The skin: baby’s first line of defence

06 November 2018

First published December 2014

What are the risks of getting skin care wrong?

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Opinion and evidence-based skincare

Skincare should always be age-appropriate; this is even more crucial for newborn and infant skin as it is fundamentally different from adult skin (Telofski et al, 2012). Current skincare practices for infants in Europe vary between populations and are based mainly on tradition, experience and cultural factors (Blume-Peytavi et al, 2009). This inevitably leads to confusion and conflicting advice on infant skincare among both healthcare professionals and parents (Lavender et al, 2009). Currently, there is no national evidence-based UK guidance for infant skincare in the first year of life; the NICE guidance (2006) on postnatal care covers only the first eight weeks after birth only, and is based on opinion rather than empirical evidence (Crozier et al, 2010).

Infant skincare guidance is relevant to all health visitors, community practitioners, midwives and maternity staff, and should be incorporated into daily practice. Infant skin is subject to many environmental onslaughts as it moves from intra-uterine to extra-uterine to development in the first year of life. Skincare guidance and protocols should therefore incorporate an understanding of the physiology of infant skin development, to ensure an evidence­based approach as best practice for advising parents and carers on infant skincare.

This article will focus on sharing evidence-based infant skincare information. It aims at helping community practitioners and health visitors develop a knowledge base of healthy skin development, which may potentially help prevent common infant skin conditions. This is through an understanding of the differences between infant and adult skin, and the need for appropriate infant skincare.

 

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Understanding infant skin

The stratum corneum, the outer layer of the epidermis, has an essential role as the skin barrier. The mature skin barrier acts as the first line of defence against infectious agents, irritants and allergens, while regulating the loss of water and nutrients from the body, and supporting thermoregulation (Ness et al, 2013). In infants, skin remains immature and continues to develop through the first year of life, meaning that infant skin barrier is very vulnerable (Telofski et al, 2012).

How infant skin is different from adult skin

Skin develops in the uterus, from 20 weeks’ gestation, protected by the vernix caseosa, gradually becoming functional with a protective barrier at 24 weeks with full maturity at 34 weeks’ gestation (Ness et al, 2013). Healthy full-term neonates are born with a competent skin barrier, which prevents organ dehydration. However infant skin continues to develop in the first year and there are distinct differences between infant and adult skin in structure and function (Telofski et al, 2012). The stratum corneum is on average 20% to 30% thinner in infants (Dyer, 2013). Infant corneocytes are smaller and their turnover rate is higher than in adult skin (Ness et al, 2013; Telofksi et al, 2012). This is significant as the barrier properties of the skin depend on the thickness and integrity of the stratum corneum. In infants, the water-holding capacity of the skin increases during the first year, but barrier integrity remains low due to higher transepidermal water loss (TEWL). By one year, TEWL then reduces to adult levels (Telofski et al, 2012).

Full-term infants have a neutral skin acidity (pH) at birth, between 6.34 and 7.5 pH (Ness et al, 2013), which rapidly decreases during the first one to four days, then continues to fall over three months (Visscher et al, 2013). The formation of the acidic stratum corneum is essential for optimal skin barrier development and repair (Cork et al, 2009). Many other factors also contribute to the formation of the acid mantle, including sebum secretion, sweat (lactic acid), amino acids and their derivatives (urocanic acid and pyrrolidone carboxylic acid) (Telofski et al, 2012).

Skin is considered as the boundary separating the body from the external world and functions as a barrier between the two. In this capacity, it has evolved to be an integral part of the immune system; however, infant skin is particularly susceptible to irritation, inflammation and infection (Stamatas et al, 2013). It is thought that early micro-colonisation of the skin influences the development of immune function (Telofski et al, 2012).

A full overview of such implications of infant skin is discussed below.

 

KEY DIFFERENCES BETWEEN INFANT AND ADULT SKIN

Difference in skin structure, composition and function between infants and adults

  • Stratum corneum is up to 30% thinner
  • Stratum corneum is more hydrated
  • Low levels of inflammation
  • Higher pH
  • Microbiome is gradually acquired from birth, changing over the first year of life.

 


Implications for infant skin

  • Barrier integrity is low
  • Absorbs more water, but loses water faster – greater tendency to dryness
  • More prone to allergies and irritants
  • Developing acid mantle
  • Skin immunity reduced, more prone to infection

 

The physiological differences between infant and adult skin gives a body of knowledge for age-appropriate skincare for infants. Infant skincare should aim to support the developing skin barrier, hydrate skin, not alter the normal skin pH, or cause irritation.

Risks of getting skincare wrong

The risks of inappropriate skincare for infants and the importance of the development of the normal skin microbiome is now discussed. This section will also explore the potential for the development of atopic eczema in a genetically predisposed infant (an infant with parent/s with a history of atopic eczema, asthma, allergic rhinitis or Ig-E mediated food allergy).

Skin microbiome

The skin microbiome is defined as the collective skin commensal microbial communities (normal bacteria of the skin) which live on the human skin surface (Dyer, 2013; Sanford, 2013). The normal mature skin microbiome plays an important role in skin immunity. Many different microbial communities thrive on the skin; but failure to control the skin microbiome, leading to an imbalance called dysbiosis, can result in skin disease, particularly in vulnerable groups such as infants (Sanford et al, 2013).

The skin is colonised by bacteria at birth, and it is thought that birth delivery shapes the diversity for the skin microbiome, with infants born through the vaginal canal colonised with different microbes to those born by caesarean section (Capone et al, 2011). All infants have an initial skin microbiome that has a low diversity across the skin, compared with a high diversity in healthy adults (Capone et al, 2011). A study assessing the skin microbiome of 31 infants, aged between one and 12 months, showed that in the younger infant age groups (under six months), there was a predominance of common skin flora, streptococci and staphylococci, accounting for 40% of the total skin microbiome, with 23 other genera making up the rest of the microbial community. The type of birth only appeared to influence the microflora on the arms and buttocks, and not the forehead. In the older infant age group (over the age of six months) abundance of the low-predominance genera (<10%) increased, whereas the levels of streptococci and staphylococci decreased. This study suggests that the development and diversity of the skin microbiome evolves after birth during the first year of life (Capone et al 2012; 2011).

Appropriate infant skin cleansing is important in maintaining the balance of the skin microbiome. Using appropriately formulated cleansers can help maintain normal skin surface pH, which is important to support skin maturation and the development of the immune system (Telofski et al, 2012).

 

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Atopic eczema and the atopic march

Atopic eczema is a common childhood skin condition that affects up to 20% of children in the UK aged three to 11 years (Schofield et al, 2009). Atopic eczema is a complex condition that occurs as a result of an interaction of environmental factors with an abnormal immune system in a genetically predisposed individual (Cork, 1997). There is no single individual cause for atopic eczema but there are many trigger factors, including inappropriately formulated detergents, irritants (for example, wool and synthetic clothing) inhalant allergens (for example, dust mites), climate, environmental factors (for example, hard water), genetics and food (NICE, 2007).

Exposure to one or more environmental triggers may potentially develop and exacerbate eczema in infants. The prevalence and incidence of atopic eczema in children continues to increase year on year (Schofield et al, 2009). Atopic eczema often presents in the infant; approximately 60% of children with atopic eczema developed the condition in the first six months of life (Schofield et al, 2009).

The primary event in the development of atopic eczema is disturbance to the skin barrier (Cork et al, 2009). Genes that regulate the integrity of the skin barrier have been shown to have different variants when linked with atopic eczema. Filaggrin is a key protein that facilitates terminal differentiation of the epidermis and formation of the skin barrier. In atopic eczema, changes in filaggrin alter protease and protease inhibitors, which leads to a reduced level of natural moisturising factors (NMFs), causing dry skin due to the breakdown of the skin barrier (Cork et al, 2009). NMFs play an important role in regulating surface skin pH. A reduction in NMFs can affect the acid mantle of the skin, which can be enhanced by environmental triggers such as products with a high pH not specially formulated for infant skin (Cork et al, 2009). In order to visualise skin barrier breakdown, imagine a brick wall, with crumbly mortar and broken bricks, open to the elements and unable to remain waterproof (Cork et al, 2009).

Infants who are predisposed to atopic eczema, by inheritance of the atopic gene and genetic mutation of filaggrin, need appropriate skincare from birth. This will reduce the likelihood of skin barrier breakdown and potentially the development of atopic eczema. Prevention of the development of atopic eczema in infants is the subject of a clinical study currently being conducted by the Centre of Evidence-Based Dermatology at Nottingham University and due to be completed by early 2019. The Barrier Enhancement for Eczema Prevention (BEEP) study is looking at whether enhancing the skin barrier function in infants born to parents with allergic disease by limiting skin cleansers coupled with the liberal use of emollients could prevent development of atopic eczema and even the progression to asthma (Williams et al, 2012).

The role of filaggrin and the importance of preventing skin barrier breakdown in infants predisposed to atopic eczema is significant for other atopic diseases (Shaker, 2014). The ‘atopic march’ describes the development of atopic diseases, beginning with a family history and usually commencing in infancy/childhood with the development of atopic eczema and IgE-mediated food allergy; then in childhood asthma and rhinitis (Shaker, 2014). The prevalence of all atopic disease is rising and increased rates of food allergy are not completely understood. The interrelationships between atopic diseases can be explained by genetic risks, such as the mutation of filaggrin; the role of an atopic immunologically dysfunctional skin barrier is likely to be central to the evolution of allergic responses in atopic patients with relevant environmental exposure (Shaker, 2014).

 

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Impact of different cleansers on the skin barrier

Many classic bar soaps have high levels of pH – around 10 – which can have a sustained negative pH impact on the skin and lead to skin barrier breakdown. However, washing with water alone may have a more drying effect on skin compared with use of a mild cleanser. In both infants and adults, hardness of water is linked to skin dryness. An ‘ideal cleanser’ for baby skin is one that does not alter the normal pH of the skin (Blume-Peytavi, 2009).


INFANT SKIN AND ATOPIC ECZEMA

  • Infant skin is fundamentally different in structure and function to adult skin, so age-appropriate skincare is essential for infant skin health and development.
  • The skin microbiome plays an important role in skin immunity and continues to develop in infants during the first year.
  • All infants have an initial skin microbiome that has a low diversity across the skin, compared with a high diversity in healthy adults.
  • The primary event in development of atopic eczema is disturbance in the skin barrier.
  • The interrelationships between atopic diseases can be explained by genetic risks such as the mutation of filaggrin and the role of an atopic immunologically dysfunctional skin barrier.
  • Appropriate infant skin cleansing is important in maintaining the balance of the skin microbiome and maintaining the infant skin barrier. 

Importance of skincare for infants with atopic eczema

Atopic eczema generally develops in infants between three to six months of age, but can be present at birth. Skincare for infants with atopic eczema should be complete emollient therapy (CET), which consists of emollient creams or ointments, emollient wash products, and emollient bath and shower products. Everything that goes on the skin should be emollient-based. Those that are not correctly formulated for infant skin should be replaced with an emollient wash or appropriate bath products (NICE, 2007).

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SHARING EVIDENCE-BASED PRACTICE TO ADDRESS CURRENT QUESTIONS AND DISPEL MYTHS AROUND INFANT SKINCARE

There are many differing opinions on infant skincare, both inside and outside the healthcare professional community. Currently, there are many national and local guidelines for community practitioners, coupled with parental information from various sources, and the range of baby skincare products continues to expand. A study exploring women’s and health professionals’ views has highlighted confusion among parents, who may choose skincare toiletries for their baby on the basis of trial and error rather than evidence (Lavender, 2009).

This study reveals that advice on infant skincare often results from opinion rather than evidence base; indeed, current information sources may also conflict with current evidence. This section looks at the evidence base for infant skincare, addresses common myths and provides an overview of good skincare practice.

1. Is water good?

The current NICE postnatal care guidelines (2006) recommend bathing newborns in water alone and using a mild, non­perfumed soap where required. This guidance is based on opinion rather than empirical evidence. In fact, water has been shown to irritate and dry the skin, due to a neutral pH 7.0 that is alkaline compared to the normal acid mantle of skin (Tsai and Maibach, 1999). Water-only washing is better with soft water, which has an acidic pH. Hard water has an alkaline pH and it has been shown that rinsing with even slightly alkaline tap water can raise skin pH for several hours, disturbing the developing acid mantle of infant skin and becoming a potential skin irritant (Ewen et al, 2011; Tsai and Maibach, 1999).

In a clinical study, midwife and dermatology researchers at the University of Manchester ran their own independent trial to compare the effects of cleansing with a specially formulated baby cleanser versus water alone on healthy newborn skin. The trial found the baby cleanser used in the trial to be as safe as water alone for cleansing delicate newborn skin, from the very first day (Lavender et al, 2013). Parents can be given the choice between water alone and a pH balanced liquid cleanser; however, in hard water areas, baby skin cleansers that are mildly acidic (pH 5.5) may help to counteract water pH.

On a practical level, some healthcare professionals are sceptical about the effectiveness of water as a cleanser when it is used alone (Lavender et al, 2009). It is also worth considering that when it comes to cleaning the genital area, water alone may not be effective. Infants’ health depends on keeping the skin free of harmful bacteria found in urine and faeces that cause irritation and may lead to infection if transferred to the baby's mouth (Telofski et al, 2012). Infantile faecal matter has a higher percentage of fats than adult faecal matter, and therefore a mild, liquid baby cleanser or wipes are required to remove the fatty deposits from the baby’s skin (Blume-Peytavi et al, 2009).

2. Is a mild soap appropriate to cleanse?

Soap, produced from the chemical reaction saponification, can be an effective cleanser, but this can be outweighed by the negative effects of soap on skin lipids (fats) and pH (Cork et al, 2009). All soap (with the exception of cleansing bars) are typically alkaline and have been shown to increase the pH of infant skin and disturb the acid mantle for up to 90 minutes (Cork et al, 2009).

Sustained pH increases, such as those caused by some soap-based cleansers, have been shown to enhance the activity of degradatory proteases and decrease the activity of the lipid synthesis enzymes (Cork et al, 2009). This evidence indicates that it is important to choose soap-free skincare products to wash infants.

3. Are all wash products bad?

One common perception is that all wash products are bad for delicate infant skin and confusingly products which are labelled with claims such as 'gentle' and 'for sensitive skin' are not necessarily supported by data and can therefore be misleading (McLeod et al, 2013).

Researchers at the University of Manchester conducted a randomised controlled clinical study to compare the effects of bathing with water alone to a pH-adjusted wash product especially formulated for newborn infant skin (Lavender et al, 2013). The outcomes were measured at two weeks and four weeks; with objective  measurements of transepidermal water loss (TEWL) and skin surface pH of all the infants in the clinical trial; and other measures including midwife observation with a validated skin scale (assessing erythema, excoriation and dryness) and daily skin observations from the mother. The study concluded that no differences were detected between the newborn wash product and water alone. This study provides evidence that wash products that are specially formulated for newborn cleansing are non-inferior to water alone in terms of safety and efficacy (Lavender et al, 2013).

4. Are baby wipes harsh for infant skin?

There have been reported concerns over the safety of using baby wipes on infant skin due to the chemicals found in such products. NICE guidance (2006) recommends that ‘medicated wipes’ should not be used; however, the term is ambiguous. The definition of a medicated wipe is a wipe with an ingredient added for skin health (for example, cosmetic face wipes with anti-ageing ingredients) or skin treatment (for example, wipes for haemorrhoids with local anaesthetic ingredients). Therefore, a baby wipe for infant cleansing is not normally considered to be ‘medicated’.

In a clinical study, midwife and dermatology researchers at the University of Manchester ran their own independent trial to compare the effects of cleansing with a baby wipe versus cotton wool and water on healthy newborn skin. The trial found baby wipes to be just as safe as using cotton wool and water, from the very first day (Lavender et al, 2012). The choice of baby wipes for cleansing infants during nappy change should be based on alcohol-free baby wipes that have a stable, mildly acidic pH, so are less likely to disrupt the infant skin barrier.

5. Is olive oil appropriate for massage use?

One study found that 81% of staff in NHS maternity and neonatal units who recommended massage advised parents to use olive oil (Cooke et al, 2011). Many parents now use olive oil for baby massage in spite of research that shows that olive oil significantly damages the skin barrier, and therefore has the potential to promote the development of atopic dermatitis. This is potentially due to the high concentrations of oleic acid in olive oil, which has been shown to damage the skin barrier (Danby et al, 2012).

At a practical level, it is worth noting that olive oil is usually intended for cooking, and is not certified as a skincare product. As a result, purity and composition may vary and cause potential skin irritation, or it may become chemically unstable, rancid or contaminated with micro-organisms.

After olive oil, the second most recommended oil by NHS maternity and neonatal staff is sunflower seed oil (Cooke et al, 2011), primarily because of its high levels of linoleic acid, an essential fatty acid which may help to protect the barrier layer of skin. In general, oils with low levels of oleic acid and high levels of linoleic acid are considered desirable for baby massage (Danby et al, 2012). However, further research is needed to assess the benefit and merits of using natural oils for healthy and eczematous baby skin. Further research on the effects of vegetable oil on infant skin is needed as evidence for a preferential infant massage oil is currently lacking (Danby et al, 2012).

Only 12% of staff in NHS maternity and neonatal units surveyed routinely recommended the use of baby oil to parents (Cooke et al, 2011). Mineral oil is derived from petroleum, which is used in many moisturisers for dry skin that are on sale or available on prescription in the UK. As a result, its safety has been tried and tested numerous times. It’s also worth noting that the mineral oil used in baby products is highly purified, comprised of pharmaceutical­ grade mineral oil and is as effective as other commonly used massage oils (Stamatas et al, 2008).

6. Is preservative-free good?

Preservatives are necessary and included in the formulation of any water-based product to prevent bacterial and fungal growth. Ideally, preservatives should be hypoallergenic and active against a broad range of micro-organisms. Generally, combinations of preservatives are required to fulfil these requirements (Fowler et al, 2013). Some products labelled preservative-free can contain preservatives as other excipients may be used for a primary purpose but have secondary preservation qualities.

Infant skincare question

  • Is water good?
  • Is a mild soap appropriate to cleanse?
  • Are all wash products bad?
  • Are baby wipes harsh for infant skin?
  • Is olive oil appropriate for massage?
  • Is preservative-free good?

Evidence-based response

  • Hard water can raise skin pH
  • All soaps (except moisturising cleansing bars) raise skin pH significantly and can adversely affect the skin barrier
  • Certain pH-balanced liquid cleansers have been clinically proven as safe as water
  • Certain alcohol-free, unperfumed baby wipes have been clinically proven to be as safe as water
  • Olive oil can damage the skin barrier
  • Preservatives prevent bacterial and fungal growth and ensure product stability.

 

Learn more about NMC revalidation here.

References

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

Capone K, Nikolovski J, Stamatas GN, Green M, Cox S, Dowd SE. (2012) Exploration of bacteria comprising the human skin microbiome throughout the first year of Life. Journal of Obstetric, Gynecologic and Neonatal Nursing 41(S1): S147-8.

Capone KA, Dowd SE, Stamatas GN, Nikolovski J. (2011) Diversity of the human skin microbiome early in life. Journal of Investigative Dermatology 131(10): 2026-32.

Cooke A, Cork MJ, Danby S, Lavender T. (2011) Use of oil for baby skincare: a survey of UK maternity and neonatal units. British Journal of Midwifery 19(6): 213-20.

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. (1997) The importance of skin barrier function. Journal of Dermatological Treatment 8(S1): S7-13.

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

Danby SG, AlEnezi T, Sultan A, Lavender T, Chittock J, Brown K, Cork MJ. (2012) Effect of  olive and sunflower seed oil on the adult skin barrier: implications for neonatal skincare. Pediatric Dermatology 30(1): 42-50.

Dyer JA. Newborn skin care. (2013) Seminars in Perinatology 37(1): 3-7.

Ewence A, Rumsby P, Rockett L, Davey A, Williams H, Danby. (2011) A review of skin irritation and tap water quality. See: dwi.defra.gov.uk/research/completed-research/reports/dwi70-2-257.pdf (accessed 6 August 2018).

Fowler JF, Eichenfield LE, Elias PM, Horowitz P, McLeod RP. (2013) The chemistry of skin cleansers: an overview for clinicians. Seminars in Cutaneous Medicine and Surgery 32(2S2): S25-27

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, 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.

McLeod RP, Elias PM., Eichenfield LF, Fowler JF Jr, Horowitz P. (2013) A lifetime of well skin care: practical recommendations for clinicians and patients. Seminars in Cutaneous Medicine and Surgery 32(2S2): S28-29.

Ness MJ, Davis DM, Carey WA. (2013) Neonatal skincare: a concise review. International Journal of Dermatology 52(1): 14-22.

NICE (2007) Atopic eczema in under 12s: diagnosis and management (CG57). See: nice.org.uk/cg57 (accessed 6 August 2018).

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

Sanford JA, Gallo RL. (2013) Functions of the skin microbiota in health and disease. Seminars in Immunology 25(5): 370-7.

Schofield JK, Grindlay D, Williams HC. (2009) Skin conditions in the UK: a healthcare needs assessment. Centre of Evidence-Based Dermatology: Nottingham.

Shaker M. (2014) New insights into the allergic march. Current Opinion Paediatrics 26(4): 516-20.

Stamatas GN, Morello AP, Mays DA. (2013) Early inflammatory processes in the skin. Current Molecular Medicine 13(8): 1-20.

Stamatas GN, de Sterke J, Hauser M, von Stetten O, van der Pol A. (2008) Lipid uptake and skin occlusion following topical application of oils on adult and infant skin. Journal of Dermatological Science 50(2): 135-42.

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.

Visscher MO, Taylor T, Narendran V. (2013) Neonatal intensive care practices and the influence on skin condition. Journal of the European Academy of Dermatology and Venereology 27(4): 486-93.

Williams HC, Chalmers JR, Simpson EL. (2012) Prevention of atopic  dermatitis. F1000 Medicine Reports 4:24.

 

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