Author Name:
Sharon Trotter, Midwife

Biography:
Sharon trained as a general nurse at the Dorset School of Nursing in 1979. She moved to London in 1983 to complete her midwifery training at Queen Charlottes Maternity Hospital and following her marriage to Aidan in 1984, they moved to Scotland. They now live on the west coast, where Sharon has worked at the local maternity unit for over 20 years, in between bringing up their four children. Sharon has recently returned to Paisley University to complete her BSc in Advanced Studies in Midwifery and is due to graduate later this year. Her first publication, Breastfeeding: the essential guide gives for parents and professionals and is the result of many years work.

Introduction

The way we bath our babies may not appear to be important in the big scheme of things. However, I would like to give you a better understanding of why this could be an important factor to the health of our baby's skins.

For many years now, we have been bathing our newborns using Baby Bath products. We believe that these products are mild and suitable for our baby's delicate skins, but is this the case?

In maternity units all over the UK, it has been common practice to use lots of bubbles to wash a baby after delivery. I am sure we have all witnessed the conscientious nurse scrubbing away every trace of vernix at the first bath.

In order to change these outdated practices, I would have to research the subject thoroughly, come up with some persuasive arguments and recommend an appropriate alternative. I did not know where this would take me, but I was willing to give it a try. This article is the result of all my hard work and will hopefully bring about a new understanding.

My Personal Experience
As the mother of four children, I, along with most others, bathed the older two, in a solution of Baby Bath product. They both suffered from rashes, spots and cradlecap. These were not serious conditions, but did cause concern and required treatment.

Over the years, I became more aware of research into Neonatal Skincare and was profoundly affected by a short article in the 'Midwives' journal by Brennan, 1996. I decided to change my blinkered attitude and attempt to re-educate others. As you can imagine, this did not go down too well. People just thought I was being alarmist and over-cautious. Shortly after reading the article in question, I became pregnant again and decided I would carry out my own research.

After delivery my son was bathed in plain water, using only cottonwool to wipe the skin. The vernix was left to absorb naturally. A baby's comb was gently used to remove any debris, from his hair. He didn't smell of baby bubbles, but he smelt gorgeously of New-Baby. After the first month, I gradually introduced Baby Bath products. My youngest son, who is now 2 years old, also had the same skincare regime and they both have perfect complexions. They did not suffer from the rashes, spots or cradlecap and although I was pleasantly surprised, it was not an unexpected outcome.
All my children have been exclusively breastfed for the first 4 months of life, so the only change in the care of my last two children, was the withdrawal of Baby Products in their early weeks.

Objectives
My small research study may not have been groundbreaking, but it did spur me on to look further.. The more I thought about it, the more determined I became to bring about change. The time has come for an independent review of neonatal skincare and the introduction of National Guidelines. These need to be standardised research based and will hopefully avoid the early sensitisation, which can go on to develop into allergies and skin conditions.
I was surprised to find that there has been research into this, and similar subjects, since the 1960s. One of the most in-depth and recent studies was American and surprisingly, this was sponsored by Johnson& Johnson ( Lund C H et al, 1999a, 1999b, 2001a, 2001b).

Nowhere, on any of the 'Instructions for use' of Baby Products, does it warn of the possible dangers of early overuse. In fact, on one leading brand, it actually says: 'mild enough for newborn babies'.
Maternity Units up and down the UK provide free use of Baby Bath and Baby Wipes to new mothers. (These are donated by the manufacturer, presumably to instil an early allegiance to their products). Is this an appropriate course of action, when we are no longer allowed to advertise Baby Milks? This endorsement gives a message to new mothers that these products are perfectly safe to use on their babies skin. I believe, that this practice has got to stop. There is no need to have these products available, as most of the babies are under a week old, so plain water is quite sufficient. Even in Special Care Baby Units (SCBU), where there is likely to be older babies, there still seems little point to have products. Premature skin is even more sensitive than that of a term infant (see next section), so the longer you can wait, prior to the introduction of these products, the better.

The Anatomy and Physiology of the Skin
I would like to spend some time explaining how the skin of the newborn differs from that of the adult and how, as a result, we can use this knowledge to protect our babies.

The skin is the largest organ in the body and is made up of three main layers. The Epidermis, the Dermis and the underlying Subcutaneous fatty tissue. Within these layers lie the blood vessels, nerves, sweat/oil glands and hair follicles. The Epidermis, or outer layer, is further divided into the; Stratum Corneum, Stratum Granulosum and Stratum Germinatium. The latter of these is at the junction of the Epidermis and Dermis and is where the renewal of the Basal Cells is carried out. These cells constantly divide and are called Keratinocytes. Simplistically, these can be thought of as analogous to the bricks in a wall, with the mortar between, made up of lipids (fat cells).

It is this barrier, which allows the retention of fluids within the Epidermal cells, which remain plump and therefore prevent the introduction of micro-organisms, chemicals and allergens. When intact, this imaginary wall, regulates temperature, acts as a barrier to infection, balances water/electrolytes, stores fat and insulates against the cold. The skin is also a large tactile area, for the interpretation of stimuli.

The Stratum Corneum itself, is made up of 10-20 microscopic layers in an adult and the term infant. In premature infants, this number drops to between 2-3 layers. In extremely premature infants, of less than 23 gestational weeks, this layer may be virtually non-existent. ( Holbrook 1982, Nonato 1998). Consequently, the risk to these babies is even higher.

Babies are born with an alkaline skin surface, with an average pH of 6.34 ( Behrendt and Green 1971). However, within days, the pH has fallen to about 4.95 (acid). This also occurs in premature infants, although the process may take weeks rather than days to complete( Eaglestein 1985). This is known as the 'Acid Mantle' and is the skins protector. The development of this 'Acid Mantle' takes between 2 and 8 weeks, depending on gestational age (Evans and Rutter 1986, Harpin and Rutter 1983), so it is even more important to avoid damage to the premature infant, in their early weeks of life.

The introduction of Baby Bath products, wipes and creams etc, along with the exposure to urine and faeces, could disrupt this delicate protective barrier and lead to problems, including eczema, or allergic reactions (Behrendt and Green 1971, Berg et al 1986, Peck and Botwinick 1964).

Present Practices in Neonatal Skincare

A full term infant will be bathed using bath products within a few hours of birth, once the temperature has stabilised and there are no health worries. Babies in SCBU may be left for longer, depending on their condition. Once stable, they too, including extremely premature infants, will be washed in a solution of Baby Bubbles. Antiseptic wipes/sprays, iodine lotion and sticky-tape are all frequently used in order to attach the many leads, tubes and wires etc. These are a necessary by-product of the complex care that a neonate receives in a modern SCBU. This extra risk must be balanced against the long term needs of the infant. Skin damage is common and can include; nappy rash, pressure sores/ulcers, burns, infections and adhesive removal grazes. These can prove difficult and expensive to treat. However, the cost in physical and emotional pain is incalculable. Anything we can do, to help reduce these risks, can only be for the good.

We must also ask ourselves; what is the concentration of the Baby Bath solution that we are using on the neonate?

One manufacturer recommends a dilution of 7mls per 9 gallons of bath water. When using a standard baby bath, it is highly likely, that the resultant concentration will be stronger, as no accurate way of measuring the strength is in use. In SCBU, the concentration is likely to be higher still, due to the tiny amounts of water used in small basins.
Consequently, this means, that the most at-risk neonates are being subjected to the highest concentrations of Bath solution because of inadequate care instructions and poor education of Nurses, Midwives and Mothers. This situation is unsatisfactory for all concerned.

Possible New Guidelines
American Paediatric units have now implemented their new guidelines, which were published in 2001 (Washington 2001).

Although we have no such guidelines in the UK, it would seem sensible to inform women of the possible risks involved, when using Baby Bath Products too early. Prior to discharge, Midwives, need to re-enforce the message that anything placed 'On', 'In' or 'Around' the newborns skin has the potential to harm.

These could include:
First baths should be carried out using only plain water and cottonwool for cleansing. A baby comb can be used gently to remove any debris from thick hair. Vernix should always be left to absorb naturally.
Continue with this regime for the first 2-4 weeks, then gradually introduce tiny amounts of Baby Bath Product. This should be of neutral pH, contain minimal dyes and perfumes and be used only 2-3 times a week (Cetta at al, 1991). A thin layer of petroleum jelly can be used, as a protection against nappy rash. If this does occur, a zinc-based cream is recommended in small quantities ( Washington, 2001).
Baby Wipes should be mild and alcohol-free. They should also be avoided in the first 2-4 weeks.
Any bedding or clothes, that will come into contact with the babies skin, should have been washed in non-biological washing powder and be thoroughly rinsed (Halton, 1990). If you use a fabric conditioner, try to use products that are free from colours and perfumes.
Breastfeeding is the obvious choice for feeding, as it conveys some protection against the development of allergies. This is because the cowsmilk protein, that is used in formula feeds, can sensitise the immature gastrointestinal system, which, can then go on to cause asthma and eczema. It has been shown that even one formula feed, is enough to sensitise a baby (Parsonage and Clark 1981).
When introducing mixed feeding, start gradually with pureed fruit and vegetables. Avoid all wheat (gluten) based products, opting instead for rice or oat cereals for the first 9 months. Avoid milk products for 9-12 months. If you want to give yoghurt or fromage frais, then use the milk-free alternatives made especially for babies. Eggs or nuts should also be withheld until a year old.

Special Precautions

If you have a history of atopic eczema in your family, Professor Michael Cork (2002), suggests it would be wise to take these further precautions:

Avoid carpets - fit hard floors and have washable non-slip mats. This will substantially reduce the house dust mite levels
Bedding to be washed at 60 degrees in order to kill the dust mite.
Soft toys may be stored in the freezer overnight, as this also kills off the dust mite ( It may be sensible to buy toys in pairs ).
Use anti-dustmite mattress and pillowcase covers.
Vacuum regularly.
Keep pets out of bedrooms.
If skin is dry, bathe and moisturise with emollient-based products.
Use washable roller blinds or curtains.
Keep humidity levels below 70% and the temperature between 17-19 degees.

Research Projects
Carolyn Lund et al (1999a, 1999b, 2001a, 2001b) is the most comprehensive study to date, into the treatment of neonatal skin. However, other similar studies are ongoing. I am quite sure that in, the not too distant future, these subjects will be investigated in more depth. This will create interest and be associated with the usual media attention.

Two such projects that have been in the news recently, are worthy of a mention:

Firstly, Prof. Michael Cork (2002), who is based at Sheffield University. He, and his team have concentrated on the alarming rise in childhood Atopic Eczema and its possible causes.
Secondly, Prof. Jean Golding (2002) who is based at Bristol University. She heads the Avon and Somerset Longitudinal Study of Parents and Children (ALSPAC), which is a long-term project looking into many aspects of childcare and resultant disease patterns.

Conclusion
As Midwives, it is essential to keep up to date with current research projects, which may have an impact on how we carry out, even the simplest of tasks.

So, next time you reach for the bubbles, STOP, think and put them back. This small change of habit, could make a huge difference to the health of our babies skins. If the supply of these products were removed from Maternity Units, then the temptation to use them would also be removed.

The distribution of free samples by various companies could still continue. However, women must be re-educated, so that they are aware of the potential risks associated with early overuse. In this way, the products can still be used, but at a time, when their effect is less likely to cause any harm. Their skin, will consequently be stronger and will hopefully not become sensitised. This in turn could avoid the development of allergic conditions that can cause so much distress to infants and children. This is an excellent opportunity, where the power of research can, at last, change the way we care for our newborns skin, for the better.

References
Behrendt H, Green M. (1971)
Patterns of Skin pH from Birth through Adolescence. Springfield, IL, CharlesC. Thomas.
Berg R, Buckingham K, Stewart R. (1986)
Etiologic Factors in Diaper Dermatitis: The Role of Urine. Pediatric Dermatology 3: 102.
Brennan, G. (1996)
Opinion: Care of the Newborn Babys Skin, Midwives 109 (1303): 240.
Cetta F, Lambert G H, Ross S P. (1991)
Newborn Chemical Exposure from Over the Couner Skin care Products. Clinical Pediatrics 30: 286-289.
Cork Michael J et al (2002)
The rising prevalence of atopic eczema and environmental trauma to the skin. Dermatology in Practice. 10(3): 22-26
Eaglestein W H. (1985)
Experiences with Biosynthetic Dressings. Jo Ame Acad Dermatology 12: 434.
Evans N J, Rutter N. (1986)
Development of the Epidermis in the Newborn. Biology of the Neonate, 49: 74-80.
Halton G. (1990)
Sensitive Matters, Nursing Times 86 (18): 63-65.
Harpin V A, Rutter N. (1983)
Barrier Properties of the Newborn Infants Skin. Journal of Pediatrics 102: 419-425.
Holbrook K A. (1982)
A Histological Comparison of Infant and Adult Skin. In maibach H, Boisits E R (eds): Neonatal Skin:Structure and Function. New York, Marcel Decker: 3-31.

Lund C, Kuller J, Lane A, Lott J W, Raines D A. (1999a)
Neonatal Skincare: The Scientific Basis for Practice. JOGNN , May/June, 241-254
Lund C H. (1999b)
Prevention and Management of Infant Skin Breakdown, Wound Care Management, December, l34 (4): 907-920.
Lund C H, Kuller J, Lane A T, Lott J W, Raines D A, Thomas K K. (2001a)
Neonatal Skincare: evaluation of the AWHONN/NANN research based practice project on knowledge and skincare practices. Association of Womens Health, Obstetric and Neonatal Nurses/ National Association of Neonatal Nurses. J Obstet Gynnecol Neonatal Nurs. Jan/Feb, 30 (1): 30-40.
Lund C H , Osborne J W, Kuller J, Lane A T, Lott J W, Raines D A. (2001b)
Neonatal Skincare: clinical outcomes of the AWHONN/NANN evidence based clinical practice guideline. Association of Womens Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs, Jan/Feb 30 (1): 41-51.
Nonato L. (1998)
Evolution of Skin Barrier Function in Neonates. In Bioengineering. Berkley University of California, p160.
Parsonage S, Clark J. (1981)
Infant Feeding and Family Nutrition. London: H.M and M.
Peck S, Botwinick J. (1964)
The Buffering Capacity of Infants Skin Against an Alkaline Soap and Neutral Detergent. Journal of Mt. Sinai Hospital 31: 134.

Sheriff A, Golding J and the ALSPAC study team (2002a).
Archives of Disease in Childhood, 86: 30-35 + 87: 26-29.
(ALSPAC: Avon and Somerset Longitudinal study of Parents and Children: www.alspac.Bristol.ac.uk )
Washington (DC). (2001)
Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) January.

Trotter S (2002) Skincare for the newborn: exploring the potential harm of manufactured products. RCM Midwives Journal 5 (11): 376-8

This article is posted on Express Yourself Mums by kind permission of the Royal College of Midwives Journal who hold the Copyright.

Sharon also wrote the following:
"As a midwife and mother, I have been researching the subject of neonatal skincare and cord care since 1996. The resulting articles have been published in the RCM Midwives Journal (Nov 2002), The RCM Midwives Journal (July 2003) and most recently in the British Journal of Midwifery (March 2004). These are all available to read on my website at www.tipslimited.com

Only by using evidence based research can we fully understand how the skin works and how best to treat it, especially in the early weeks of life, when it is so vulnerable to damage from outside irritants such as chemicals, pollutants, allergens and micro- organisms. This is why I recommend the use of water only for the first month of life. This allows the delicate skin a chance to mature and form its protective barrier. At this point it is advisable to use the mildest products available, preferably those that do not contain any artificial colours, perfumes, petro-chemicals or other such additives.