Sharon Trotter RM BSc

Why no baby skincare product should be advertised or promoted as ‘suitable for newborn skin’

The full reference for this draft article is: Trotter S (2013). Why no baby skincare product should be advertised or promoted as ‘suitable for newborn skin’. Midirs Midwifery Digest 23(2): p217-221.

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

• Abstract
• Introduction and personal perspective
• Why is it vital to follow a water-only approach to baby skincare?
• What about recent research?
• What might happen if baby skincare products are overused in the early days?
• Best practice for neonatal skincare
• Inappropriate advertising of baby skincare products
• The way forward...
• Reference

Abstract

Recently published articles question the value of a water-only approach to neonatal skincare, but the evidence they provide is unconvincing.
This paper aims to update those who may be new to this subject, and reinforce the importance of the ‘less is more’ approach to neonatal skincare. It will explain why neonatal skin is delicate and more at risk of damage. It will also highlight the insidious and inappropriate marketing of baby skincare products, focusing on the use of ‘suitable for newborns’ terminology, in this hugely competitive (and lucrative) industry. Credible and evidence-based guidelines for neonatal skincare already provide professionals with the tools they need to drastically reduce the steady rise in infant skin conditions which appears to be co-incident with the introduction of manufactured baby products over 50 years ago (Cork 2002). However, with UK rates of childhood eczema among the highest in the world we need to go even further. We must insist that manufacturers of baby skincare products and the baby press liaise with non-aligned healthcare professionals to ensure that parents get accurate and consistent advice based on the national skincare guidelines.

Keywords: neonatal, eczema, baby skincare products, water-only, skin barrier, vernix caseosa, oleic acid.
Disclosure: the author has no conflict of interest to declare

Correspondence: TIPS Ltd P O Box 8583, 12 Church Street, Troon, Scotland, KA10 7WT; email: sharontrotter@tipslimited.com

Introduction and personal perspective

I feel it is important for me to start by explaining how I first became interested in neonatal skincare.
In 1996 I read an article in the RCM Midwives Journal about the use of baby skincare products. Although this was a short viewpoint article, it stayed with me. At that time, my two older children were 9 and 7 years old, and although they had been exclusively breastfed they suffered from skin complaints (see Photograph 1). Baby products had been used with both children from birth. At the time I was working as a midwife at my local NHS maternity unit where there was no formal policy on neonatal skincare. So I was prompted to stop using baby skincare products on newborns in my care to see if it was possible to achieve the same level of cleanliness and I was encouraged to discover that it was. I found that plain water was equally successful at cleaning babies and I felt better for not exposing them to unknown ingredients when there seemed no valid reason to use anything but plain water.

I encouraged my peers to use only plain water too, but this was met with a wall of indifference and comments such as: ‘but it smells nice!’ Soon after this I became pregnant again and decided to avoid all baby skincare products for at least the first few weeks of my baby's life (see photograph 2). The absence of any skin condition was marked. I knew I would have to build on these findings if I was to change attitudes and ultimately alter policy, not only in my local unit but in maternity units around the UK. This was just the beginning...
Neonatal skincare has been my passion for over 15 years. During this time I have published many articles on the subject, including chapters in academic textbooks which have lead to a change in practice in UK maternity units. The award-winning leaflet Babycare – back to basics ™ forms the basis of the first UK policy on neonatal skincare . I am often asked to comment on new research or media stories which question the value of current guidelines to use only plain water for the neonatal period. I am yet to come across any significant studies, past or present that may lead me to question my original hypothesis regarding neonatal skincare: anything placed on, in or around the neonate has the capacity to harm.

Recently published articles question the value of a water-only approach to neonatal skincare, but the evidence they provide is unconvincing.

This paper aims to update those who may be new to this subject, and reinforce the importance of the ‘less is more’ approach to neonatal skincare. It will explain why neonatal skin is more delicate and more at risk of damage. It will also highlight the insidious and wholly inappropriate marketing of baby skincare products, focusing on the use of ‘suitable for newborns’ terminology, in this hugely competitive (and lucrative) industry. Credible and evidence-based guidelines for neonatal skincare already provide professionals with the tools they need to drastically reduce the steady rise in infant skin conditions which appears to be co-incident with the introduction of manufactured baby products over 50 years ago. However, with UK rates of childhood eczema among the highest in the world we need to go even further. We must insist that manufacturers of baby skincare products and the baby press liaise with non-aligned healthcare professionals to ensure that parents get accurate and consistent advice based on the national skincare guidelines.

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Why is it vital to follow a water-only approach to baby skincare?

The neonatal skin barrier is thinner, more permeable than that of the older baby so less able to withstand the potentially irritating and drying effects of environmental allergens and baby skincare products . 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.

It is important to clarify 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 . 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.
Vernix Caseosa (VC) is a highly sophisticated bio-film consisting of antimicrobial peptides/proteins and fatty acids. These combine to form a protective barrier that is not only antibacterial but also antifungal. An article about VC states: ‘studies confirm that maintaining an intact epidermal barrier by minimizing exposure to soap and by not removing VC are simple measures to improve skin barrier function’.

All the evidence we have suggests that this is nature’s best protector and leaving it to naturally absorb should be standard practice. Detergents have the potential to remove this delicate barrier which is another reason why the use of plain water is preferable to baby products in the first few weeks of life.

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What about recent research?

Last year, I was asked to review a research study in MIDIRS Midwifery Digest . The researchers 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.“

While it is always vital to keep an open mind, the body of evidence suggesting that ‘water is best’ is now so vast that it is unlikely to be challenged successfully. Research studies in the western world continue to be published and conference papers presented but they demonstrate that there is no benefit (and often potential harm instead) in using products on newborn baby skin. The integrity of studies that do appear to show that such products may be as safe as water is often questionable, either in terms of methods used and/or source of funding.

There has recently been some debate as to why health care professionals seem to be recommending the use of olive oil in baby care and for massage . Olive oil is high in oleic acid. Ironically this 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 safer and while there is evidence to support its use on premature babies, as sunflower oil appears to give some antibacterial protection it is important to highlight the possible dangers associate with a blanket use of inappropriate oils.

While certain oils may still be useful for specific purposes, I would not recommend the use of any oil or indeed any skincare product on the skin of a healthy term infant. This approach should be followed for at least the first month of life (preferably much longer) until the natural barrier has had a chance to develop its own protective mechanisms. This is not to say that infant massage should be avoided. The benefits of skin-to-skin contact cannot be overstated and should be strongly encouraged from birth. As well as promoting successful breastfeeding, skin-to-skin contact stabilises a baby’s heart rate and temperature. Baby massage follows on naturally and many parents enjoy doing this. It is important for parents to be given accurate consistent to avoid using petroleum based oils and oils with perfumes. If there is a history of nut allergies in the family they should also avoid nut-based oils. If possible, ask a qualified baby massage therapist for their advice - The International Association of Infant Massage website (www.iaim.net) provides information on what oils can be used for infant massage.

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What might happen if baby skincare products are overused in the early days?

Due to the myriad of ingredients that have been shown to cause irritant/sensitising reactions, it would seem sensible for manufacturers to remove any potentially toxic chemicals from their baby skincare products. The object of washing newborn skin is to clean without removing the lipid barrier that is essential to the surface ecosystem . Studies have shown that using mild soap has minimal effects on skin bacterial colonization in the neonatal period, so plain water is more than sufficient. Avoid bathing until the separation of the umbilical cord is complete so as not to disrupt the flora at the base of the cord and potentially hinder the natural process of cord separation.

All cleansing agents, even tap water, influence the skin’s fat content to some degree. However, the dissolution of fat molecules in the upper epidermis by synthetic detergents is worrying and also avoidable. It should be considered that even short term effects, when repeated several times a day, can disrupt the natural barrier and lessen its protective function. This leads to dry and squamous skin in some infants.

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Best practice for neonatal skincare

If a parent wishes to start using products then they should be advised that, once introduced, products should be used sparingly and harsh detergents avoided altogether. With this in mind best practice for neonatal skincare should include the following:

• water-only babycare should be advocated for at least the first month of life (see photograph 3)
  there is no need to bath a baby daily, two or three times a week is adequate
• wash cloths should not be used as they can be harsh - washing baby using your hand, cotton wool (organic is better) or a natural sponge is gentler
• it is best to leave the delicate area around the eyes untouched - staff can advise on how to clean this if it does become sticky
• ears and nose should also be left alone and cotton buds should be avoided
• VC should always be left to absorb naturally
• bath with plain water for at least the first month. If desired by the parent baby products may be gradually introduced in small amounts. They should be free from sulphates (SLS and SLES), parabens, phthalates, artificial colours and perfumes
• baby wipes should not be used for the first month - after this, it is best to use wipes that are free from alcohol, parabens, phthalates, artificial colours and perfumes
• shampoo is not needed until is a year old - after this, any shampoo used should be sulphate free (SLS and SLES)
• a thin layer of barrier cream may be used on the nappy area - ideally, the preparation should be free from preservatives, colours, perfumes and antiseptics. You should always wash your hands carefully before using a nappy balm. This will help reduce the risk of bacteria passing from your fingers to the product and ensure that the nappy balm is effective for longer.
• parents who decide to use baby skincare products after a few weeks should be advised to read the labels carefully. Products that contain ingredients a baby is sensitive to must not be used.
• a product should be tested on a small area of skin when used for the first time - even if it claims to be natural or organic. This is to make sure baby does not suffer an adverse reaction.

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Inappropriate advertising of baby skincare products

The manufacturers of baby skincare products, and the baby press who help to promote these products, have a responsibility to provide parents with truthful information, both in editorials or adverts. Information and claims used in marketing and PR should be verified by a non-aligned and respected expert in their field and be in line with current Department of Health (DoH) or National Institute for Health and Clinical Excellence (NICE) guidelines.
An advert for a newly launched baby wipe appears on the back cover of a UK Bounty booklet. Bounty provides excellent online resources which includes accurate advice on baby skincare. How then can a full page advert promoting a baby wipe as ‘suitable for newborns’ be deemed appropriate for insertion in this publication. This contradictory behaviour can only add to parents' confusion.

Many ranges of 'natural' and 'organic' baby skincare products provide parents with a lot of choice but, it is the author’s opinion that no baby skincare product is ‘suitable for newborn skin’. In order to have an extended shelf life, every product needs to contain a preservative of some kind. This means that all products have the potential to irritate newborn skin and present a risk which is not worth taking. Even if parents are careful to avoid using baby skincare products it is not uncommon for newborns to suffer from mild skin problems. Milk spots, dry patches, or redness can take up to 12 weeks to clear but do not need treatment, only patience.

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The way forward...

Following an official complaint to the UK Advertising Standards Authority about the advert for a baby wipe (aimed at newborns) published in the Bounty catalogue and an email to Bounty (UK) Ltd; I am thrilled to report that Bounty has decided to refuse future adverts for baby wipes if they are aimed at the newborn market. This is enormously encouraging and a significant breakthrough. I hope this will apply to all baby skincare products and that other publications will follow Bounty’s lead. Parents deserve and should expect to receive consistent advice from healthcare professionals, which in turn can help guide them through the minefield of potentially misleading marketing and advertising materials. New parents are easily persuaded and vulnerable consumers. If we ensure the above the prevalence of baby skincare conditions may well decline.

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References:

Lavender T, Bedwell C, O’Brien E et al (2011). Infant skin-cleansing product versus water: A pilot randomized, assessor-blinded controlled trial. BMC Pediatrics, 11:35. E-version accessible at: http://www.biomedcentral.com/1471-2431/11/35

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.

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

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

Cork MJ, Murphy R, Carr J et al (2002). The rising prevalence of atopic eczema and environmental trauma to the skin. Dermatology in Practice 10(3):22-6.

Williams H, Stewart A, Von Mutius E et al (2008). Is eczema really on the increase worldwide? -International Study of Asthma and Allergies in Childhood (ISAAC) Phase One and Three Study Groups. DOI: 10.1016/j.jaci.2007.11.004. Journal of Allergy and Clinical Immunology April 2008, 121 Issue 4, p947-954.

Brennan, G. (1996) Opinion: Care of the Newborn Baby’s Skin, Midwives 109 (1303): 240.

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 (2010a). Neonatal skincare. In: Care of the Newborn by Ten Teachers. Hodder Education, Health Sciences, Chapter 7. ISBN: 9780340968413

TIPS Ltd (August 2013) Baby care – back to basics™ leaflet (v9). TIPS Limited, Scotland

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

Trotter S (2004b) Care of the Newborn: Proposed new guidelines. British Journal of Midwifery 12 (3): 152-7

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.

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

Tollin M, Bergsson G, Kai-Larsen Y et al (2005). Vernix caseosa as a multi-component defence system based on polypeptides, lipids and their interactions. Cell Mol Life Sci, 62 (19-20): 2390-99.

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

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

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

Trotter S (2003). Management of the umbilical cord - a guide to best care. RCM Midwives Journal 6(7): 308-11.

Fatter G, Hackl P & Braun F (1997). Effects of soap and detergents on skin surface pH, Stratum Corneum Hydration and fat contents in infants. Dermatology, 195:258-62.

Trotter S (2011). Views on the news: A response to advertising used in baby skincare adverts. Essentially Midirs, December 2011, 2(11): 25k

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Sharon Trotter©2013