The first breath taken within seconds of birth is a vital role allowing the lungs to fill with air (Kenner and Lott, 2014)—signifying the moment the baby is now living in a gaseous (air) environment rather than a fluid (amniotic fluid) environment. This change in environment can greatly impact the skin, the bodies largest organ; moving from a wet to dry environment. A crucial role of the skin is to act as a barrier; problems occur if this barrier becomes impaired. Watkins (2016) acknowledged how many common health complaints in newborns relate directly to the skin, these include: cradle cap, dry skin and rashes, including milia, heat rash and nappy rash.
Establishing good skincare regimes from birth has been seen to be beneficial in supporting healthy skin throughout life (Ness et al, 2013). Nikolovski et al (2008) identifies how the stratum corneum (the outer most layer of the skin) fully develops during the first 12 months of life; making this first year even more critical in ensuring appropriate evidence-based skincare regimes are implemented.
Understanding newborn skin
A newborn's skin is highly vulnerable and requires protection, particularly during the first 12 months of life, when the immature, fragile skin can be easily damaged (Weatherspoon, 2018). Understanding the delicate nature of a newborn's skin, and how different factors can impact it, ensures informed evidence-based choices can be made, offering protection while preventing damage occurring; supporting the skin to act as a fully functioning barrier.
The skin is made up of several layers, with the epidermis forming the outermost (external) layer of the skin—the stratum corneum. The primary function of the stratum corneum is to act as a barrier, preventing water loss and repelling fluid, while also protecting the deeper layers of the skin. This is performed by the function known as transepidermal water loss (TEWL). TEWL is performed by the epidermis preventing excess loss or gain, thus allowing an effective skin barrier function (Voegeli, 2016). The stratum corneum regulates moisture, trapping moisture to prevent it from drying out, while additionally preventing the entry of foreign irritants and microbes (Flanagan, 2013).
It takes around the first 12 months of life for the stratum corneum to fully develop (Nikolovski et al, 2008); a newborn's stratum corneum is 30% thinner than that of an adult's (Lio et al, 2012). Lawton (2013) acknowledges the risk of skin problems occurring at this stage are significantly increased due to the immaturity of the stratum corneum. During this vulnerable period, it is paramount that optimum care and protection are delivered.
Skin (stratum corneum) becomes overhydrated when in prolonged contact with wetness attributed to urine and faeces, producing a more alkaline pH reading (Stamatas and Tierney, 2014). The fragile, swollen skin is at increased susceptibility of other factors, including friction from nappies, vigorous cleansing techniques or residue from cleansing products (Hugill, 2017). Damage caused to the stratum corneum, combined with friction from the nappy, can lead to the nappy area becoming red, inflamed, broken or blistered (Weatherspoon, 2018).
While it remains essential to maintain skin integrity, a fully functioning skin barrier is also reliant on the correct pH balance (Lavender et al, 2011), aiding the role of the skin to fully function as an effective barrier. It is widely recognised that the pH of the skin should be around 5.5, producing a slightly acidic mantle (Voegeli, 2010). The pH of a newborn's skin is raised (slightly alkaline) from birth up to day 28 (Blume-Peytavi et al, 2012). This change in pH allows the skin to become colonised with micro-organisms, building protection against harmful bacteria (Jones, 2013); an essential role in the development of the skin, allowing it to act as a fully functioning barrier in preparation for future life. Supporting the changes occurring during these first 28 days with an altering pH ensures the skin has built in natural defences.
After the first month from birth, the pH of a newborn should stabilise at around 5.5. The slightly acidic pH reading of 5.5 discourages bacterial colonisation while lowering the risk of opportunistic infection (Flanagan, 2013). Faeces and urine on the skin can adversely affect pH levels. Beeckman et al (2015) acknowledges that skin overhydrated by urine will result in a more alkaline environment (a higher pH reading); creating an environment suitable for the multiplication of bacteria. Faecal enzymes produced within faeces can also detrimentally impact pH levels, increasing the risk of infection (Beeckman, 2016). Blume-Peytavi et al (2012) concur that the prolonged exposure of stool protease enzymes to damaged skin will cause further harm.
Nappy rash
It is imperative that the midwife fully understands the structures of the skin in order to minimise the risk of complications to it. Watkins (2016) identified nappy rash as one of the most common complaints in newborns; other common skin complications include dry skin, generalised rashes, milia (milk spots) and cradle cap.
Buckley et al (2016) believe nappy rash, or nappy dermatitis, is a broad term utilised to describe the inflammatory changes which occur within the nappy area. Hugill (2017) refers to nappy rash as an inflammatory skin reaction of a varying severity which is known to affect the buttocks, perianal and perineal areas in addition to the abdomen. Shin (2014) acknowledges how a variety of factors predispose the skin to harm by interacting with one another to impair the barrier function of the skin; the stratum corneum becomes disrupted within a moist environment and presence of friction in a nappy area aggravates the skin further.
A moist environment produced by urine and faeces not only disrupts the functioning pH level of the skin, reducing its ability to prevent infection, but also overhydrates the skin, leaving the stratum corneum thinner (due to swelling) and more susceptible to damage from external forces, such as cleansing techniques or a nappy. Lumbers (2019) summarises how swollen (stretched, overhydrated) skin allows the penetration of fibres or further fluid through, severely compromising the skin to act as a functioning barrier. Beeckman (2016) acknowledges an increased risk of cutaneous infection when the skin barrier function is impaired.
The NHS (2019) identified an incidence rate for nappy rash of around 33% of nappy wearing individuals, with wider literature reviews reporting incidence rates varying between 8–50%. Most parents and practitioners will have witnessed episodes of nappy rash or atopic eczema as it affects both sexes equally with no differences observed between different races (Gupta and Skinner, 2004). Atopic eczema (also known as atopic dermatitis) refers to a skin condition triggered by allergens (atopic).
‘Swollen (stretched, overhydrated) skin allows the penetration of fibres or further fluid through, severely compromising the skin to act as a functioning barrier’
Nappy rash can present in a range of severity from mild to severe. Initial damage will be seen as red, intact inflamed skin; severe damage presents as red, broken, bleeding skin. Associated risk of infection increases with severity of damage, due to both the skin barrier being impaired and the immaturity of the skin increasing the risk of infection (Eichenfield et al, 2014). Weatherspoon (2018) identified nappy rash presenting with small white bumps amongst the redness may be a yeast infection requiring a course of antifungal ointment; further evaluation should be undertaken if the rash does not respond to treatment (National Institute for Health and Care Excellence [NICE], 2015).
As with all skin damage first presenting as reddened skin, the practitioner should be aware that the darker the skin pigmentation on the baby, the more difficult it is to notice the first signs of redness. Any damage to the skin, whether superficial or deeper, is highly likely to be associated with a level of pain, with nerve endings and pain receptors exposed and irritated. Watkins (2016) acknowledged an increase in the incidence of nappy rash developing coinciding with teething;—linking this time period with increased saliva and upset bowels.
Exacerbating factors for nappy rash
It is widely agreed that factors others than urine and faeces alone are contributory factors in the development of nappy rash (Hugill, 2017). While accepting that an altered pH level and overhydrated skin are present in incidences of nappy rash, other aggravating factors of friction from nappy – such as over vigorous cleansing and residue from cleaning products – also play a critical role in the development of nappy rash (Weatherspoon, 2018). NICE (2015) suggest that in addition to skincare and hygiene regimes being reviewed, sensitivity to fabric softeners, detergents and other external products that have contact with the skin should be considered as contributory factors to the development of nappy rash.
White and McFadden (2008) observed an increase in the incidence of atopic skin disease over the past 50 years, with a weakness in the skin barrier being a contributory factor in the development of this disease (Lavender et al, 2011). Atopic skin disease is attributed to a combination of both genes and environmental factors, with Lavender et al (2011) accepting the use of skin cleansers to be a contributing factor. In 2008, White and McFadden (2008) also hypothesised that a link exists between the use of skin cleansing products on newborns, leading to the development of atopic dermatitis (atopic skin disease) with an increased use of skin cleansing products noted.
Use of water or wipes?
A baby will require hundreds of nappy changes; protecting the skin in this area impacts both the current and future health of the child. Many studies report benefits of using warm water and cotton wool to cleanse the skin, with residue from wipes linked with altering skin pH (Weatherspoon, 2018). Back in 2001, Ehretsmann et al (2001) discussed how many wipes are marketed as being pH neutral at 5.5 yet evidence shows a newborn up to 28 days does not have a skin pH of 5.5.
NICE (2015) clinical guidelines for postnatal care up to eight weeks post-birth continue to advocate the use of water only for cleansing purposes. This is consistent with the understanding of the skin development, acknowledging the associated complications with a thinner stratum corneum and altering pH levels. Insight into the development of the skin, in particular the stratum corneum taking up to a year to fully develop, will offer benefits that can be seen up to a year (Nikolovski et al, 2008).
Literature reviews reveal very limited unbiased research studies available, comparing cleansing regimes of water to wipes. With many studies either funded by leading baby wipe manufacturers or an association between the author and such companies is present, ethical issues and possible research bias are also present. When reviewing research, the midwife should acknowledge the inclusion and exclusion criteria for the study, assessing the impact these criteria may have on the research findings. Exclusion criteria may include pre-existing conditions or limit the age of the participants; study outcomes may be relevant to participants who have not been included in the study. Furber et al (2012) produced a comparison study of wipes to water; the report focussed on difficulty encountered, such as access to water, yet data highlighted a higher incidence of nappy rash in the wipes group.
‘Insight into the development of the skin, in particular the stratum corneum taking up to a year to fully develop, will offer benefits that can be seen up to a year’
Use of wipes is a common place occurrence; Hughes (2011) believes this is mainly associated with the convenience of this practice, as opposed to a decision made on best practice. Blume-Prytavi et al (2012) acknowledge that the manufacturing of wipes has improved, with the modern wipe containing emollients and pH stabilisers. Further research would be hugely beneficial in supporting future evidence-based best care.
Nappy technology
In the UK, disposable nappies started to replace the traditional nappy in the early 1980s. Technology within the product has undergone significant development since, increasing absorption whilst preventing fluid leakage.
For many nappies widely available in the UK market, the absorbent pad contains super absorbent polymers (Lumbers, 2018). This technology is designed to wick away fluid, leaving the skin dry. This fluid is then locked away and turned into a gel. With the fluid now a gel, even when pressure is applied to the nappy (from a newborn being held or laid down, for example) fluid cannot seep out and create a wet environment to the newborn's skin.
Use of barriers
Undertaking best practice regimes will support best outcomes, minimising risk yet risk cannot be eliminated. At times, the use of a skin barrier product may prove beneficial (in both healing and prevention). The selection process for utilising a barrier, either cream or film, is heavily reliant on an understanding of nappy technology and the impact a barrier may have on this, in addition to the severity of the damage and overall health needs of the newborn (Lumbers, 2019).
Various skin barrier products are designed to create a physical barrier between the moisture source and the skin (Voegeli, 2016). Penzer (2013) identified the dual purposes of skin barriers being that of both skin protection, where moisture is repelled in addition to barriers functioning to repair damaged skin whilst continuing to moisturise intact skin. Voegeli (2016) raised concerns over the possibility that some skin barrier products may block the pores on the incontinence pad (nappy), thus preventing fluid absorption being undertaken and fluid leaking as a consequence. Hale (2013) noted that some barrier creams are over applied, creating a clogging affect to the pad, detrimentally impacting absorption capacity and effectiveness of the incontinence pad (nappy). Guest et al (2011) acknowledges the benefits of a long lasting, breathable, flexible, waterproof barrier film or cream to protect and heal vulnerable or damaged skin.
Summary of care: cleanse protect restore
With skin conditions a common complaint in newborns, it is critical that the midwife offers evidence-based best practice information to the carers and families of newborns regarding safest management of the skin. Many newborns enter our world with a soft, waxy white substance of vernix caseosa covering them. Brandon et al (2018) discusses the natural absorption of this has been shown to offer protection during the first few days of life by forming an antibacterial and anti-fungal layer; allowing this to absorb can be beneficial to the newborn.
With a newborn undergoing hundreds of nappy changes, a newborn's bottom will become the main focus of cleansing regimes. Hugill (2017) advocates removing soiled matter with the nappy or nappy liner that is being removed.
Gentle cleansing of the nappy area should be undertaken, wiping from front to back using water as a first-line approach (NICE, 2015); benefits to this regime can be seen up to 12 months, while the significant changes to the skin occur (Lumbers, 2018). Cleansing agents or medicated wipes are not recommended for use within the first eight weeks (NICE, 2015).
Weatherspoon (2018) and Hugill (2017) concur that removal of faeces should be undertaken as soon as possible after the event, with regular, frequent nappy changes undertaken. Nappies using super absorbent cores will help reduce the risk of moisture damage. Skin barriers should be used if a high risk of skin breakdown is likely, or where damage already exists. Care should be taken to ensure the product is suitable to be used on broken skin.
Agree on local policy
Continuity in advice from professionals helps support the public's trust in the healthcare profession. All healthcare professionals, whether from the acute or primary care setting, who work with families and carers, should be delivering the same advice and care regimes.
Agreed practice should involve joint working from all disciplines involved, ideally including midwives, health visitors, medics, paediatric nurses, and all other health professionals involved locally who work with families and carers of the young nappy wearing community. Agreeing on local policy or guidance in care to cleanse and care for a baby, and helping to prevent and treat nappy rash supports collaborative working and continuity in practice.
Educate staff and families
With parents and carers undertaking the majority of nappy changes, it is essential they are fully informed with the latest and most appropriate evidence-based best practice techniques; supporting the development of healthy skin and its ability to fully function as a barrier. Parents and carers require guidance on how best to care for the skin of their newborn. The midwife is privileged to have both antenatal and postnatal contact, leaving them well-placed to help prevent and treat nappy rash, in addition to preventing recurrence.
NICE (2015) advocate the use of water to cleanse in addition to stating that cleansing agents and medicated wipes should not be used. Families need to be supported by health professionals in selecting methods which deliver ease of use. Cotton wool is available in a variety of formats and includes balls, pads and sheets; finding the one most suitable type to both the caregiver and newborn encourages compliance. Exploring products to ensure the safe transportation and instant availability of water will again support compliance; a small flask can be utilised and stored with nappies, ensuring this remains readily available (even when no water supply is close by). Convenience has been reported as a reason supporting the increased use of wipes; health professionals need to demonstrate how other methods can also become convenient choices. Furber et al (2012) acknowledge that parental decisions made around nappy cleansing techniques are based on confidence in the technique being both effective and best practice for the baby; demonstrating and explaining how simple techniques are achievable will have a positive impact.
Conclusion
Understanding the vulnerability of a newborn's skin, with further insight into the impact of changes to pH levels and effects of overhydration, supports the practitioner in making informed choices on care delivery and a clear rationale for choice. The impact of external factors of friction from the nappy, vigorous cleansing techniques and residue from cleansers further impacts the vulnerable skin—with a combination of factors ever increasing risk of damage. The skin has to be supported to fully function as an effective barrier; this is achieved by minimising the associated risk factors. Gentle cleansing with warm water while undertaking frequent nappy changes is supported by NICE (2015), with guidance not to use medicated wipes for the first eight weeks. Selecting an appropriate barrier, which doesn't interfere with the nappy function, can be effective in both prevention and management strategies. Supporting the naturally changing pH levels is achievable, allowing the skin barrier function to fully develop to help prevent future ill health.