Bathing newborns has multiple purposes, including removal of waste materials, improving appearance and potentially reducing microbial colonization. A bath is an ideal means of cleaning an infant completely, and also a special time for contact between the newborn infant and caregiver in terms of tactile communication and interaction. However, when the body is immersed in water, the superficial layers of the stratum corneum are hydrated and become thicker and there is reduced cellular cohesion [7]. The hyperhydrated skin is then more fragile, and the threshold at which friction can cause damage is lower. For these reasons, newborn infants should not be immersed for more than 5 min [8].
Products used for skin cleansing include soap in solid or liquid form, which should be applied in small quantities using a washcloth or compress. The skin should be washed gently to avoid injury. For premature infants, sterile water is the safest choice, and the temperature of the bath water should not exceed 37°C. A solid or liquid soap or syndetic substance with a neutral pH is used to clean the skin.
No studies comparing cleansing agents, bathing techniques or effect of products on skin pH in premature or full-term newborn infantss are available. However, the existing literature includes recommendations incorporating principles of risk reduction:
- Neutral pH;
- Minimal dyes and perfumes (to reduce risk of future allergic sensitization to topical agent) [8].
Bubble bath products, even when specially prepared for children, could cause irritation and dry the skin, particularly when used too frequently or at inappropriate dilutions. Soaping should be followed by careful rinsing. The infant must be carefully and completely dried, special attention being paid to skinfold areas.
Cleansing Equipment
Equipment for cleansing (i.e. plastic surfaces) can be contaminated by micro-organisms, and should be safe in terms of minimizing the likelihood of trauma. A total of 32 deaths from drowning among infants and young children were collected in a retrospective study [9].
Napkin Changes
Napkins should be changed frequently, at least at each nursing or feeding time. The infant should be carefully washed in lukewarm water and then rinsed off and dried thoroughly. If a cleansing cream is used instead of soap, it should be wiped off with a towel before the skin is rinsed. Frequent nappy changes reduce the risk of irritant erythema or rash.
Scalp
The same detergent used to wash the skin can also be used for the scalp. Shampoo is not essential, although the risks associated with its use are evidently quite low, given the vast quantities sold and the few cases of intolerance reported. If the first signs of seborrhoeic dermatitis appear (yellowish scales or crust), application of vegetable or mineral oil limits the spread of lesions.
Nails
These should be kept short and clean.
The Ears
The ears should be carefully cleaned with water or salt solution, avoiding a direct jet onto the tympanic membrane. Non-traumatic swabs should be used with care, and not at all in the ear canals.
Umbilicus
After birth, the umbilical cord dries out and drops off within 5–10 days. Some products containing eosin or other stains (triple dye: brilliant green, Gentian violet, proflavine hemisulphate) are still applied in some countries, although more for a drying than an antiseptic effect.
Isopropyl alcohol is not recommended. A recent study comparing the efficacy of daily treatment with isopropyl alcohol and wiping with sterile water in 148 infants showed that the cord separation time lengthened by 2–3 days with isopropyl alcohol use and no pathogen or umbilical infection occurred in either of the two groups [10]. In a larger study [11], 1811 infants were randomized to receive either alcohol treatment or natural drying. There were no umbilical infections in either group and cord separation was significantly shorter in the air drying group (8.1 vs. 9.8 days).
Napkin Dermatitis
The development of napkin dermatitis has a number of causes in infants and is influenced by the degree of wetness of the skin. Moist and macerated skin becomes more permeable and susceptible to injury and more heavily colonized with micro-organisms [12].
Prevention of napkin dermatitis includes maintenance of a dry skin surface with the use of napkins containing absorbent gel. Superabsorbent napkins are clearly superior to cloth napkins in preventing irritant napkin dermatitis [13].
Antibacterial ointments are not systematically indicated, but if Candida albicans is involved in the napkin rash an antifungal ointment or cream should be used. Application of protective skin barrier creams that contain zinc oxide prevents further injury while allowing the skin to heal.
References
1 Lane AT. Development and care of the premature infant’s skin. Pediatr Dermatol 1987;4:1–5.
2 Yoshio H, Tollin M, Gudmindsson GH et al. Antimicrobial polypeptides of human vernix caseosa and amniotic fluid: implications for newborn innate defense. Pediatr Res 2003;53:211–6.
3 Marchini G, Lindow S, Brismar H et al. The newborn infant is protected by an innate antimicrobial barrier: peptide antibiotics are present in the skin and vernix caseosa. Br J Dermatol 2002;147:1127–34.
4 Bertone SA, Fisher MC, Mortensen JE. Quantitative skin cultures at potential catheter sites in neonates. Infect Control Hosp Epidemiol 1994;15:315–18.
5 Malathi I, Millar MR, Leeming JP et al. Skin disinfection in preterm infants. Arch Dis Child 1993;69:312–16.
6 Lund CH, Osborne JW, KullerJ et al. Neonatal skin care: clinical outcome of the AWHONN/NANN evidence-based clinical practice guideline. J Obstet Gynecol Neonatal Nurs 2001;30:41–51.
7 Peters KL. Bathing premature infants: physiological and behavioral consequences. Am J Crit Care 1998;7:90–100.
8 Gelmetti C. Skin cleansing in children. J Eur Acad Dermatol Venereol 2001;15:12–15.
9 Cetta F, Lambert GH, Ros SP. Newborn chemical exposure from over-the-counter skin care products. Clin Pediatr (Phila) 1991;30:286–9.
10 Rauschwalbe R, Brenner RA, Smith GS. The bathtub seats and rings in infant drowning deaths. Pediatrics 1997;100:E1.
11 Medves JM, O’Brien BA. Cleaning solutions and bacterial colonization in promoting healing and early separation of the umbilical cord in healthy newborns. Can J Publ Health 1997;88:380–2.
12 Dore S, Buchan D, Coulas S et al. Alcohol versus natural drying for newborn cord care. J Obstet Gynecol Neonatal Nurs 1998;27:621–7.
13 Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol 1986;3:102–6.
Skin Care in the Premature Infant
A survey conducted in 823 neonatal intensive care units (NICUs) in the USA demonstrated that a wide variety of skin care management strategies are used for preterm infants and there was an absence of consensus, especially concerning routine infection control, type of lotion or emollient used and treatment of skin breakdown [1]. More recently, a prospective evaluation of the collaborative neonatal skin care research-based practice project was published [2], demonstrating, after implementation of the guideline and assessment of 2464 premature newborns, effectiveness of treatments and improvement of skin condition in the cohort of premature infants.
Preventive Measures
Recent advances in neonatal care have greatly decreased mortality and morbidity among premature infants. Skin maturation proceeds rapidly in the preterm infant after birth [3]. Premature infants from 26 weeks’ gestation are cared for routinely in NICUs, where they seem very small indeed in comparison with the life support equipment around them. These infants are kept warm and nursed in incubators. Environmental conditions in these units are potentially harmful to infant skin, which is subject to scarring [4]. Cosmetically or functionally significant lesions are caused by needle marks, central venous catheters, transcutaneous oxygen monitoring, chest drain insertion, extravasation of intravenous fluid or skin stripping by adhesive tape. To reduce the frequency and severity of skin damage, neonatal staff need to be aware that many routine procedures can lead to long-term scarring [5].
The anatomical features and functional properties of the skin of a premature infant are not the same as those of a term newborn infant. Thus, to avoid skin breakdown, the nursing staff must be continuously attentive.
Disinfection
Systemic infection remains a major problem for the preterm infant. In NICUs, the most common infective agents causing septicaemia after the first 2 days of life are coagulase-negative staphylococci in relation to intravascular catheter placement [6]. Prevention begins with good hygiene practice, particularly handwashing, by staff and parents [7].
Handwashing
If healthcare providers generally acknowledge the importance of handwashing, they overestimate their own compliance. The importance of strict adherence to hygienic hands by healthcare providers cannot be overemphasized.
Irritated hands harbour an increased number of non-identified colonizing species and, recently, artificial nails have been implicated as a potential risk factor for the transmission of Gram-negative bacteria and should be prohibited in the NICU. Hand hygiene regimens have been assessed in NICUs, comparing traditional antiseptic wash with chlohexidine-containing detergent and mild soap wash with subsequent alcohol-based rinsing. No significant differences in microbial count or type of organisms were found, but nurses in the mild soap group reported significant improvement in their skin condition [8].
Routine Disinfection of Blood Sample or Puncture
In nurseries, decontamination of skin is routine before invasive procedures such as venepuncture and placement of umbilical catheters or chest tubes, and should be carefully performed. Anecdotal reports of skin injury from disinfectant solution including blistering and burns from isopropyl alcohol [9] or povidine–iodine [10,11] use have been reported [12]. The risks involved with the use of potentially toxic antiseptics over large skin areas [9,11] require the limitation of disinfection to the immediate site of intravenous puncture or intravascular catheter placement.
The Incubator
Changing the infant’s position in the incubator reduces the risks of skin erosion and especially bedsores, which are a particular problem in patients with haemodynamic disorders. 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 in the newborn infant has been described in conjunction with pressure ulcers after extracorporeal membrane oxygenation or hypoxaemia–hypoperfusion during the neonatal period. The occurrence of non-blanchable erythema and disruption of the epidermis are indicators of a need for postural change [13].
Transcutaneous Oxygen Monitors
Continuous monitoring of oxygen pressure, heart rate and other parameters requires the use of electrodes in direct contact with the infant’s skin. These electrodes (to measure transcutaneous PO2 and PCO2), which function by resistances and are heated to 40°C, should not be left in place for more than 1 h without surveillance. Non-blanchable erythema and hyperpigmented skin craters have been reported in association with transcutaneous PO2 monitoring. Newer synthetic gel electrodes are easy to remove and replace but difficult to use in the high heat and humidity atmosphere of the incubator.
Control of Transepidermal Water Loss
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