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Protecting baby's skin

How should parents clean their young baby’s skin during nappy changing and between baths? This module explores this question, and will give healthcare professionals more confidence in explaining to parents how best to keep their baby clean, healthy and comfortable.

LEARNING OBJECTIVES

After studying this module you should:

  • Know the structure of newborn baby skin, and how it matures 
  • Understand the guidelines and advice for cleaning a newborn and young baby's skin, particularly during nappy changing
  • Be confident in advising parents how best to manage topping and tailing

NEXT STEPS

  • Read the clinical review: if you don't have a printed version, click here to download a pdf
  • Complete the online assessment
  • Receive CPD certificate

AUTHORS

Written by: Diane Lace BSc (Hons), PhD
Reviewed by: Nicky Clark RM, RGN, ADM, Cert Ed (adults), MA, SFHEA

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Pre-learning reflection

Please take a moment to answer these pre-learning questions.  Once completed, click 'next step' below to start this module.  These answers will be logged on your CPD certificate which will be emailed to you on completion as evidence of your learning.


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Introduction

A baby’s skin is particularly delicate during their first 6 months, and should be kept as free from the dirt, pathogens, irritants and allergens as possible. Gently cleaning a baby’s skin ensures their comfort and minimises exposure to potentially harmful substances. However, a bath is not needed every day – two or three times a week is sufficient,1,2 with topping and tailing in between.1 Nappies must, of course, be changed as required: babies with delicate skin may need changing as soon as they wet themselves, while others can wait until before or after each feed; all should be changed when soiled.3 A newborn might need changing up to 12 times a day. That’s over 300 nappies in their first month!

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Already studied the clinical review? Go straight to the test here
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Newborn and young baby skin acts as a protective barrier

The skin consists of three main layers: epidermis, dermis and subcutaneous fatty tissue. The epidermis comprises five layers: stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum and stratum basale. The uppermost layer – the stratum corneum – has an important role as a barrier to pathogens, chemicals and allergens.

A newborn and young baby’s skin is different to that of older babies and adults. It is thinner,4 more permeable,5 and has a greater surface area:volume ratio (due to a denser network of microrelief lines).5 Consequently, it is more fragile, less functionally stable and more vulnerable to chemicals, allergens and microorganisms. A preterm baby’s skin is even more delicate and vulnerable due to its immaturity.6

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Newborn and young baby skin acts as a protective barrier

icon1Compared with adult skin, a newborn’s stratum corneum is 30% thinner, and the epidermis is 20% thinner; it gradually thickens over the first 12 months.4
icon2Skin is less hydrated at birth, but by 1 month is more hydrated than adult skin, although more vulnerable to water loss.7,8 Water in the stratum corneum is important for maintenance of barrier function.8
icon3Skin pH is neutral at birth (range approx. pH 6.6 to 7.5 depending on the site), and becomes slightly acidic (approx. pH 5) over the following few weeks and months.8,9 A thin acidic film on the skin surface, containing sebum, sweat and other factors, is termed the acid mantle; it is highly important for barrier function, including maintaining components of the stratum corneum,10 supporting a healthy skin microflora8 and infection control.11
icon4Baby skin microflora is developing; it evolves over the first year. The skin’s microflora is involved in disease prevention.9,11
icon5Transepidermal water loss (TEWL) is thought to be higher in babies,8 particularly in the nappy area,7 and gradually settles by 12 months.7,12 It fluctuates more than adult skin due in part to a thinner stratum corneum and epidermis.8,12
icon6The skin changes over the first 12 months of life: the stratum corneum thickens, the pH stabilises, the microflora matures, and barrier function and water-handling become more effective.

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Barrier function is essential to health

The skin’s barrier function in younger babies and in babies with eczema is more unstable than that of older babies and children.

Poor or unstable barrier function imparts a vulnerability to developing problematic skin conditions and ill health. It is therefore important to look after baby skin appropriately to ensure that the characteristics critical to good barrier function – intact stratum corneum, good hydration, acid mantle and an appropriately developing microflora – are well supported.

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The importance of keeping a baby's skin clean

Baby skin should be kept clean and free of unwanted substances, including irritants (saliva, milk, nasal secretions, urine, faeces, and faecal enzymes), dirt, and transient germs.9 Clean skin helps to keep a baby comfortable and healthy. If not kept clean, the skin’s barrier function can become compromised, increasing the risk for illness and the potential for developing nappy rash5 and/or eczema13 (see Box 1). This is particularly relevant in babies with sensitive skin. The nappy area is vulnerable due to the presence of urine and faeces, and the alkaline environment caused by chemical breakdown of urea.

However it is important that the cleaning process itself does not disrupt the effectiveness of the skin’s barrier (see Box 2).

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Frequency of cleaning

Although many parents and their babies enjoy the bathtime experience, there is no need to bath every day: two or three times a week is sufficient.1,2 On non-bathing days, gently washing by ‘topping and tailing’ along with frequent nappy changes will keep a baby clean and comfortable. In fact, new parents might feel more comfortable waiting a few days before giving their baby a first bath, and may prefer to wash their baby by topping and tailing in the meantime.18

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Cleaning a baby's skin

Teaching new parents the principles behind topping and tailing will help them to understand and remember the correct technique.1,9,19 Cleaning exposed areas (hands, eyes, ears, nose, face and neck, and, at times, the feet), the nappy area and, importantly, places that can particularly harbour dirt and germs (skin folds and creases, and the genitals) keeps the skin healthy and reduces the risk of infection.

In cases of mild nappy rash or eczema, a thin layer of barrier cream provides a protective lipid film, which reduces skin contact with faeces/urine, reduces humidity, minimises TEWL and reduces the potential for skin irritation and maceration.20 Ointments are generally more effective than creams and lotions, and provide a better moisture barrier.20

If nappy rash is persistent and severe, parents should be encouraged to seek advice from their GP: for inflammation and discomfort, treatment with short-term topical steroids may be sufficient; when candidal infection is suspected, an antifungal may be necessary; when an infection is suspected/confirmed, an oral antibiotic might be prescribed.14,20

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Cleaning a baby's skin

For the ‘topping’ element of topping and tailing, current guidelines from the NHS and the NCT recommend using water and cotton wool.1,19 For ‘tailing’ (or nappy changing), the advice from the NHS and NICE is to use warm water and cotton wool, or fragrance-free,3 alcohol-free,3 non-medicated21 baby wipes. Both cotton wool and water, and appropriately formulated, non-medicated baby wipes are recommended because they are soft and gentle on a baby’s skin.

However, recent European recommendations2 go further to propose that if wipes are used, they should: contain pH buffers to maintain slight acidity of the skin; be free from potential irritants such as alcohol, fragrance, essential oils, soap and harsh detergents (e.g. sodium lauryl sulphate); and contain well-tolerated preservatives.

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Are water and cotton wool still the 'best' option?

Some sources suggest that using tap water alone may not always be the optimal choice for cleaning an infant’s skin – that it might have a drying effect,9 impose an alkaline environment,9,22,23 which has the potential to upset the acid mantle, and does not remove oil-soluble material and faeces properly.9,24,25 Some of these effects may be related to water ‘hardness’ – the mineral content of tapwater.22


Nevertheless, a 2016 European Roundtable Meeting2 concluded that water alone is appropriate for infant skin cleaning, and that, when nappy-changing, the cleaning capability of water alone has not been shown to be inferior to that of baby wipes. Importantly, the NHS continues to support the use of water and cotton wool for topping and tailing, and nappy changing.

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What should parents use for everyday cleaning of their baby's skin?

While it is possible that hard tap water might have an impact on the skin’s barrier function in babies with sensitive skin, nappy rash or eczema, until the latest evidence has been fully assessed and guidelines prepared, parents should be advised to follow NHS and NICE recommendations regarding topping and tailing and nappy changing.3,21

Healthcare professionals understand that, in practice, once parents leave the hospital, they find it time-consuming and sometimes difficult to always use cotton wool and water, especially when out and about. The NHS advice regarding the option to use appropriate wipes is therefore very helpful in reassuring parents that convenience need not be a compromise. If parents choose to use wipes for cleaning the nappy area, they should check their ingredients and select carefully to avoid potentially harsh products, e.g. medicants, alcohol, soap and fragrance etc., particularly in younger babies, or if their baby has sensitive skin, nappy rash or eczema.

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Key points

  • Help parents to understand that baby skin is more delicate and permeable than adult skin, and how important it is to maintain the barrier function of the outermost layer – the stratum corneum.
  • Advise that when cleaning their baby between baths, and changing nappies, parents should use water alone or products that are non-irritating and non-sensitising, and will not disturb baby’s delicate skin and compromise barrier function.
  • Remind parents to check the ingredients of any baby wipes they are using if they are unsure.
  • Ensure that parents have the knowledge and confidence to make the best choices for their baby and their lifestyle.

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Now that you have reviewed the learning, please complete the following multiple choice questions to test what you've learnt and receive your CPD certificate. 

Assessment – Skin properties

Which of these statements is true? (Check all that apply)
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Assessment – Skin's barrier function

Which of the following contribute to good skin barrier function?
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Assessment – Keeping baby's skin clean

Why is it important to keep a baby's skin clean? (Check all that apply)
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Assessment – Nappy rash

In what circumstances is nappy rash likely to occur? (Check all that apply)
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Assessment – Supporting barrier function

When cleaning a baby's skin, barrier function can be supported by cleaning in a way that preserves:
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Assessment - Topping and tailing

A good topping and tailing technique involves cleaning:
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Assessment - Cleaning during a nappy change

Which of these statements is true? (Check all that apply)
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Post-learning reflection

Please take a moment to answer these post-learning questions.  These answers will be logged alongside your pre-learning responses on your CPD certificate which will be emailed to you on completion as evidence of your learning.



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References and further reading

1. NHS 2018a: Topping and tailing tips. Your pregnancy and baby guide. https://www.nhs.uk/conditions/pregnancy-and-baby/washing-your-baby/. Accessed 06 June 2019.

2. Blume-Peytava U, Lavender T, Jenerowicz D et al. Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care. Pediatric Dermatology 2016;33(3):311-321. Doi: 10.1111/pde.12819.

3. NHS 2018b: How to change your baby’s nappy. Your pregnancy and baby guide. https://www.nhs.uk/conditions/pregnancy-and-baby/nappies/?tabname=your-newborn. Accessed 06 June 2019.

4. Stamatas N, Nikolovski J, Luedtke MA, Kollias N, Wiegand BC. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatric Dermatology 2010;27(2):125-31.

5. Sznurkowska K, Liberek A, Brzozowska K et al. Evaluation of a new cosmetic topical formulation in the management of irritant diaper dermatitis. SelfCare 2015:6(S1):12-24.

6. Jackson A. Time to review newborn skincare. Infant 2008;4(5):168-171.

7. Oranges T, Dini V, Romanelli M. Skin physiology of the neonate and infant: Clinical implications. Advances in Wound Care 2015;4(10):587-595.

8. 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. International Journal of Cosmetic Science 2011;33:17-24.

9. Telofski LS, Morello AP, Mack Correa MK, Stamatas GN. The infant skin barrier: Can we preserve, protect and enhance the barrier? Dermatology Research and Practice 2012;2012:1-18. Doi: 10.1155/2012/198789.

10. Cooke A, Bedwell C, Campbell M, McGwan L, Ersser SJ, Lavender T. Skin care for healthy babies at term: A systematic review of the evidence. Midwidery 2018; 56:29-43.

11. Egert M, Simmering R, Riedel CU. The association of the skin microbiota with health, immunity, and disease. Clinical Pharmacology and Therapeutics 2017;102(1):62-69.

12. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC. Transport properties of infant stratum corneum are different from adult and continue to develop through the first year of life. Journal of Investigative Dermatology 2008;128(7)1728-1736.

13. Horimukai K, Morita K, Narita M et al. Transepidermal water loss measurement during infancy can predict the subsequent development of atopic dermatitis regardless of filaggrin mutations. Allergology International 2016;65:103-108.

14. Atherton D & Mills K. What can be done to keep babies’ skin healthy? Midwives Magazine 2004;7(7):288-290.

15. Danby SG, Brown K, Wigley AM et al. The effect of water hardness on surfactant deposition after washing and subsequent skin irritation in atopic dermatitis patients and healthy control subjects. Journal of Investigative Dermatology 2018;138:68-77.

16. British Association of Dermatologists. Atopic Eczema. http://www.bad.org.uk/for-the-public/patient-information-leaflets/atopic-eczema/?showmore=1&returnlink=http%3A%2F%2Fwww.bad.org.uk%2Ffor-thepublic%2Fpatient-information-leaflets#.XO0_tohKjIU. Accessed 06 June 2019.

17. Perkin MR, Craven J, Logan K et al. Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life: A population-based cross-sectional study. Journal of Allergy and Clinical Immunology 2016;138(2):509-516.

18. NHS 2019. Tips for new parents. Your pregnancy and baby guide. https://www.nhs.uk/conditions/pregnancy-and-baby/being-a-parent/. Accessed 19 July 2019.

19. National Childbirth Trust: A guide to topping and tailing. https://www.nct.org.uk/baby-toddler/everyday-care/guide-topping-and-tailing. Accessed 06 June 2019.

20. NICE 2018. Nappy rash. Management of nappy rash. https://cks.nice.org.uk/nappy-rash#!scenario. Accessed 06 June 2018.

21. NICE 2015. 1.4 Maintaining infant health: Physical health and wellbeing: Skin. 1.4.23. https://www.nice.org.uk/guidance/cg37/chapter/1-Recommendations#maintaining-infant-health. Accessed 06 June 2019.

22. Tsai T-F & Maibach HI. How irritant is water: an overview. Contact Dermatitis 1999;41:311-314.

23. Lavender T, Furber C, Campbell M et al. Effect on skin hydration of using baby wipes to vlean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial. Pediatrics 2012;12:59. http:www.biomedcentral.com/147-2431/12/59.

24. Walters RM, Fevola MJ, LiBrizzi JJ, Martin K. Designing cleansers for the unique needs of baby skin. Cosmetics & Toiletries Magazine 2008;123(12)53-60.

25. Gelmetti C. Skin cleansing in children. Journal of the European Academy of Dermatology and Venereology 2001;15(1)12-15.

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