Update on Newborn Bathing

Joanne McManus Kuller, RN, MS

Disclosures

NAINR. 2014;14(4):166-170. 

In This Article

Selecting a Cleanser

There has been a lot of information on the internet and in lay publications about possible health threats from ingredients in skin care products. As health care providers, we should be able to address the questions and concerns of parents. Clinicians should read product labels to enhance their awareness of product formulations and to help parents make better decisions about ingredients. Communicate with families to identify risks for barrier dysfunction in their family history (i.e., atopic dermatitis.) Be aware that parents may have culturally based needs and desires for skin care products for their newborn. Recommend that the number of products applied on infants should be limited to those that are necessary. Limiting the use of products will reduce the risk of contact sensitization. Advise families to select products that have been safety-tested on newborns.

There are currently a range of recommendations on whether the first bath should be water only or should include a cleanser. The Neonatal Skin Care Evidence-Based Clinical Practice Guideline,[8] developed by the Association of women's Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN) recommends using warm tap water or a mild, neutral pH cleanser, if desired, to assist with the removal of amniotic fluid and blood. The WHO recommends that warm water be used for bathing; there is no mention of the use of cleansers. NICE with the Collaborating Centre for Primary Care in the United Kingdom[41] advises against adding cleansing agents or lotions to the bath water, but that a mild, non-perfumed soap can be used.

Washing the skin with water alone may not be adequate for cleansing because some of the substances that need to be removed from the surface of the skin are not water soluble, but fat-soluble. Only about 65% of oil and dirt on the skin can be removed with water.[37,42] Cleansers emulsify dirt and organisms on the skin so they can be easily washed away. A mild baby wash is more effective than water at removing feces and urine residue from the skin surface.[26] Alkaline soaps made with lye (pH >7.0) increase skin pH interfering with development and function of the acid mantle and are generally more irritating to the skin. On the other hand, mild liquid cleansers protect or aid in acidification of the stratum corneum since they are formulated to be mildly acidic (pH 5.5–7.0).[5,43] The mildness is determined by the type of surfactant used and the pH of the product. In older infants, children and adults, cleansing agents including alkaline soaps and water alone may affect skin pH, fat content and surface hydration. Osmolarity, pH, hardness and chemical content of water are also potential irritants since water alone is incapable of any pH buffering action.[44]

A limited number of studies have looked at the question of how skin barrier function is affected by bathing with water alone or with a mild cleanser. Bathing with water and a cleanser versus water alone has been shown to have no effect on colonization with normal flora.[45] Improved skin hygiene and reduced skin irritation resulted when a mild cleanser was used rather than water alone for bathing 180 healthy infants in one randomized controlled trial.[46] In a study of over 300 infants during the first month of life, Lavender et al.[47] reported that using a mild baby wash made no difference in the pH or the TEWL of the skin. She did find that SCH hydration was higher, and dryness less visible with the baby wash product at the end of the month.

Some of the criteria that should be used to assess baby care products are: pH, ocular safety, irritancy, preservative use, packaging, cost, fragrance and ingredient assessment. Ideally, a cleanser should not cause skin irritation, disrupt the normal pH of the skin or cause stinging or irritation of the eyes. The product should be mildly acidic (pH 5.5–7.0) or have been shown to have minimal impact on the developing acid mantle. Irritancy should have been assessed using methods for measuring skin barrier disruption; erythema, pH and TEWL. Ocular safety is important since an infant's blink reflex at birth is present but is much slower than in adults. Defensive blinking, which is necessary to protect against eye injury is not a fully reliable response until about 4 months of age.[48]

There are limited data available about many natural and organic products, and definitions of these categories products also may vary. Realize that "natural" does not necessarily mean better and that everything is a chemical. An orange peel contains about 24 different chemicals — including several known as allergens. Although many herbal therapy products may be safe for adult use, caution is recommended for use in newborns since some these products have not been tested on neonates.[49] Allergic contact dermatitis, or eczema, is the most common skin condition resulting from the use of herbal therapies. Some of the herbs known for causing this reaction include aloe, arnica, bromelain, calendula, chamomile, goldenseal, tea tree oil and yarrow.[50]

Personal care products with high water content are highly susceptible to bacterial and fungal contamination and therefore, should have preservatives in them. The absence of preservatives has been associated with contaminated products, allergic reactions, inflammation and skin infections. Products stored in jars where the hand is repeatedly dipped in to retrieve the contents are the most susceptible to this type of contamination. Organisms thrive and grow in the dark moist environments of skin care products if nothing is present to inhibit this growth.[51] Finally, preservatives that have demonstrated tolerability and safety in newborns should be chosen. Product ingredients, individually and as a whole, should be assessed for appropriateness, irritancy or allergenic response. Oleic acid, a key ingredient in olive oil based soaps (castile) has documented skin irritancy potential and increases TEWL.[52]

Fragrances are added to many products for customer appeal. According to the U.S. Food and Drug Administration, any ingredient added solely to impart scent should be listed as "fragrance or "parfum" on the product label.[27] Products may be listed as "fragrance free" if the scent-imparting ingredient is added for another purpose such as a preservative. "Unscented" means that a product has been formulated to have no scent. Unscented products may still contain a fragrance if it is added to mask the odor of the product.[53] Natural fragrances are not always considered to be safer than synthetic fragrances because some ingredients such as natural essential oils may be allergens or irritants.[54] Topical oils and their effect on skin barrier recovery were studied on hairless mice. Sunflower seed oil accelerated skin barrier recovery while mustard oil, olive oil and soybean oil delayed skin barrier recovery. A study involving premature and full term newborns compared the use of cloth and water versus and acidic pH diaper wipe to cleanse the perineum and buttocks during diaper changes. The results showed an improved pH, lower TEWL, an less erythema with the diaper wipe.[55]

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