Care of the Newborn: Proposed new guidelines
The full reference for this draft article is:Trotter S (2004) Care of the Newborn: Proposed new guidelines. British Journal of Midwifery 12 (3): 152-7
This article questions the potential harm associated with early overuse of skincare-manufactured products. There is an undeniable need for standardised guidelines that can be introduced nationally, which will inform and educate. Although predominantly involving skincare and cord care, it is important to remember that anything placed on, in or around the neonate has the capacity to harm. With this in mind, and with no available evidence to support their use, it is no longer appropriate for hospitals to supply free, products that are clearly not relevant to the care of the neonate. These new guidelines will not only simplify and supersede previous advice, but also encompass the role of health promotion. This role, which is central to every midwife, cannot be underestimated. If, as a result of the new guidelines, less babies go on to develop skin conditions, then the savings in treatment alone could be considerable. Not withstanding the emotional and psychological effects of such conditions, this, in the cost-effective climate of today's NHS, must be seen as evidence-based practice at its most effective.
The Anatomy and Physiology of the Skin
The Physiology of Cord Care
Proposed New Guidelines for Baby Care
The Premature or Sick Infant
Since first writing about the subject of Neonatal Skincare and Cord Care (Trotter S 2002, Trotter S 2003) opinions have begun to change in favour of a water only regime in the first month of life. I will revise the physiology of the skin/cord and its relevance to this care. Furthermore, I will introduce new evidence-based guidelines that could be adopted nationwide. This would not only avoid confusion but also promote a contiguous understanding between staff and parents.
In light of this work, present practice is being reviewed throughout the UK. Some leading manufacturers are even advocating the use of water for the first two weeks of life (Boots 2003, Aromababy 2003). Midwives are in the enviable position of being able to influence the care of newborns through education and health promotion. This role is central to midwifery and forms part of the Code of Professional Conduct (NMC 2002). This education needs to be introduced at an early stage, preferably in the antenatal period, so that good habits can be adopted. It is no longer appropriate for hospitals and maternity units to openly supply free baby products, when there is no evidence to support their use. Best practice, based on recent research (Lund et al, 1999a; 1999b; 2001a; 2001b) suggests that such products are now superfluous. Consequently, women do not need to take products into the maternity unit, as was once the case. Instead, the only requirements are cotton wool, water and maybe a baby comb (see new guidelines). It is important to mention here that the media play a large part in encouraging women to take all manner of products into hospital with them. It could be argued that this type of marketing plays a part in attempting to foster an early allegiance towards certain products. This is counter productive in the long term, as early sensitisation can lead to allergies and skin conditions which could, in turn, lead to intolerance of products altogether. In this instance, not only do the manufacturers loose out but, more importantly, the affected baby and their wider family also suffers. [back to top]
The Anatomy and Physiology of the Skin
The skin is the largest organ in the body and is made up of three main layers.
- The Epidermis.
- The Dermis.
- The underlying subcutaneous fatty tissue.
Within these layers lie the blood vessels, nerves, sweat/oil glands and hair follicles.
The Epidermis, or outer layer, is further divided into:
The latter of these is at the junction of the Epidermis and Dermis and is where the renewal of the Basal Cells is carried out. Basal cells constantly divide and are called Keratinocytes. They can be thought of as the bricks in a wall, with the mortar between, made up of lipids (fat cells).
It is this barrier, which allows the retention of fluids within the Epidermal cells, which remain plump and therefore prevent the introduction of micro organisms, chemicals and allergens. When intact, this 'wall' regulates temperature, acts as a barrier to infection, balances water/electrolytes, stores fat and insulates against the cold. The skin is also a large tactile area, for the interpretation of stimuli.
The Stratum Corneum itself is made up of 10-20 microscopic layers in an adult and the term infant. In premature infants, this number drops to between 2-3 layers. In extremely premature infants, of less than 23 gestational weeks, this layer may be virtually non-existent. ( Holbrook 1982, Nonato 1998). Consequently, the risk to these babies is even higher.
Babies are born with an alkaline skin surface, with an average pH of 6.34 (Peck & Botwinick 1964). However, within days, the pH has fallen to about 4.95 (acid). This is known as the 'Acid Mantle' and is the skins protector. The development of this 'Acid Mantle' happens within days irrespective of gestational age, which is probably a direct result of the skins exposure to air, instead of amniotic fluid (Harpin & Rutter 1983, Evans & Rutter 1986). However, The Stratum Corneum is still much thinner in the pre-term infant, especially in the 23-33 week age range. Therefore it would seem sensible to take extra care during this period to avoid any undue damage.
The introduction of Baby Bath products, wipes and creams etc, along with the exposure to urine and faeces, could disrupt this delicate protective barrier and lead to problems, including eczema, or allergic reactions (Peck and Botwinick 1964, Berg et al 1986, Cetta et al 1991). [back to top]
The Physiology of Cord Care
The umbilical cord is a unique tissue consisting of two arteries and one vein covered by a mucoid connective tissue known as Wharton's jelly, which is covered by a thin layer of mucous membrane (a continuation of the amnion). During pregnancy the placenta provides all the nutrients for fetal growth and removes waste products simultaneously through the umbilical cord. Following delivery, the cord quickly starts to dry out, harden and turn black (A process called dry gangrene). This is helped by exposure to the air. The umbilical vessels remain patent for several days, so the risk of infection remains high until separation. Colonisation of the area begins within hours of birth as a result of non-pathogenic organisms passing from mother to baby via skin-to-skin contact. Harmful bacteria can be spread by bad hygiene; poor hand washing techniques and especially by cross infection by health care workers. Separation of the umbilical cord continues at the junction of the cord and the skin of the abdomen, with leucocyte infiltration and subsequent digestion of the cord. During this normal process, small amounts of cloudy mucoid material may collect at the junction. This may unwittingly be interpreted as pus. A moist and/or sticky cord may present, but this too is part of the normal physiological process. Separation should be complete within 5-15 days, although it can take longer. The main reasons behind prolonged separation include the use of antiseptics and infection. Antiseptics appear to reduce the number of normal non-pathogenic flora around the umbilicus. This reduction in leucocytes prolongs the healing process and hinders cord separation. After the cord has separated, a small amount of mucoid material is still present until complete healing takes place a few days later. This means that there is still a risk of infection, although not as great as in the first few days. [back to top]
Proposed New Guidelines for Baby Care
Carolyn Lund et al (1999a; 1999b; 2001a; 2001b) have carried out the most comprehensive study into the care of neonatal skincare. 51 American acute-care settings for premature and full-term neonates were included in their trials. The objective was to test the effectiveness of evidence-based clinical practice guidelines on selected clinical outcomes for newborns. Baseline observations of skin condition, care practices and environment of newly admitted neonates were collected by specially trained site co-ordinators. This was followed up by post-implementation observations. The results can be summarised as follows:
Uniformity of Care practices nationally.
Overall improved skin integrity.
Reduced bathing using little or no products.
Increased emollient use.
No increase in infection rates.
Identification of risk factors, leading to early introduction of appropriate treatment. (Lund et al 2001b)
The guidelines implemented by Lund (2001b) were primarily aimed at premature or sick neonates in the acute hospital setting. With this in mind, the author has written a new set of guidelines, aimed at the healthy term infant, with some reference to premature and sick infants. [A Specific Policy, within the Neonatal Unit (NNU) will be introduced separately]. Collaboration between midwifery, medical and paediatric staff has led to the approval of these guidelines within Ayrshire and Arran Acute Hospital Trust (AAAHT).
A colourful and informative fold-out leaflet has also been designed for parents which includes the following advice:
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- Before and after carrying out any baby-care, especially cord care, it is important to wash hands thoroughly.
- First baths will now be carried out using plain water and cotton wool. This will help to protect the delicate skin while it is vulnerable to germs, chemicals and water loss. A baby comb can be used to gently remove any debris from thick hair after delivery. Please bring a baby comb into hospital with you.
- It is best to leave the delicate area around the eyes untouched. If it does become sticky, please notify a member of staff and they will advise you. The ears and nose should also be left alone and cotton buds should be avoided.
- Vernix (the white sticky substance that covers your baby's skin in the womb) should always be left to absorb naturally. This is nature's own moisturiser.
- Premature babies skin is even more delicate, so it is important to withhold all products for a period of 6-8 weeks, as their skin takes longer to mature. The staff in the Neonatal Unit (NNU) will be happy to advise you.
- If your baby is overdue, his/her skin may well be dry and cracked. This is to be expected, as the protective vernix has all been absorbed. Don't be tempted to use any creams or lotions as this may do more harm than good. The top layer of the babies skin will peel off over the next few days, leaving perfect skin underneath. This will now need 2-4 weeks to develop its naturally protective barrier.
- Cord care for the Healthy Term Baby: Keep this area clean and dry. The best way to achieve this is to leave the area alone. After the 1st bath in plain water, pat dry with a clean towel and fold back the nappy, at each change, until the cord separates. In the first few days, it is advisable to top'n'tail your baby to allow the cord to dry out. Wet Cotton wool can be used if the area becomes soiled, otherwise leave alone. There is no need to use any wipes or powders. The cord clamp will be removed by a member of staff in hospital or by your Community Midwife, if you are at home. If the cord or surrounding area does become red or smelly, notify a member of staff. This advice is based on the World Health Organization (WHO) recommendations published in 1999.
- Cord Care for the Sick or Premature Baby: This may differ slightly, due to the increased risk of infection. Antiseptic solutions and/or powders may be used for the first few days. Otherwise cord care should be the same as for any other baby. Be guided by staff in the NNU and they will advise you on the best possible care for your baby.
- Continue with plain water for 2-4 weeks before gradually introducing baby products. By this time the skins natural barrier will have developed. These products should be free from colours and perfumes and used sparingly.
- Baby wipes should also be avoided for 2-4 weeks. Once introduces, try to use ones, which are mild and free from alcohol and perfume.
- Shampoo is not necessary when your baby is under a year old. Once you have introduced baby products, simply rinse your baby's hair in the bath water solution.
- A thin layer of barrier cream can be used, if required, on the nappy area.
- If after a few weeks you wish to use a moisturiser, choose products that are emollient based. These will not dry out the skin, but they will give it some protection.
- Wash all baby clothes and bedding in non-biological washing powder. Fabric conditioners, if used, should be mild and free from colours and perfumes.
- Feeding: Breastfeeding is obviously the best choice for your baby as it gives some protection against allergies developing. However, whether you breastfeed or bottle-feed, remember to take care when introducing a mixed diet. This should not be attempted before four months of age, but can safely be left until six months, as recommended by the World Health Organization (WHO). Avoid any wheat (gluten) based products for the first six months as these could trigger an allergic response in the baby's immature digestive system. Stick to rice-based cereals instead. Cows milk should not be given as a drink until a year old. However, milk in cooking and milk products (yoghurts and fromage frais) can be introduced from six months. Eggs are best left until 9 months. Nuts should be avoided for at least the first year, but can present a choking hazard until the age of five. The Dietician will be happy to advise you further, if necessary. [back to top]
The Premature or Sick Infant
The reasons behind change of practice for these vulnerable infants are due to the higher risks of nosocomial (hospital acquired) infection, the increased number of carers and the infants compromised immune system.
Although the work of Carolyn Lund (Lund et al 1999a, 1999b, 2001a, and 2001b) and the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses (AWHONN/NANN) provides the benchmark for best practice in neonatal skincare, there are many worthy projects ongoing in the UK.
Prof. Michael Cork (Cork et al 2003a, 2003b) has looked into the adverse effects of emollient use and targeted health education by specialist dermatology nurses. This is vital if the care and treatment of skin conditions, especially eczema, is to be effective.
Prof. Jean Golding and the ALSPAC study team (Lack et al 2003) have researched the link between arachis (peanut) oil used in skin treatments and the subsequent development of peanut allergies in children. In light of this research, and considering the availability of products that include ingredients derived from nuts and/or nut oils, further investigation is indicated. They have also looked at the prevalence of food allergy and intolerance in the under sevens (Northstone K et al 2002).
Although these studies are not directly related to the neonate, they do highlight the importance of evidence-based guidelines that are easy to follow and are implemented with support from qualified staff. They also emphasize the need for great care when choosing products for treatment and dietary advice, all of which have the potential to harm as well as heal. [back to top]
From the emails and correspondence I receive, it is clear that a large knowledge/practice gap still exists on the best way to care for the neonate. I hope that this paper will go some way to addressing this. Further work is needed to assess the consequential reduction in childhood skin conditions as a direct result of the introduction of new guidelines. In today's climate of cost-effectiveness within the NHS and the high cost of treatments, we would be ill advised to underestimate their potential impact. However, financial constraints aside, it is the physical and emotional costs that are incalculable. [back to top]
Increased use of manufactured products appears to be directly related to an increase in childhood eczema.
The Skins protective barrier takes 2-4 weeks to develop, longer in premature infants.
'Water only' is recommended for the first month of life, longer for premature infants.
Antiseptics interfere with the natural process of cord separation.
When introduced, products should be as mild as possible and free from alcohol, colour, perfume and petrochemicals.
Follow guidelines for mixed feeding and remember to wash anything that comes into contact with baby using non-biological products. [back to top]
Arfi C (2003) Aromababy [online], Available: www.aromababy.com [11.01.04].
Berg R W, Buckingham K W, Stewart R L. (1986) Etiologic Factors in Diaper Dermatitis: The Role of Urine. Pediatric Dermatology 3: 102-6.
Boots guide to pregnancy and early parenthood. Autumn and Winter 2003: 81 & 85.
Cetta F, Lambert G H, Ross S P. (1991) Newborn chemical exposure from over the counter skin-care products. Clinical Pediatrics. 30:289-9.
Cork M J, Timmins J, Holden C, Carr J et al. (2003a) An audit of adverse drug reactions to aqueous cream in children with atopic eczema. The Pharmaceutical Journal 271:746-7.
Cork M J, Britton J, Butler L, Young S et al (2003b) Comparison of parent knowledge, therapy utilisation and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. British Journal of Dermatology. 149: 582-9.
Evans N J, Rutter N. (1986) Development of the Epidermis in the Newborn. Biology of the Neonate, 49: 74-80.
Harpin V A, Rutter N. (1983) Barrier Properties of the Newborn Infants Skin. Journal of Pediatrics 102: 419-25.
Holbrook K A. (1982) A Histological Comparison of Infant and Adult Skin. In H I Maibach & E K Boisits (Eds): Neonatal Skin: Structure and Function. New York, Marcel Decker: 3-31.
Lack G, Fox D, Northstone K, Golding J, ALSPAC Study Team. (2003) Factors associated with the development of peanut allergy in childhood. New England Journal of Medicine. 348: 977-85.
Lund C, Kuller J, Lane A, Lott J W, Raines D A. (1999a) Neonatal Skincare: The Scientific Basis for Practice. J Obstet Gynnecol Neonatal Nurs. May/June, 28(3): 241-254.
Lund C H. (1999b) Prevention and Management of Infant Skin Breakdown. Wound Care Management, December, 34 (4): 907-920.
Lund C H, Kuller J, Lane A T, Lott J W, Raines D A, Thomas K. (2001a) Neonatal Skincare: evaluation of the AWHONN/NANN research based practice project on knowledge and skincare practices. Association of Women's Health, Obstetric and Neonatal Nurses/ National Association of Neonatal Nurses. J Obstet Gynnecol Neonatal Nurs. Jan/Feb, 30 (1): 30-40.
Lund C H, Osborne J W, Kuller J, Lane A T, Lott J W, Raines D A. (2001b) Neonatal Skincare: clinical outcomes of the AWHONN/NANN evidence based clinical practice guideline. Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs, Jan/Feb 30 (1): 41-51.
Nonato L B. (1998) Evolution of Skin Barrier Function in Neonates. Unpublished doctoral dissertation, University of California, Berkley. UMI Publication numberAAT9827176.
Northstone K, Golding J, ALSPAC Study Team. (2002) The prevalence of food allergy in children up to the age of seven in ALSPAC: a population cohort study. Food Allergy and Intolerance. 3: 104-14.
Nursing and Midwifery Council. (2002) Code of Professional Conduct for nurses, midwives and health visitors. NMC: London. P 3(1.2).
Peck S, Botwinick J. (1964) The Buffering Capacity of Infants Skin Against an Alkaline Soap and Neutral Detergent. Journal of Mt. Sinai Hospital 31: 134.
Trotter S. (2002) Skincare for the newborn: exploring the potential harm of manufactured products. RCM Midwives Journal, 5(11): 376-8.
Trotter S (2003). Management of the umbilical cord - a guide to best care. RCM Midwives Journal, 6(7): 308-11.
World Health Organization. (1999) Care of the Umbilical Cord: A Review of the Evidence (44 pages). Reproductive Health (technical support) Maternal and newborn Health/safe motherhood. Geneva, WHO (document WHO/RHT/MSM/98.4). [back to top]