Sharon Trotter RM BSc

Skincare revisited – a festive dilemma for parents?

The full reference for this draft article is:
Trotter S (2011). Skincare revisited - a festive dilemma for parents. Essentially MIDIRS, December 2011, 2(11):47-49.

Click on the links below to read sections of the article:

• Introduction
• A quick overview
• What's new
• Responding to research
• Professional consensus
• Footnote
• References

Introduction

The run-up to the festive season generally involves a good deal of shopping, as we fill our trolleys with food, treats and gifts. Shops load their shelves accordingly, with shiny gift-wrapped bundles suitable for every member of the family, and those who are buying for babies are faced with a whole range of possibilities, including beautifully presented, colour co-ordinated packages of toiletries for the youngest family member’s stocking. But are these colourful and fragranced delights -perhaps like the sugary confections that we might place on the coffee table throughout December - a harmless seasonal indulgence, or is it important to promote the importance of natural no-frills skincare and encourage parents to avoid these treats year-round? This article offers an update on issues concerning baby skin care.

My work on neonatal skincare has been ongoing since 1996. This led me to set-up the TIPS Award Scheme in 2007 (TIPS® Ltd) which comprises in-depth market research on carefully selected babycare products. The principle at the heart of this programme is that all companies involved must adhere to current skincare guidelines (NICE 2006, DOH 2010): namely to advocate the use of plain water for at least the first month of life. Through setting up and arranging these trials my knowledge base has grown and the qualitative test data I have collated from parents and healthcare professionals are extensive. This means that, if I am asked whether it is still sensible to advocate not using any baby skincare products (apart from nappy balms) for at least the first month of life, the short answer is an emphatic YES! .

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A quick overview

The neonatal skin barrier is thinner, more permeable and less able to withstand the potentially irritating and drying effects of environmental allergens and baby skincare products (Stamatas et al 2010 ). The structure and function of this delicate layer is easily damaged leading to a wide spectrum of inflammatory symptoms caused mainly by the destruction of the skin’s barrier (delipidization) within the stratum corneum by the overuse of detergent based products (sulphates) and the stimulation of an inflammatory immune response which in turn compromises the skin’s barrier (Kownatzki 2003).

The use of plain water avoids these effects and I have advocated this over a number of years. Encouragingly, the use of water appears to have received increasing support as an initial telephone survey of twelve maternity units in 2002, showed that only 8% of units advised parents to use plain water. This increased to 66% in 2004 and from an online survey of parents in 2009, 70 per cent of the 183 respondents had been advised to use water-only by their HCPs. I have published various articles on neonatal skincare (Trotter 2008, 2010a) contributing to the first guidelines on neonatal skincare in Ayrshire, Scotland (Trotter 2004). The recent publication of the 8th edition of the award winning ‘Babycare – back to basics’ leaflet remains consistent with my original hypothesis that anything placed on in or around the neonate has the capacity to harm (Trotter 2011)

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What’s new?

It is vital for parents to get consistent advice about baby skincare and related issues, and this includes the use of oil. Recent debate questions why health care professionals now seem to be recommending olive oil (Cooke et al 2011). Olive oil is high in oleic acid which ironically can have the same effect on the skin as detergents. It can strip away the delicate barrier that is there to protect the baby’s skin from damage. Oil that is lower in oleic oil, for example sunflower oil, is preferable and there is evidence to support its use on premature babies, as the oil appears to give some antibacterial protection (Darmstadt et al 2004).

Certain oils may still be useful for specific purposes. However I would not recommend the use of any oil (olive or otherwise) or indeed any skincare product on the skin of a healthy term infant for at least the first month of life until the natural barrier has had a chance to develop its own protective mechanisms. If the oil is for use in massage you can get excellent advice about this on the International Association of Infant Massage website, which is accessible at www.iaim.org What I would like to clarify is the definition of the term ‘acid mantle’, especially its overuse (sometimes inaccurately) within marketing literature of baby skincare products.

Babies are born with an alkaline skin surface, with an average pH of 6.34. However, within days, the pH falls to about 4.95 (acidic) forming what is known as the ‘acid mantle’, a very fine film that rests on the surface of the skin acting as a protective barrier. Its delicate balance must be maintained if the skin is to achieve an optimum level of protection. There is no evidence however to prove the acid mantle exists beyond the first few days, so acidic pH detergents are not thought to provide any protection (Kownatzki 2003). In short; baby products (or any other product ranges) cannot “become” or “replace” the acid mantle because it is the body that produces and maintains it.

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Responding to research

It is inevitable that researchers – and companies – will continue to look at questions relating to this area, and that we will see the continued publication of research looking into the use of a variety of substances in different settings and for assorted indications. Last year, I reviewed a research study in MIDIRS Midwifery Digest (Trotter 2010a). The researchers (Cutland et al 2009) had studied more than 8000 subjects in their bid to ascertain whether simple washing of both mother and baby with 0.5% chlorhexidine solution had the potential to reduce vertical transmission and/or delay early onset of neonatal sepsis in the first three days of life. I noted that:
“This paper has done nothing to change my view that a simple water-only regime of bathing for mother and neonate continues to be the safest advice. The introduction of antibacterial applications, which may seem innocuous on their own, have the potential to disrupt normal colonisation notwithstanding their potential to irritate sensitive skin. With this in mind, it is sensible to keep exposure to an absolute minimum.“ (Trotter 2010).

While it is always vital to keep an open mind, the body of evidence suggesting that ‘water is best’ is now so vast that we are unlikely to see a massive change in this conclusion. Research studies continue to be published and conference papers presented but they clearly show no benefit (and often show potential harm) in using products on newborn baby skin. Or, where they do appear to show that such products may have equal value to water, clear and concerning questions often exist around the possible entry of bias, either in the methods used and/or in relation to the source of funding.

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Professional consensus

One of the most interesting aspects of this area, as mentioned above, is that there is clear evidence that health care professionals are taking the message on board and offering appropriate and evidence-based advice to new parents. This is particularly heartening given the fact that, in many other areas of maternity care, advice often varies widely between individual professionals and geographical areas. Perhaps we can take heart from the fact that, no matter how shiny and appealing the packaging gets, we are doing our best to get the message out to parents that they really are doing the best thing for their newborn baby by avoiding the temptation to literally shower them with costly ‘bathtime goodies’ and instead focus on cleansing them with pure water and ensuring that they feel loved.

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Footnote

After 15 years campaigning Sharon has recently made a significant breakthrough regarding the inappropriate advertising of baby products to the newborn market. You can find out more here... The full reference for this article is Trotter S (2011). A response to advertising in baby skincare adverts (Views on the news...). Essentially MIDIRS, December 2011, 2(11):25

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References:

Cooke A, Cork M, Danby S et al (2011). Use of oil for baby skincare: a survey of UK maternity and neonatal units. British Journal of Midwifery, Vol 19 (6): 354-62.

Cutland CL, Madhi S A, Zell E R et al (2009). Chlorhexidine maternal-vaginal and neonate body wipes in sepsis and vertical transmission of pathogenic bacteria in South Africa: a randomised, controlled trial. The Lancet, Volume 374, Issue 9705, Pages 1909 – 1916.

Darmstadt GL, Badrawi N, Law PA, Ahmed S, et al (2004). Topically applied sunflower seed oil prevents invasive bacterial infections in preterm infant in Egypt: a randomized, controlled clinical trial. The pediatric Infectious Disease Journal 23(8):719-725

DoH (2010) - NHS Choices: Your baby after the birth – your baby’s skin. Accessed on 19/06/11 at: http://www.nhs.uk/planners/pregnancycareplanner/pages/babysfirstdays.aspx

Kownatzki E (2003) Hand hygiene and skin health. Journal of Hospital Infection 55: 239-45

National Institute for Clinical Excellence (2006). Routine postnatal care of women and their babies. Quick reference guide. London: NICE.

Stamatas GN, Nikolovski J, Luedtke MA et al (2010). Infant skin microstructure assessed in vivo differs from adult skin in organisation and at a cellular level. Pediatric Dermatology 27(2):125-31.

TIPS Ltd (March 2007). TIPS Award Programme, Scotland, UK. Visit: www.tipslimited.com

TIPS Ltd (August 2011) Baby care – back to basics™ leaflet (V8). TIPS Limited Scotland

Trotter S (2004). Audit following the introduction of evidence-based guidelines for skincare & cord care. August 2004 – NHS Ayrshire & Arran – unpublished report.

Trotter S (2008). Neonatal skincare and cordcare – implications for practice. In: Examination of the newborn and neonatal health – a multidimentional approach. Churchill Livingstone, Elsevier Worldwide, Chapter14.

Trotter S (2010). Midirs reviewer's comments. MIDIRS Midwifery Digest 20(2):263-5.

Trotter S (2010a). Neonatal skincare. In: Care of the Newborn by Ten Teachers. Hodder Education, Health Sciences, Chapter 7.

For more information go to: www.tipslimited.com and www.sharontrotter.org.uk

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Sharon Trotter©2011