Effective newborn skin cleansing

05 November 2018

First published May 2013.

What is best practice for newborn skin cleansing?

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Establishing a cleansing routine that keeps neonatal skin healthy can be a particular challenge for parents. Community practitioners play an essential role in helping parents to ensure the best start in life for their baby.

Opinion and evidence

When advising parents on newborn skin cleansing, practitioners are guided by recommendations in professional guidelines. However, current guidelines are largely based on expert opinion rather than on evidence (Crozier and Macdonald, 2010; Lavender et al, 2009) and continue to cause debate among healthcare professionals and confusion for parents. Clinical research published within the last decade (Lavender et al, 2013; Blume-Peytavi et al, 2012; Lavender et al, 2012) adds to the body of evidence in this area to support practice and provides community practitioners with information to help parents to make an informed choice about cleansing their baby.

UK guidelines

The NICE guideline Postnatal care up to eight weeks after birth was published in 2006. It was last checked in 2017, and a full update is expected in 2020. The guideline aims to identify the essential ‘core care’ that every woman and her baby should receive, as appropriate to their needs, during the first six to eight weeks after birth. NICE emphasises that the aim of the guideline is to enhance the continuity and quality of postnatal care for all new mothers and their babies, based on the following ethos:

  • Core postnatal care provision is undertaken in partnership with women. Therefore, care is always offered to the woman and not imposed upon her.
  • Care is individualised through a process of education and discussion to meet the needs of each mother-infant dyad.
  • Women’s views, beliefs and particular circumstances are respected.
  • Interventions offered are evidence-based. 
    (Demott et al, 2006)

The guidelines were formulated by a guideline development group (GDG) that included two health visitors, two midwives, a GP, a community paediatrician, an obstetrician and three lay representatives. Other experts were co-opted to the GDG for specific topics. In formulating the guideline recommendations, the GDG followed the standard process used by NICE. The first step was to identify all available published evidence through a literature review, based on key clinical questions developed by the GDG and the technical team. The evidence from the literature review was then graded from A to E (Centre for Evidence-Based Medicine, 2009; Demott, 2006; NICE, 2006).

In their discussions, the GDG noted the lack of Grade A evidence from randomised controlled trials (RCTs) for many of the topics included in the guideline (Demott et al, 2006). In 2005, a systematic review found no prospective clinical trials of neonatal skincare that met the authors’ inclusion criteria (Walker et al, 2005a). Since no research studies specifically addressing the general skincare of a full-term infant were identified, the NICE recommendations on best practice for newborn skin cleansing were based on the expert experience of the GDG: ‘Parents should be advised that cleansing agents should not be added to a baby’s bath water nor should lotions or medicated wipes be used. The only cleansing agent suggested, where it is needed, is a mild, non­perfumed soap’ (NICE, 2006).

In contrast, professional guidelines from the American Association of Women’s Health, Obstetrics and Neonatal Nurses recommend using warm tap water for routine bathing with the option of using mild cleansers with a neutral pH (Lund et al, 2001). These recommendations were, however, based largely on evidence derived from research in pre-term infants (Lund et al, 2001) and some authors have questioned their applicability to full-term newborns (Steen and Macdonald, 2008). A European consensus panel has recently published guidance on bathing and cleansing in healthy full-term newborns. Having reviewed the available scientific and clinical evidence, panel members concluded that, when used appropriately, liquid cleansers might have advantages over soaps or water alone when used to cleanse infants in the first year of life (Blume-Peytavi et al, 2009).

Debate

These differences in professional and academic opinion have led to continuing debate among practitioners (Steen and Macdonald, 2008) and some inconsistencies in practice. While midwives recommend water alone for bathing newborns in hospital, they may also suggest using baby wipes ‘now and again’ based on their experience of caring for their own babies (Lavender et al, 2009). Even when official advice is to use water alone, hospitals may also stock a wide range of bathing and cleansing products for use on neonates, some of which they supply to mothers (Walker et al, 2005b).

The discrepancy between official advice and the realities of everyday practice is also confusing for mothers, especially when they are faced with the task of cleaning the baby after defecation. Mothers want their baby to be clean and pleasant-smelling, and many women believe that this is only possible if they use cleansing products (Lavender et al, 2009). However, because they are aware of advice to use water alone, women may also feel guilty and anxious about using cleansing products (Furber et al, 2012).
 


Healthcare professionals and mothers: what do they really think?

HEALTHCARE PROFESSIONALS  MOTHERS
‘I remind them [women] that the skin is an organ and it's got to develop its own capacity to produce oils and unblock the sweat glands... really there isn’t any necessity to use any soaps or lotions’ (community midwife) ‘The advantages [of water and cotton wool] are I suppose that there’s nothing in it that’s going to cause any irritation on his [baby] skin... I’ve got no reason to doubt what they’re [midwives] telling me’
‘I have been a health visitor for a long time and although I know what I ought to tell women [water only for bathing], it is not as simple as that... At home you think about the individual mum and baby and don’t worry about what you should and shouldn't do’ (health visitor) ‘It tends to be sort of trial and error... It’s my family and friends really who I trust or listen to otherwise I would trial and error myself’
‘Water is natural. Water is no extra cost to the mums and it does the job well’ (community midwife)

‘I like using just cotton wool and water as they contain no additional chemicals which could potentially react on baby’s skin’

 

‘You could be there for ages with water... It’s just bizarre, but it can almost feel like it’s not clean enough’

(Furber et al, 2012; Lavender et al, 2009)

Newborn skin is different

Until recently, there has been a dearth of evidence about best-practice cleansing of newborns from RCTs – the ‘gold standard’ for evidence-based practice (Centre for Evidence-Based Medicine, 2009). There has, however, been a great deal of scientific research examining the characteristics of newborn skin and how it differs from the skin of older children and adults.
 

One of the skin’s most important functions is to act as a barrier. Healthy skin prevents water loss from the body, while protecting against the entry of infectious, irritant or allergenic micro­organisms. In newborns, as in adults, the barrier function of the skin is primarily performed by the stratum corneum, the uppermost layer of the thin outer layer of the skin or epidermis (Cork et al, 2009).

The stratum corneum is made up of flattened, overlapping, disc-like cells called corneocytes. The corneocytes are continually being shed and replaced by cells that begin life in the stratum basale. This lowest layer of the skin lies on the basement membrane, which separates the epidermis from the dermis or inner layer of the skin. As the stratum basale cells divide, they move up into the next layer, the stratum spinosum, where cells called melanocytes give the skin its colour. The cells then move upwards into the stratum granulosum, where they form corneocytes.
 
In the stratum corneum, the corneocytes are bonded together with a mixture of lipids or fats called the lipid lamellae. This enables the stratum corneum to act like a weatherproof ‘brick wall’, preventing undue water loss and protecting against the entry of harmful micro-organisms. Full-term babies are born with a competent stratum corneum that acts as a skin barrier to protect the body’s organs against dehydration, but there are important differences between infant and adult skin. 

The stratum corneum in infants is about 30% thinner and the remaining epidermal layers about 20% thinner than in adults. These differences are important, since the barrier function of the stratum corneum depends greatly on its thickness and integrity to prevent transepidermal water loss (TEWL) from the skin. Infant skin also handles water differently. Although newborn skin is noticeably dry, skin hydration increases with age over the first months of life. However, while the stratum corneum is more hydrated in infants aged three to 12 months than in newborns, it also loses water at significantly higher rates than adults’ skin (Telofski et al, 2012).

There are other differences between infant and adult skin. An acidic stratum comeum is essential if the epidermal barrier is to mature and be able to repair itself. Humans are born with a neutral skin pH of 6.3 to 7.5, which falls within the first two weeks of life to around pH 5 – similar to the acidic skin surface of adults. The composition of the skin’s microflora also changes over the first year of life and, although the implications are unclear, this is likely to be an important factor in developing the immune function of the skin (Telofski et al, 2012).

 



Figure 1: The epidermis.
 

Figure 2: Transepidermal water loss in infant and adult skin (adapted from Telofski et al, 2012)
Infant and adult skin: stratum corneum (SC) hydration and water transport properties. The SC of infant skin (a) and adult skin (b) is hydrated (small blue spheres) under normal conditions. Infant SC is more hydrated but also loses water at higher rates than adult SC. 

Effective skin cleansing

To be effective, cleansing must remove harmful impurities and irritants such as urine and faeces (Blume-Peytavi et al, 2009). Choosing the right method of cleansing is crucial to ensure that it has a positive, rather than negative, effect on the health of newborn skin. Inappropriate cleansing can damage and break down the skin barrier, increasing TEWL and allowing the entry of irritants and allergens (see Figure 3), increasing the likelihood of skin problems (Telofski et al, 2012; Cork et al, 2009).

 


 

Figure 3: Skin barrier function (based on Cork et al, 2006)


The brick wall analogy of the stratum corneum (SC) of the epidermal barrier. In healthy skin, the corneodesmosomes (iron rods) are intact throughout the SC. At the surface the corneodesmosomes start to break down as part of the normal desquamations process, analogous to iron rods rusting. If the iron rods are already weakened, an environment agent, such as soap, can corrode them more easily. The brick wall starts falling apart and allows the penetration of allergens. 

What’s wrong with water?

Water is the basic component of any cleansing routine and is seen as more ‘natural’ by mothers (Furber et al, 2012). However, water is not an inert substance and some research suggests that cleansing with water alone is not appropriate for newborn skin (Blume-Peytavi et al, 2009; Gelmetti, 2001; Tsai and Maibach, 1999). 

By itself, rinsing with water does not entirely remove harmful impurities from the skin. Oil and water do not mix, so rinsing with water cannot dissolve greasy, fat-soluble substances such as faeces (Tsai and Maibach, 1999). To remove them from the skin, it is necessary to use water plus a cleanser that contains emulsifying agents. This type of cleanser suppresses the surface tension that allows fatty substances to remain on the skin surface, dispersing them into fine droplets that can be removed by water.

After washing with water, skin surface pH can rise from 5.5 to 7.5, a level which can damage the skin barrier (Atherton and Mills, 2004). Depending on the frequency of bathing and the quality of the water (hard water appears to have an irritating effect), washing with water alone can also cause infant skin to become drier, further impairing the skin barrier (Blume-Peytavi et al, 2009).

There may also be unforeseen consequences in recommending that mothers use water alone for cleansing. Although women consider it important to always cleanse the nappy area after defecation, they are more likely to regard cleaning after urination as less important if they use cotton wool and water (Furber et al, 2012). The problem with this approach is that it leaves the skin in contact with urine for longer, leading to softening and weakening of the stratum corneum. This, in turn, makes the newborn’s skin more vulnerable to friction from the nappy and increases the risk of dermatitis or nappy rash (Atherton and Mills, 2004).

Why not just use soap? 

Soap is undoubtedly effective at cleansing the skin, but it can increase its surface pH. This explains why traditional alkaline soaps and adult cleansing products, especially those containing sodium lauryl sulphate, are associated with skin dryness and irritation, increased TEWL and breakdown of the skin barrier (Cork et al, 2006; Ananthapadmanabhan et al, 2004). It is also an important reason why a European consensus panel recommended using liquid, pH-neutral or mildly acidic cleansers during the first year of life. Because of the problems associated with using water alone, the panel also identified some potential benefits of using liquid cleansers when bathing newborns (Blume-Peytavi et al, 2009).



Benefits of liquid cleansers in bathing 

  • Liquid cleansers that contain emollients provide further protective effects on skin that cannot be provided by water.
  • Liquid cleansers can cleanse and hydrate the skin better than water in adults. Further studies are required in newborns and infants.
  • Washing with water alone may have a more drying effect on skin compared with the use of a mild cleanser. 
  • Hardness of local water is linked to the incidence of atopic dermatitis in children.


(Blume-Peytavi et al, 2009)



CLINICAL TRIALS

The structure and composition of newborn skin means that it needs special care to maintain its integrity when cleansing. Clinical trials provide the most robust evidence but, despite the critical importance of appropriate newborn skincare, there have until recently been few of these studies to support practitioners when advising parents on the most appropriate skincare regimen.

Reviewing the evidence

A recent review of studies relating to how the skin matures and adapts, bathing practices and bathing products concluded that bathing with mild liquid cleansers appears to be comparable with, and possibly superior to, bathing in water alone (Blume-Peytavi et al, 2012). In particular, two randomised studies found that, compared with using just water, bathing with a specific mild detergent cleansing product does not adversely affect the development of the skin barrier in healthy full-term newborns, and may reduce skin irritation and improve hygiene (Dizon et al, 2010; Garcia Bartels et al, 2010). However, the findings from these studies cannot necessarily be generalised to all mild detergent cleansing products.

The review authors recommended further research due to the different methodologies and outcome measures of the studies they included in their analysis (Blume-Peytavi et al, 2012). Considerations like these may have been among the reasons for the NICE decision not to revise its recommendations concerning neonatal skincare at the routine five-year review of its postnatal care guideline (NICE, 2012).

New randomised studies

Since the NICE decision, two large RCTs have been published by independent, peer-reviewed professional journals (Lavender et al, 2013; 2012). The trials were part of a research programme examining whether a product formulated for infants would be appropriate for newborn cleansing. The programme began with a qualitative study that demonstrated inconsistencies in bathing practices and the readiness of women to use bathing products (Lavender et al, 2009). At the time, there was little general information on study methodology or data from previous studies on newborns to set a precedent in designing such clinical trials. The same researchers then conducted a small RCT including 100 healthy newborns. This pilot study informed decisions on the feasibility and design of the larger studies, including the ‘power’ of the studies (such as number of participants) and the practicality of using TEWL as an outcome on newborn babies (Lavender et al, 2011).

The two large RCTs were both designed as non-inferiority studies. This means that the investigators’ objective was to demonstrate that the products being studied had an equivalent effect to usual care with water and cotton wool when used to cleanse newborn skin. Both trials were independent – that is, they were designed and led by the investigators and sponsored by Manchester University and hospital. Funding was by an unrestricted educational grant from Johnson & Johnson. Investigators were free to publish their results regardless of the outcomes of the two studies.

Both trials included healthy full-term babies recruited within 48 hours of birth in a large teaching hospital in the north-west of England. The babies were assigned to their treatment group by computer­generated telephone randomisation. The study groups were similar in terms of their demographics (maternal age, ethnicity, and parity), birth mode, the babies’ sex and birthweight, and feeding method. In both studies, research midwives blinded to the treatment allocation assessed the condition of the babies’ skin, and mothers were asked to complete questionnaires and diaries.
 

Baby wipes versus water 

The first trial included 280 newborns, which were randomised to have their nappy area cleansed either with an alcohol-free baby wipe (Johnson’s Baby Extra Sensitive Wipes) or with water and cotton wool. On the primary study outcome, the wipes were equivalent to water and cotton wool in their effects on skin hydration on the babies’ buttocks from the first assessment (within 48 hours of birth) to four weeks after birth. There were also no significant differences between the wipes and water on secondary study outcomes, including changes in erythema, TEWL and skin surface pH, and perianal bacterial colonisation. The exception was the occurrence of nappy rash as observed by mothers, which was more likely in babies randomised to water and cotton wool (Lavender et al, 2012).

Cleanser versus water 

The second trial also randomised newborns: in this case 307 babies who were assigned to either an infant skin-cleansing product (Johnson’s Baby Top-to-Toe Bath) diluted in water, or water alone for bathing. On the primary outcome of TEWL at 14 days, there was no significant difference between the cleansing product and water. There were also no differences between the groups of babies on the study’s secondary outcomes, which included the degree of skin dryness, erythema or excoriation. The exception was skin hydration, which was statistically greater in the babies assigned to the cleansing product. However, this difference was not clinically apparent (Lavender et al, 2013).

Implications for practice

RCTs are recognised by guideline committees, including NICE, as representing one of the highest levels of clinical evidence. As the largest randomised trials to date of cleansing practices in healthy newborns, these studies provide important evidence to support health visitors and community practitioners when advising parents on cleansing their newborn.

The results of both studies are reassuring, but their findings cannot be generalised to other baby care products. It remains essential for practitioners to be able to advise parents on cleansing their baby, including information on the appropriate choice of products, should parents wish to use them.

EVIDENCE INTO PRACTICE

Skincare products are evaluated to ensure that they meet regulatory standards before they are marketed. However, although they may be labelled as being ‘dermatologically tested’, products do not always undergo further clinical research to assess their effects on babies’ skin.

This makes it very challenging for practitioners when parents ask for advice. After a review of the guideline in 2015, NICE left the recommendation on newborn cleansing unchanged. But the recommendations of the consensus European panel include some very practical, detailed advice about bathing in general and cleansers in particular for practitioners to pass on to parents (Blume-Peytavi et al, 2009).

Benefits of bathing

The European panel identified several advantages of bathing over cloth or sponge washing as part of routine care during the first year of life. According to the panel, babies are generally calmer and quieter when bathed compared with cloth washing.

Bathing is also associated with less heat loss and a lower risk of skin dryness than doth washing, with no differences in the rates of infection or bacterial colonisation (Blume-Peytavi et al, 2009).

The panel also highlighted the psychological benefits of bathing in providing an enjoyable experience for the newborn as well as promoting bonding with adults. Compared to cloth washing and shower-bathing, bathing is more effective for calming, relaxing and soothing a baby. In particular, the panel identified bathing as a simple intervention that can be used to manage a persistently crying baby – a problem reported by up to 20% of parents (Blume-Paytavi et al, 2009). 

Choosing a cleanser

After reviewing the evidence, the panel concluded that the timing of the introduction of liquid cleansers into a newborn’s bathing routine differs between cultures, and seems to be related to personal preference. Similarly, practices regarding use of a shampoo to wash the baby’s hair seem to vary according to culture and personal preference (Blume-Paytavi et al, 2009).

The panel concluded that the properties of soap-free liquid cleansers suggest that they are preferable to soap, and that liquid preparations, which often contain emollients, are preferable to bars (Blume-Paytavi et al, 2009). If parents do decide that they would like to use a cleanser, they should always be advised never to use products that are manufactured for adults, as many of these are not pH neutral and will not be mild enough for sensitive newborn skin (Lund et al, 2001).

When choosing cleansing products, an ‘ideal cleanser’ for newborns is one that is specially formulated so that it does not alter the normal pH of the skin, cause skin irritation, or lead to irritation or stinging of the eyes. Even apparently harmless substances can be potentially damaging – for example, olive and vegetable oils have been shown to be associated with contact dermatitis in adults. So the product and its individual ingredients should have undergone rigorous testing in everyday use as well as in the laboratory (Blume-Paytavi et al, 2009).

The listing of ‘preservatives’ on a product’s label can act as a red flag to parents anxious to protect their baby. It is important to explain that appropriately formulated and tested preservatives are essential to prevent contamination of the product by harmful bacteria. Healthcare professionals should also remind parents of the importance of reading and following the package instructions (see What do labels really mean? box), especially when diluting or adding the product to bath water. 
 

What do labels really mean?

Alcohol free

Free from ethanol or ethyl alcohol (Cosmetic Toiletry and Perfumery Association, 2013)

Chemical

Substances made of atoms or molecules whether synthetic (man-made) or of natural origin. This means that everything including product ingredients are chemicals (Sense About Science, 2006)

Dermatologically tested

There is no legal definition when applied to a cosmetic product, but it generally means ‘tested on the skin’. It is not necessary for a doctor or dermatologist to be involved in the testing, though the protocols may have been reviewed by a medically qualified person (Cosmetic Toiletry and Perfumery Association, 2013)

For sensitive skin

Less likely to cause irritation (that is, a reaction that does not involve the immune system, and stops when the product is no longer used) (Cosmetic Toiletry and Perfumery Association, 2013)

Hypoallergenic

Less likely to cause allergic reactions (excessive reactions by the

immune system that may lead to life-long sensitivity) (Cosmetic Toiletry and Perfumery Association, 2013)

Natural

A substance derived from nature. Natural substances are not necessarily healthier or safer (for example, nicotine or arsenic) (Sense About Science, 2006)

Organic

There is no UK standard definition for organic cosmetics. The Soil Association certifies products as organic if they contain more than 95% organically produced ingredients (Soil Association, 2012)

pH balanced

Generally means that the product has a pH close to that of healthy skin (that is, slightly acidic at around pH 4.5 to 5) (Cosmetic Toiletry and Perfumery Association, 2013)

Preservative

Ingredient designed to protect products and the user against contamination by micro-organisms during storage and use (Sense About Science, 2006)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Conclusions

A fine balance is necessary between effective cleansing of newborn skin and the preservation of the skin barrier. Some scientific evidence is now available, but more research is urgently needed to inform evidence-based practice. Although observational studies and expert opinion provide valuable guidance, RCTs are essential to test products that may be used in newborn skin cleansing. Such studies will provide high-grade evidence to support health visitors and community practitioners when helping mothers to make informed choices about caring for their babies’ skin.

 

Learn more about NMC revalidation here.

 

Useful resources and further reading

 

  • American Academy of Dermatology: aad.org
  • British Association of Dermatology: bad.org.uk
  • Association of Women’s Health, Obstetric and Neonatal Nurses. (2007) Neonatal skin care: evidence-based clinical practice guideline (second edition). Association of Women’s Health, Obstetric and Neonatal Nurses: Washington.
  • Atherton DJ. (2009) Managing healthy skin for babies. Neonatal Nursing 5(4): 130-2.
  • Blume-Peytavi U, Cork MJ, Faergermann J, Szczapa J, Vanaclocha F, Gelmetti C. (2009) Bathing and cleansing in newborns from day one to first year of life: recommendations from a European round-table meeting. Journal of the European Academy of Dermatology and Venereology 23(7): 751-9.
  • Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia Bartels N. (2012) Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatric Dermatology 29(1): 1-14.
  • Clinical knowledge summaries. (2013) Nappy rash. See: cks.nhs.uk/nappy_rash (accessed 20 July 2018).
  • NHS Choices. (2016) Clinical trials. See: nhs.uk/Conditions/Clinical-trials (accessed 20 July 2018).
  • Steen M, Macdonald S. (2008) A review of baby skin care. See: rcm.org.uk/learning-and-career/learning-and-research/in-depth-papers/a-review-of-baby-skin-care (accessed 20 July 2018).

 

References

 

Ananthapadmanabhan K, Moore DJ, Subramanyan K, Misra M, Meyer F. (2004) Cleansing without compromise: the impact of cleansers on the skin barrier and the technology of mild cleansing. Dermatologic Therapy 17(Suppl 1): 16-25.

Atherton D, Mills K. (2004) What can be done to keep babies’ skin healthy? RCM Midwives 7(7): 288-90.

Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia Bartels N. (2012) Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatric Dermatology 29(1): 1-14.

Blume-Peytavi U, Cork MJ, Faergemann J, Szczapa J, Vanaclocha F, Gelmetti C. (2009) Bathing and cleansing in newborns from day one to first year of life: recommendations from a European round-table meeting. Journal of the European Academy of Dermatology and Venereology 23(7): 751-9.

Centre for Evidence-Based Medicine. (2009) Levels of evidence. See: cebm.net/2016/05/ocebm-levels-of-evidence (accessed 20 July 2018).

The Cosmetic, Toiletry & Perfumery Association. (2018) What’s in my cosmetic? See: thefactsabout.co.uk/whats-in-my-cosmetic/content/40 (accessed 24 July 2018).

Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J, Lane ME, Moustafa M, Guy RH, Macgowan AL, Tazi-Ahnini R, Ward SJ. (2009) Epidermal barrier dysfunction in atopic dermatitis. Journal of Investigative Dermatology 129(8): 1892-1908.

Cork MJ, Robinson DA, Vasilopoulos Y, Ferguson A, Moustafa M, MacGowan A, Duff GW, Ward SJ, Tazi-Ahnini R. (2006) New perspectives on epidermal barrier dysfunction in atopic dermatitis: gene-environment interactions. Journal of Allergy and Clinical Immunology 118(1): 3-23.

Crozier K, Macdonald S. (2010) Effective skin-care regimes for term newborn infants: a structured literature review. Evidence Based Midwifery 8(4): 128-35.

Demott K, Bick D, Norman R, Ritchie G, Turnbull N, Adams C, Barry C, Byrom S, Elliman D, Marchant S, Mccandlish R, Mellows H, Neale C, Parkar M, Tait P, Taylor C. (2006) Postnatal care. Routine postnatal care of women and their babies. See: nice.org.uk/guidance/cg37/evidence/full-guideline-485782237 (accessed 20 July 2018).

Dizon MV, Galzote C, Estanislao R, Mathew N, Sarkar R. (2010) Tolerance of baby cleansers in infants: a randomised controlled trial. Indian Pediatrics 47(11): 959-63.

Furber C, Bedwell C, Campbell M, Cork M, Jones C, Rowland L, Lavender T. (2012) The challenges and realties of diaper area cleansing for parents. Journal of Obstetric Gynecologic, & Neonatal Nursing 41(6): E13-25.

Garcia Bartels N, Scheufele R, Prosch F, Schink T, Proquitté H, Wauer RR, Blume-Peytavi U. (2010) Effect of standardised skin care regimens on neonatal skin barrier function in different body areas. Pediatric Dermatology 27(1): 1-8.

Gelmetti C. (2001) Skin cleansing in children. Journal of the European Academy of Dermatology and Venereology 15(Suppl 1): 12-5.

Lavender T, Bedwell C, Roberts SA, Hart A, Turner MA, Carter LA, Cork MJ. (2013) Randomized, controlled trial evaluating a baby wash product on skin barrier function in healthy, term neonates. Journal of Obstetric, Gynecologic and Neonatal Nursing 42(2): 203-14.

Lavender T, Furber C, Campbell M, Victor S, Roberts I, Bedwell C, Cork MJ. (2012) Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial. BMC Pediatrics 12: 59.

Lavender T, Bedwell C, O'Brien E, Cork MJ, Turner M, Hart A. (2011) Infant skin-cleansing product versus water: a pilot randomised, assessor-blinded controlled trial. BMC Pediatrics 11: 35.

Lavender T, Bedwell C, Tsekiri-O’Brien E, Hart A, Turner M, Cork MJ. (2009) A qualitative study exploring women's and health professionals' views of newborn bathing practices. Evidence Based Midwifery 7(4): 112-21.

Lund C, Osborne JW, Kuller J, Laane AT, Lott JW, Raines DA. (2001) Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Journal of Obstetric Gynecologic, & Neonatal Nursing 30(1): 41-51.

NICE. (2012) Recommendation for guidance executive. Review of clinical guideline (CG37) –Postnatal care. See: nice.org.uk/guidance/cg37/evidence/review-decision-2012-pdf-546209533 (accessed 30 July 2018).

NICE. (2006) Postnatal care up to 8 weeks after birth (CG37). See: nice.org.uk/guidance/cg37 (accessed 6 August 2018).

Sense about Science. (2014) Making sense of chemical stories. See: http://senseaboutscience.org/wp-content/uploads/2017/07/MSofChemicalStories.pdf (accessed 24 July 2018).

Soil Association. (2018) Organic standards: health and beauty products. See: soilassociation.org/media/15444/health-and-beauty-v16-7-2018.pdf (accessed 24 July 2018).

Steen M, Macdonald S. (2008) A review of baby skin care. See: rcm.org.uk/learning-and-career/learning-and-research/in-depth-papers/a-review-of-baby-skin-care (accessed 20 July 2018).

Telofski S., Morello AP, Mack Correa MC, Stamatas GN. (2012) The infant skin barrier: can we preserve, protect, and enhance the barrier? Dermatology Research and Practice 198789: 1-18.

Tsai TF, Maibach HI. (1999) How irritant is water? An overview. Contact Dermatitis 41(6): 311-4.

Walker L, Downe S, Gomez L. (2005a) Skin care in the well term newborn: two systematic reviews. Birth 32(3): 224-8.

Walker L, Downe S, Gomez L. (2005b) Survey of soap and skin care product provision for well term neonates. British Journal of Midwifery 13(12): 768-73.

 

Image credit | iStock

 

 

 

 

 

 

 

 

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