Key learning points:
– The infant skin barrier continues to mature during the first year of life and is vulnerable
– Bathing for infants is generally recommended two to three times a week, however how the infant is washed is more important than frequency of bathing
– Recent evidence concludes there is no difference between washing an infant with water alone or with a pH5.5 adjusted fragrance-free cleanser, especially formulated for infants; it is down to parental choice
Parents constantly ask health visitors, midwives and nurses for advice on skin care for their newborn baby. Skin care for infants is actually a ‘hot topic’ as there are several myths, which can lead to conflicting advice. The reality is that there is a sound evidence-base best practice and correct advice for infant skin care. This article outlines best practice and looks at current evidence-based guidance and consensus for bathing, washing/cleansing and dry skin care for full-term infants.
The developing infant skin barrier
Skin is an organ that continues developing after birth; the maturation of the protective skin barrier continues during the first year until full formation at 12 months.1
Protection is a key function of mature skin barrier acting as a first-line of defence against irritants, allergens and infection, while regulating water loss and supporting thermoregulation.2 The stratum corneum is the outer skin barrier layer, which is 20-30% thinner in infants, with a higher degree of trans-epidermal water loss (TEWL); an important difference as the barrier properties of skin depend on thickness and integrity.3
The development of the optimal ph 5.5 acid mantle in the stratrum cornuem is key for effective skin barrier repair; full –term infants skin acidity at birth is between ph 6.3 – 7.5, which decreases after birth in the first three months.4 In addition, the infant skin microbiome evolves during the first year. All infants have a initial skin microbiome, which has a low diversity across skin compared to a high diversity in adults.5 The infant skin micrbiome is additionally important for influencing the development of the immune function.3
Role of vernix caseosa
The vernix caseosa is a creamy white surface biofilm that covers the skin of the developing foetus from 20 weeks gestation; and is the natural skin covering of the foetus during the third trimester of pregnancy and acts as a lubricate during delivery.6 It is composed of water, sebaceous secretions, detached fetal corneocytes and lipids and believed to provide a ‘waterproofing layer’ in utero to facilitate the formation and maturation of skin, usually by 34 weeks gestation.6 Recent evidence indicates that the vernix caseosa has important hydration, thermoregulation and bacterial protection qualities and should not be fully removed at birth.2 In addition the question of when to remove the the vernix caseosa is also guided by cultural preference.7
Bathing - the first bath
The timing of the first bath is guided by the stability of the newborn infant’s core temperature and sometimes cultural preference.8 It is recommended that if the newborn infant’s temperature is not stable at a minimum of 36.5°C, there maybe potential for hypotheramia or respiratory distress.9 In healthy neonates, a warm water bath may have a beneficial effect on body temperature, leading to more even body temperature across the trunk and peripheries.8 Clinical studies show no differences in newborn infants bathed immediately and those who were bathed up to two hours later. If the first bath is carried out by a health care professional, gloves should be worn for protection to exposure to maternal blood.8
Care of umbilical chord
The cultural preferences for bathing in the first week of life often focus on the care of the umbilical cord. There are some cultures that prefer to delay bathing until the cord has fallen off. The evidence shows that there is no differences in umbilical cord healing between those new born infants who are bathed or wiped with water and no differences in the incidence of umbilical cord infection between infants bathed or wiped.8
Parents should be advised how to keep the umbilical cord clean and dry and that antiseptics should not be used routinely.10 In 2014, a Cochrane Review looked at topical umbilicial cord care at birth and concluded that antiseptics or antibiotics had no advantage over keeping the cord stum clean and dry.11
General bathing, cleansing and washing during the first year
The Royal College of Midwives recommends that bathing should be twice weekly in the first six months.12 An expert European consensus group in 2009 agreed that bathing should be carried out two to three times a week, until the bay is crawling or as often required by cultural preferences.8 The National Institute of Health and Care Excellence (NICE) post natal guidelines give no advice on frequency of bathing.10 Many parents feel that bathing is an important bonding time with their baby and helps with night-time settling. BabyCentre UK give parents the following advice: ‘Give your baby a bath when you think he needs one, perhaps no more than every few days. After the first month or so, it can become a part of your baby’s daily routine.’13
Bathing is an important way to cleanse skin, and skin dryness will only occur if soap or detergent-based wash products are used. All soap (with the exception of some cleansing bars) are typically alkaline and have been shown to increase the pH of skin and disturb the acid mantle for up to 90 minutes, so should be avoided.4 Therefore, what an infant is washed in is possibly more important that actual frequency of bathing.
Washing with water alone is often the recommended advice, however studies have shown that depending on frequency of bathing and washing, water alone can have a drying effect on an infant’s skin, due to a neutral pH 7.0 which is alkaline compared to the normal pH 5.5 acid mantle of the infant’s skin at three months.14 Practically, water alone has alone has been identified as an ineffective cleanser, as it does not remove fat-soluble substances, such as faeces and sebum.7
Which wash products can be used for infant skin care and cleansing? The evidence stresses the important of using soap-free cleansers for infants but there is often misconception that all wash products must be bad. In 2013, a team of midwifery and dermatology researchers conducted a randomised controlled clinical study to compare the effecting of bathing with water alone to a pH adjusted (pH 5.5) wash product, especially formulated for infant skin.15
Outcomes of TEWL and skin surface pH were measured at two and four weeks, with midwife and maternal observations of general skin condition.15
The study concluded that no differences were detected between the new born pH adjusted wash product, which was fragrance-free, and water alone.15 This study will help health care professionals give parents evidence-based advice that the decision between using water alone or a pH adjusted baby wash product is entirely down to parental choice.
The importance of parental advice for infant skin care is crucial for infant skin health. All infants, due to immature skin barriers have fragile and vulnerable skin. Therefore, knowing how to care for infant skin is an important aspect of parenting; which should be coupled with consistent and practical advice from health care professionals. Guidance reviews (national and local) on infant skin is recommended, as the body of evidence-based knowledge surrounding infant skin has increased over recent years.
1. Nikolovski J, Stamatas G, Kollias N, Wiegand B. Barrier function and water-holding 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):1728-36.
2. Ness MJ, Davis DM, Carey WA. Neonatal skin care: a concise review. International Journal of Dermatology 2013; 52: 14-22
3. Telofski S, Morello AP, MackCorrea MC, Stamatas GN. The infant skin barrier: can we preserve, protect, and enhance the barrier? Dermatology Research and Practice 2012; epub 198789 doi:10.1155/2012/198789.
4. Cork MJ, Robinson DA, Vasilopoulos Y. Epidermal barrier dysfunction in atopic dermatitis. Journal of Investigative Dermatology 2009; 129: 1892-1908.
5. Capone K, Dowd SE, Stamatas GN, Nikolovski J. Diversity of the human skin microbiome early in life. Journal of Investigative Dermatology 2011; 131: 2026-2031.
6. Visscher MO, Narendran V, Pickens WL. Vernix caseosa in neonatal adaptation. Journal of Perinatology 2005; 25:440-446.
7. Gelmetti C. Skin cleansing in children. Journal of European Academy of Dermatology and Venreology 2001; 15 Suppl 1: 12-15.
8. Blume-Peytavi U, Cork MJ, Faergemann J, Szczapa J, Vanaclocha F and Gelmetti C Bathing and cleansing in newborns from day 1 to first year of life: recommendations from a European round table meeting. Journal of European Academy of Dermatology and Venereology 2009; 23 (7): 751–759.
9. Behring A, Vezeau TM, Fink R. (2003) Timing of the newborn first bath: a replication. Neonatal Network; 22: 39–46.
10. National Institute for Health and Clinical Excellence. CG 37: Routine postnatal care of women and their babies. 2006 [Online]. Available from: http://www.nice.org.uk/CG037 [accessed 16 January 2015]
11. Zupan J, Garner P, Omarai A. Topical umbilical cord care at birth.
The Cochrane Collaboration. 2013 Available at: http://summaries.cochrane.org/CD001057/PREG_topical-umbilical-cord-care [accessed 16 January 2015]
12. Steen M and MacDonald S. A review of baby skin care. Midwives On-line. Royal College of Midwives. 2008 Available at: http://www.rcm.org.uk/midwives/in-depth-papers/a-review-of-baby-skin-care/ [accessed 16 January 2015]
13. Baby Centre UK How often should I bath my baby? 2014. http://www.babycentre.co.uk/a37/bathing-your-baby. Available at [accessed 16 January 2015]
14. Tsai T and Maibach H, How irritant is water? An overview. Contact Dermatitis 1999; 41(6):311-14.
15. Lavender T, Bedwell C, Roberts SA, Hart A, Turner MA, Carter LA, Cork MJ Randomized controlled trail evaluating a baby wash product on skin barrier function in healthy term neonates. Journal of Obstetrics and Gynaecology Neonatal Nursing. 2013; 42 (2): 203-214.
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