently, many women are expressing interest in natural and/or organic products, believing them to be a safer alternative for use on their babies’ skin, due to the fact that they contain only natural ingredients. However, as with other currently marketed baby products, they have only been subject to cosmetic trials, not clinical trials. This again provides little evidence to support their use.

The use of products for baby massage is also widespread. Baby massage is an important aspect of the bonding between parents and baby, particularly in mother and baby interaction.45,46

Massage is also

claimed to have soothing and calming effects on the newborn infant.47 A Cochrane review by Underdown et al45

also noted an association of

massage with improved infant sleep, relaxation and a reduction in crying, along with a reduction in stress hormones such as cortisol. Although there were some concerns of bias in the reviewed studies and a call for further research, the overall conclusion was positive.

Baby massage has long been used in some cultures, but is relatively new in others. As a result of its perceived benefits, many women and health professionals are now committed to baby massage. This has led to the use of a wide variety of oils on baby skin, some of which are specifically formulated to be used on skin while others are generally available. Oils such as mineral, petroleum, olive, almond, safflower, jojoba, coconut,

1. Lavender T, Bedwell C, Tseriki-O’Brien E, et al., A qualitative study exploring women’s and health professionals’ views of newborn bathing practices, Evidence Based Midwifery, 2009;7:112–21.

2. Lund C, Kuller J, Lane A, et al., Neonatal skin care: the scientific basis for practice, J Obstet Gynecol Neonatal Nurs, 1999;28:241–54.

3. Holbrook K, Embryogenesis of the skin. In: Harper J, Oranje AP, Prose NS (eds), Textbook of Pediatric Dermatology, Oxford: Blackwell Science, 2000;3–42.

4. Chiou YB, Blume-Peytavi U, Stratum corneum maturation: a review of neonatal skin function, Skin Pharmacol Physiol, 2004;17:57–66.

5. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC, Barrier function and water holding and transport properties of infant stratum corneum are different from adult and continue to develop through the first year of life, J Invest Dermatol, 2008;128:1728–36.

6. Garcia Bartels N, Scheufele R, Prosch F, et al., Effect of standardized skin care regimens on neonatal skin barrier function in different body areas, Pediatr Dermatol, 2010;27:1–8.

7. Stamatas GN, Nikolovski J, Mack MC, Kollias N, Infant skin physiology and development during the first years of life: a review of recent findings based on in vivo studies, Int J Cosmet Sci, 2011;33:17–24.

8. Stamatas GN, Nikolovski J, Luedtke MA, et al., Infant skin microstructure assessed in vivo differs from adult skin in organization at the cellular level, Pediatr Dermatol, 2010;27:125–31.

9. Irving V, Caring for and protecting the skin of pre-term neonates, J Wound Care, 2001;10:253–6.

10. Visscher MO, Chatterjee R, Munson KA, et al., Changes in diapered and nondiapered infant skin over the first month of life, Pediatr Dermatol, 2000;17:45–51.

11. Cork MJ, Danby SG, Vasilopoulos Y, et al., Epidermal barrier dysfunction in atopic dermatitis, J Invest Dermatol, 2009;129:1892–908.

12. Jøhnke H, Vach W, Norberg LA, et al., A comparison between criteria for diagnosing atopic eczema in infants, Br J Dermatol, 2005;153:352–8.

13. NHS Evidence, Eczema. Available at: www.evidence.nhs.uk/ topic/eczema (accessed 26 March 2012).

14. National Institute for Health and Clinical Excellence (NICE), Clinical guideline 57, Atopic eczema in children, London: NICE, 2007. Available at: http://guidance.nice.org.uk/CG57 (accessed 26 March 2012).

15. Association of Women’s Health, Obstetric and Neonatal

meadowfoam, vegetable, sunflower seed, mustard and grapeseed have been reported in massage studies.48–53

Topical application of oil to the

However, there have been concerns raised regarding the use of certain oils, in particular those with high levels of oleic acid, which may penetrate through the skin barrier.54

skin has been found to penetrate the stratum corneum, with both mineral and vegetable oils appearing to penetrate the skin to similar degrees.52

Olive oil, which is high in oleic

acid, is widely recommended to women by health professionals. A recent survey of maternity units in the UK found that 52 % recommended the use of olive oil for the treatment of dry skin and for baby massage.54

This is of concern, as currently there is no empirical evidence to support this practice. The use of oils may fulfil women’s desire to use natural products on their babies’ skin. Health professionals have also apparently accepted the belief that ‘natural’ equals ‘safe’. However, it is important for health professionals to recognise that these natural oils may not be the apparently harmless substances they initially appear to be, and that further research is necessary to determine their suitability for use on newborn skin.

Conclusion

This paper has highlighted some of the practices and issues around newborn skin care, particularly the lack of evidence in this area. Despite the apparently innocuous nature of skin care practice, there could be long-term sequelae should the infant develop ongoing atopic dermatitis. The discrepancy between evidence and practice places health professionals in a difficult position when attempting to provide advice and guidance to women. This has resulted in inconsistencies in the advice offered to women. It is important that health professionals are aware of both the evidence base and the need to provide women with an honest and clear picture where possible, allowing them to reach their own decisions about their choices. n

Nurses (AWHONN), Neonatal Skin Care, Second Edition. Evidence- based Clinical Practice Guidelines, Washington DC: AWHONN, 2007. Available at: www.guideline.gov/ content.aspx?id=24063 (accessed 26 March 2012).

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17. Jackson A, Time to review newborn skincare, Infant, 2008;4:168–71.

18. Hughes K, Neonatal skin care: Advocating good practice in skin protection, British Journal of Midwifery, 2011;19:773–5.

19. Trotter S, Neonatal skincare: why change is vital, RCM Midwives, 2006;9:134–8.

20. Gfatter R, Hackl P, Braun F, Effects of soap and detergents on skin surface pH, stratum corneum hydration and fat content in infants, Dermatology, 1997;195:258–62.

21. Ananthapadmanabhan KP, Moore DJ, Bubramanyan K, et al., Cleansing without compromise: the impact of skin cleansers on the skin barrier and the technology of mild cleansing, Dermatol Ther, 2004;17(Suppl. 1):16–25.

22. Nagel JE, Fuscaldo JT, Fireman P, Paraben allergy, JAMA, 1977;237:1594–5.

23. Dabre PD, Aljarrah A, Miller WR, et al., Concentrations of parabens in human breast tumours, J Appl Toxicol, 2004; 24:5–13.

24. Crozier K, Macdonald S, Effective skin-care regimes for term newborn infants: a structured literature review, Evidence Based Midwifery, 2010;8:128–135.

25. Blume-Peytavi U, Hauser M, Stamatas GN, et al., Skin care practices for newborns and infants: review of the clinical evidence for best practices, Pediatr Dermatol, 2012;29:1–14.

26. National Institute for Health and Clinical Excellence (NICE), Clinical guideline 37, Postnatal care, London: NICE, 2006. Available at: http://www.nice.org.uk/CG037 (accessed 26 March 2012).

27. Tsai TF, Maibach HI, How irritant is water? An overview, Contact Dermatitis, 1999;41:311–4.

28. McNally NJ, Williams HG, Phillips DR, et al., Atopic eczema and domestic water hardness, Lancet, 1998;352:527–31.

29. Lavender T, Bedwell C, O’Brien E, et al., Infant skin- cleansing product versus water: a randomized, assessor-blinded controlled trial, BMC Pediatr, 2011;11:35.

30. Darmstadt GL, Dinulos JG, Neonatal skin care, Pediatr Clin North Am, 2000;47:757–82.

31. Lund C, Kuller J, Lane A, et al., Neonatal skin care: evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. Association of Women’s

Health, Obstetric and Neonatal Nurses/National Association of Neonatal Nurses, J Obstet Gynecol Neonatal Nurs, 2001;30:30–40.

32. Blume-Peytavi U, Cork MJ, Faergemann J, et al., Bathing and cleansing in newborns from day 1 to first year of life: recommendations from a European round table meeting, J Eur Acad Dermatol Venereol, 2009;23:751–9.

33. Bryanton J, Walsh D, Barrett M, Gaudet D, Tub bathing versus traditional sponge bathing for the newborn, J Obstet Gynecol Neonatal Nurs, 2004;33:704–12.

34. Gelmetti C, Skin cleansing in children, J Eur Acad Dermatol Venereol, 2001;15(Suppl. 1):12–5.

35. Drennan V, Goodman C, Oxford Handbook of Primary Care and Community Nursing, Oxford: Oxford University Press, 2007.

36. Camm J, Skincare for newborns: guidelines and advice, RCM Midwives, 2006;9:126.

37. Quinn D, Newton N, Piecuch R, Effect of less frequent bathing on premature infant skin, J Obstet Gynecol Neonatal Nurs, 2005;34:741–6.

38. Medves JM, O’Brien B, Does bathing newborns remove potentially harmful pathogens form the skin? Birth, 2001;28:161–5.

39. Da Cunha ML, Procianoy RS, Effect of bathing on skin flora of preterm newborns, J Perinatol, 2005;25:375–9.

40. Rutter N, Drug absorption through the skin: a mixed blessing, Arch Dis Child, 1987;62:220–1.

41. Lund C, Osborne JW, Kuller J, et al., Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guidelines. Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses, J Obstet Gynecol Neonatal Nurs, 2001;30:41–51.

42. Pairaudeau PW, Wilson RG, Hall MA, Milne M, Inhalation of baby powder: an unappreciated hazard, BMJ, 1991;302:1200–1.

43. Karageorgi S, Gates MA, Hankinson SE, De Vivo I, Perineal use of talcum powder and endometrial cancer risk, Cancer Epidemiol Biomarkers Prev, 2010;19:1269−75.

44. Danby SG, Al-Enezi T, Sultan A, et al., The effect of aqueous cream BP on the skin barrier in volunteers with a previous history of atopic dermatitis, Br J Dermatol, 2011;165:329–34.

45. Underdown A, Barlow J, Chung V, Stewart-Brown S, Massage intervention for promoting mental and physical health in infants aged under six months, Cochrane Database Syst Rev, 2006;4:CD005038.

46. Underdown A, Barlow J, Stewart-Brown S, Tactile stimulation in physically healthy infants: results of a systematic review, Journal of Reproductive And Infant Psychology, 2010;28:11–29.

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