Neonatal skincare: why change is vital
The full reference for this draft paper which was published in the April 2006 issue of the RCM Midwives Journal is: Trotter S (2006). Neonatal skincare: why change is vital. RCM Midwives Journal, 9(4): 134-8.
"Newborn skin is thinner, more permeable and less able to withstand the sensitising effects of modern detergents. It is also important to remember that anything placed on, in or around a baby has the capacity to harm" (Trotter 2004a).
The anatomical and functional differences of neonatal skin have been thoroughly reported over the years and there is now a body of evidence to back up the above statement (Fatter 1997, Gelmetti 2001, Lund 2001a & 2001b, Medves 2001, Ertel, 2003, Trotter 2002 & 2004a).
This paper sets out to confront the ignorance surrounding neonatal skincare, highlight the potential dangers of chemical ingredients used in personal care products and point the way towards a simpler skincare regime for babies using products that contain safer alternatives. In doing so newborn skin will be afforded a smoother transition from womb to world, whilst reducing the risks of conditions like eczema, asthma and related allergies developing in the future.
Neonatal skin environment
Regulation of personal care
Baby products and why change is vital…
Are there safe alternatives?
Previous work by the author has demonstrated a need for change within the practice of neonatal skincare (Trotter 2002 & 2004a). Maternity units around the UK are updating their policies in line with the author's proposed guidelines in an attempt to streamline advice to parents/professionals and avoid confusion.
Results of a recent audit following the introduction of evidence-based guidelines within NHS Ayrshire & Arran reported a reduction in the incidence of erythema neonatorum, alongside high satisfaction rates from both staff and parents (Trotter 2004b).
Manufacturers of baby skincare products have been less than enthusiastic regarding reformulation of products still containing (among others) the skin irritants Sodium Lauryl Sulphate (SLS) and Sodium Laureth Sulphate (SLES).
Fashions in healthcare not only influence how women birth their babies, but also how baby products are introduced from birth. Parents and professionals have assumed baby products are safe and even beneficial; however this may not be the case. Comments like "we used it on all our babies" and "they smell nice" are hard to challenge and it takes courage and conviction to question what has become the socially accepted norm. We are all influenced socially, psychologically, physically and culturally and to provoke change, we must be aware of these variables, whilst at the same time communicating new ideas. Only then can change be implemented and accepted as appropriate and relevant. Good communication is at the heart of this process.
Another factor is the move towards globalization where, due to the shrinking world, and as a result of technology, society has become de-centered. The cultural differences peculiar to each and every ethnic group have come full circle and in turn society has become a melting pot. As a result, the multinational organisations have combined to exert pressure on people around the globe to buy into a common set of ideals by the power of large scale branding and marketing. This can be seen at work within the context of baby products, especially infant formula and baby skincare manufactured items. Parents buy into an 'ideal' of family life, as portrayed through advertising that has somehow become synonymous with modern life. This process can be so subtle that parents and professionals alike are unaware of its effect. This leads to the acquisition of habits and practices that are hard to break, even though their origins lack credibility. [back to top]
Neonatal skin environment
The Epidermis, or outer layer of the skin, is divided into four layers; The Stratum Corneum (inert) and three living layers; Stratum Granulosum, Stratum Spinosum and Stratum Basale.
The Stratum Basale 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. The granules in the keratinocytes of the stratum granulosum are bags full of newly synthesized and stored lipids. These will be released before the cell dies and are processed enzymatically to form the lipid barrier. These lipids surround the lifeless keratin disc made of a keratinocyte after its death and called 'corneocyte'. These can be thought of as the bricks in a wall, with the mortar between made up of lipids or fat molecules. This whole structure forms the skin barrier and is situated in the Stratum Corneum, the most superficial layer of skin. The structure and function of this delicate layer is easily damaged, leading to a wide spectrum of inflammatory symptoms. The two main causes are the destruction of the skin's barrier (delipidization) within the Stratum Corneum and the stimulation of an inflammatory immune response which in turn compromises the skin's barrier (Kownatzki 2003).
At birth a baby's skin is protected by a delicate coating of lipid-rich Vernix Caseosa which is absorbed over the first few days of life. Meanwhile the skin becomes colonized with micro-organisms and develops its own stable microbiota (Tierno 2006). This transitional environment, from alkaline to acid (known as the Acid Mantle) further adds to the protective barrier and its delicate balance must be maintained if the skin is to achieve an optimum level of protection. There is no evidence to prove that the acid mantle exists beyond this point and acidic pH detergents do not have a protective effect (Kownatzki 2003).
"Epidermal lipids play a key role in maintaining the skin's barrier, integrity and health" (Ertel 2003). This is backed up by evidence of reduced levels of epidermal lipids seen in individuals suffering from atopic eczema (DiNardo et al 1996). As the epidermis continually sheds it is vital that the lipid seal around each skin cell (keratinocyte) is left undisturbed. This protective layer ensures that the skin does not dry out and this can only be achieved in the presence of certain enzymes and the right lipid precursors (Kownatzki 2003). This barrier cannot be reproduced by artificial means, so great care must be employed to avoid its destruction by delipidization as a result of chemicals used in manufactured personal care products.
Once damaged the epidermis is more prone to Trans Epidermal Water Loss (TEWL) which leads to dry skin. This in turn increases the likelihood of sensitization by foreign materials such as micro-organisms, allergens and the damaging effects of chemical irritants.
Interaction with keratinocyte surface molecules or membrane lipids lead to cell activation. Cytokines are released and these send signals requesting assistance to blood vessels and white blood cells. Activation of Langerhans Cells initiates an immune response which is particularly effective when a foreign substance is encountered repeatedly. Once a certain level of response has been exceeded inflammatory symptoms (e.g. skin irritation and eczema) become evident. [back to top]
Delipidization just means the selective removal of lipid (fat molecules) components from the Stratum Corneum. There have been many studies carried out on the damaging effects of surfactants (detergents) to the skin, subsequent changes to the skins pH, drying effects of hand cleaners and the associated swelling of Stratum Corneum (Rhein et al 1986, Ertel 2003 & Kownatzki 2003). All are agreed that whatever methods are employed to clean the skin, all affect the surface fat content thereby reducing the effectiveness of the skin barrier against the introduction of irritants, allergens and micro-organisms. Natural antibacterials are removed by washing, alongside the lipid and water-soluble substances. This could lead to increased bacterial growth that jeopardizes the original skin cleansing technique.
It is interesting to note that damage to the skin's lipid barrier caused by overhydration as a result of using latex gloves actually recovers quickly due to evaporation. This is in stark contrast to skin that has a damaged lipid barrier, caused by detergent use, which takes many days to recover. The kinetics of damage and its repair and epidemiological evidence suggest that modern synthetic detergents as used in foaming liquid cleansers are the major offender (Kownatzki 2003). If such disturbing findings have been reported on adult skin, the implications for neonatal skin are obvious. [back to top]
Regulation of personal care products
The latest study by the US Centers for Disease Control and Prevention (CDC 2005) tested for 148 (a fraction of the 80,000 commercially available chemicals) toxic substances in the blood of 2400 individuals. Dr Julie Gerberdling, Director of the CDC, said:
"This is the largest and most comprehensive report of its kind ever released anywhere by anyone!"
Potentially dangerous compounds were found in most test subjects with children absorbing more contaminants than adults.
This alarming set of results only serves to reaffirm the specific vulnerability of babies and children (and ultimately adults). Re-education of staff and parents must reflect these changes to our existing knowledge base. The National Institute for Heath and Clinical Excellence (NICE 2006) is presently entering the 2nd consultation process of The Postnatal Care Guideline, which includes updated advice on neonatal skincare and cordcare. In time, a new framework of evidence-based guidelines within neonatal skincare will become the grounded theory of tomorrow.
The American Food and Drug Administration (FDA) cannot require companies to do safety testing on their cosmetics or personal care products before marketing (FDA 1995). This means that 89% of all ingredients have not been evaluated for safety at all (FDA 2000, CIR 2003).
The toxicology of product ingredients is policed by the industry itself (Cosmetic Ingredient Review [CIR]). The Environmental Working Group's [EWG] (www.ewg.org ) six month investigation into the health and safety of more than 10,000 personal care product ingredients reinforced what they had believed for years to be of great concern. The results of these tests have developed into an online rating system with a score of 10 being the highest health concern. High profile baby brands of shampoo, lotion and baby bath products were alarmingly given a score of 7 which, considering they are positively marketed as 'safe for newborn skin', is worrying to say the least.
As the majority of baby skincare products originate from America it must be concluded that a vast number of untested ingredients make their way into products aimed at the baby/child sector of the market.
Ingredients listed on all personal care products can be confusing to the untrained eye. It is important that parents and professionals are informed about potentially harmful compounds. This is especially true for baby products and where there is no evidence to support the use of such products on neonates, advice to avoid all products for the first month of life is still the safest option.
The only exception to this is the use of a thin layer of barrier cream (preferably one that has been clinically proven to treat nappy rash, is breathable, perfume and preservative free) on the napkin area to help protect against the development of napkin rash (Atherton 2004). [back to top]
Baby products and why change is vital…
Due to the myriad of potentially toxic ingredients used in products today, it would seem sensible for manufacturers of baby products to remove any chemicals that have been shown to cause irritant/sensitising reactions. The object of washing newborn skin is to clean without removing the lipid barrier that is essential to the surface ecosystem (Gelmetti 2001). Studies have shown that using mild soap as opposed to water has minimal effects on skin bacterial colonization in the neonatal period, so plain water is sufficient. Bathing should also be avoided 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 (Trotter 2003).
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 not only worrying but avoidable. It should be considered that even short term effects, when repeated several times a day, can disturb the 'acid mantle' and its protective function, leading to dry and squamous skin in some infants (Fatter 1997).
This is why, once introduced, products should be:
- Used sparingly and harsh detergents avoided altogether (see list below).
- It is important to remember that the ratio of skin surface to body weight is highest at birth so the proportion of absorbed product will be greater than in an adult. There is also no need to bath a baby daily, two or three times a week is adequate.
- Products, however mild, should be used briefly so that potential damage to the skin surface is minimised.
- For this reason a baby should not be immersed for longer than five minutes.
- Exposure to hard water in the home may further increase the risk of eczema in children of pre-school age due to the need for more soap/shampoo to obtain a lather (McNally et al 1998) so extra care must be taken when choosing products.
- Some products have been tested using the Human Repeat Insult Patch Test (HRIPT) and due to the proximity of use to the eyes, many products are tested using the EpiOcular test. A score of 60-90 can claim to be non-irritant on packaging but this is only a guide.
- Statements like 'dermatologically tested', 'Ph balanced', 'natural ingredients' or even 'organic' (just 5% of ingredients originating from organic sources can allow the word 'organic' to be used) do not guarantee safety of ingredients.
- Many ingredients are meant only for discontinuous (short period) use. Problems arise when a combination of ingredients are used which have the capacity to exacerbate adverse reactions of individual compounds.
- Ingredients are listed by percentage of total volume. The nearer an ingredient is to the top of the list, the higher its concentration. [back to top]
With this in mind, the following ingredients should always be avoided:
- Sodium Lauryl Sulphate (SLS), also known as Sodium Dodecyl:
SLS is a very harsh industrial degreasant found in 98% personal care products (Day 2005). It is known to strip away the lipid barrier and erode the skin leaving it rough and pitted. It can stay in the tissues for days and is known to denature the proteins of eye tissues, impairing eye development permanently. It is also known to strip the skin of moisture, cause cracking and severe inflammation of the epidermis and separate and inflame skin layers. SLS is routinely used in clinical trials as a standard irritant for skin (Vance 1998). It is intended for 'discontinuous' use but when added to other chemicals, such as triclosan (which is now common with anti-bacterial preparations), it can stay next to the skin for many hours which is more likely to damage the skin's natural protective barrier. It is used because it is cheap and when added to salt it thickens making it appear more concentrated.
- Sodium Laureth Sulphate (SLES) and Ammonium Laureth Sulphate (ALES):
When SLS is ethoxylated (a chemical process that increases molecular size which is thought to produce a milder formulation, with potentially less risk of skin irritation) to enhance its foaming properties, it becomes SLES.
This is commonly used as a foaming agent in toothpastes, bath gels, bubble baths and degreasants which dissolve proteins and can lead to mouth ulcers. SLES and ALES stay in the tissues for up to five days and can form nitrates and nitrosamines (carcinogens) which go on to make the body absorb nitrates at higher levels. This means that the body is more likely to develop cancers. During the ethoxylation process the extremely harmful compound 1, 4-dioxane is created. This is one of the principal components of the chemical defoliant Agent Orange.
Leading toxicologist Dr. Samuel Epstein reports:
"The best way to protect yourself is to recognise ingredients most likely to be contaminated with 1, 4-dioxane. These include ingredients with the pre-fix word or syllable PEG, Polyethelene, Polyethelene Glycol, Polyoxylene, eth (as in sodium laureth sulphate), or oxynol (Steinman & Epstein 1995).
- Propylene Glycol (PG) and Polyethylene Glycol (PEG):
This is really industrial antifreeze and the major ingredient in brake fluid. It dissolves oil and grease and is widely used in deodorants and toothpastes (as a thickener).
Ethanol (Ethyl Alcohol):
Used in mouth washes and known to cause oral cancers in 36000 people in the US per year (Bonner 2004).
Registered with the Environmental Protection Agency as a pesticide and suspected to cause cancer in humans. It is used in antibacterial products to kill germs (eg. the microban range). Also used in toothpastes to provide 'continued protection' for 12-24 hours!
- Alcohol, Isopropyl (SD40):
Found in toothpastes. This is very dehydrating and can act as a carrier for harmful chemicals to cross into the oral cavity.
- Methylisothiazoline (MIT):
Found in many top brand shampoos. Linked to Alzheimers (Adams 2005) birth defects and neurological disorders and totally unregulated by the FDA because they are not prescription drugs.
Parabens (Methylparaben, Propylparaben, Ethylparaben and Butylparaben):
Synthetic preservatives used in cosmetics and personal care products, especially baby wipes, baby lotions and shampoo. Also used as food preservatives.
Have been found to act like the hormone oestrogen in lab experiments, although activity was weak. May cause dermatitis, rash or allergic skin conditions. Used in underarm deodorants which have been linked to breast cancer. [back to top]
Are there safe alternatives?
By shopping around and reading the labels before buying, it is possible to find safe alternatives to the above chemical ingredients.
Business revolves around the ethos of supply and demand. If parents and professionals demand safer products the market place is bound to deliver.
New products from Aromababy, Green Baby, Halos N Horns, Neways, Organic Babies/Children and SOS Barefoot Doctor are already filling the niche that has been created in recent years. These products are not only safe for use on babies (over one month of age) and children, but are also safer for the environment. [back to top]
The widespread use of potentially damaging/carcinogenic chemicals used within personal care products aimed at babies and children cannot be allowed to continue.
"It is the responsibility of midwives to deliver care based on current evidence, best practice and where applicable, validated research where it is available" (NMC 2002, p 3:1.2).
Midwives therefore have a 'duty of care' to advise parents of the potential dangers associated with the early overuse of manufactured baby products and inform them of the safe alternatives that are already available.
Manufacturers must play their part by re-evaluating formulations in light of the growing evidence against the use of synthetic detergents. These chemicals are likely to be a contributory factor in the huge rise in skin related conditions observed over the past 30 years. The widespread use of baby products is co-incident with this statistic.
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Maintenance of the skins natural protective barrier is paramount.
- Wash your hands before and after carrying out any baby care
- Use water only for baby skincare for at least the first month of life
- Once introduced, read the labels of all products and avoid the chemicals mentioned in this article
- Demand new products that have been reformulated to be as safe as possible
- Breastfeeding your baby will strengthen their immune system
- Do not overload your washing machine. This will help to avoid a build up of chemical residues on clothing from washing powders.
- Cloth nappies are as efficient as disposables and do not present a higher risk of napkin rash. They are also kinder to the environment.
- Use a thin layer of barrier cream on the napkin area to help protect against the development of napkin rash.
- Massage oils should be vegetable (not nut) based and free from mineral oils, perfume and colours.
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