Having read this chapter, the reader should be able to:
The midwife has a pivotal role in educating and advising new parents on the care of their baby while helping them adjust to their new roles. Sadly though, Wray (2006) found that two-thirds of women (50% were primiparous women) were not shown how to change their baby’s nappy or undertake a ‘top and tail’ and 34% were not shown how to bathe their baby. While this may not be a requirement for all women, primiparous women may not be confident with caring for babies and this might add to their anxieties and insecurities of becoming a new mother. This chapter focuses on the hygiene needs of the baby: bathing and washing, cleaning the genital area, the cord stump and the eyes. Oral hygiene can be important for an unwell baby but it is rarely needed for the healthy baby and is not discussed.
Afsar (2009a) advises that epidermal development of the skin is complete by 34 weeks’ gestation but some authors are now suggesting this process continues for the first year of life (Blume-Peytavi et al 2009, Garcia-Bartels et al 2010, Lavender et al 2012). The stratum corneum is the outer layer of the epidermis, the barrier layer and is composed of keratinocytes embedded in a lipid- (ceramides) rich matrix of cholesterol, ceramides, and fatty acids (Blackburn 2013, Sarkar et al 2010). The stratum corneum of the newborn term baby is thinner and less hydrated than that of an adult, which makes the baby vulnerable to microorganisms and infection, contaminants that can lead to trauma and increased fluid loss (Furber et al 2012, Lavender et al 2012), these risks are greatly increased for the preterm baby (Blackburn 2013).
The skin of the newborn baby is more permeable to topical substances and microorganisms than an adult’s skin, with permeability decreasing with increasing gestational age (Blackburn 2013). This can predispose the baby to the development of allergic and irritant reactions occurring from contact with chemicals; the risk escalates with damaged skin (Atherton 2005, Blackburn 2013, Hale 2007, Trotter 2006). The stratum corneum contains natural moisturizing factors (NMFs) which act as lubricants and humectants to assist the skin retain moisture (Blackburn 2013). Blackburn (2013) and Visscher et al (2011) advise that skin hydration is reduced immediately after birth and increases as the stratum corneum adjusts to extrauterine life.
Trans-epidermal water loss (TEWL) is higher in the term baby than the adult – 25 g/m/hr in the baby compared to 7 g/m/hr in the adult (Lavender et al 2012) and even higher in the preterm baby. Afsar (2009a) suggests the TEWL in a baby at 25 weeks’ gestation is 15-fold higher than a baby of 40 weeks’ gestation, which he advises results in significant morbidity due to dehydration, electrolyte imbalance and thermal instability.
Immediately after delivery, the skin pH of the newborn baby increases from the fetal pH of 5.5–6.0 and gradually decreases to 5.0–5.5 during the first week, reaching adult values around 3–4 weeks (Blackburn 2013). Garcia-Bartels et al (2010) and Blume-Peytavi et al (2012) suggest the skin pH at birth is close to neutral at 6.2–7.5. A high skin pH is associated with increased bacterial proliferation and increased proteolytic enzymes which Blume-Peytavi et al (2012) suggest are detrimental to good skin barrier function whereas Afsar (2009a) advises that a pH of 5.0–5.5 encourages commensal colonization and discourages the growth of pathological microorganisms. The ‘acid mantle’ which helps to protect the skin is created from the stratum corneum, sweat, sebum, superficial fat, metabolic by-products of keratinization and external substances such as amniotic fluid (Blackburn 2013). Trotter (2013) refers to it as a ‘very fine film’ resting on the skin surface; as such, this barrier is easily disturbed. Blume-Peytavi et al (2012) suggest that each time the skin is washed the outer layer is removed and it takes 120 minutes for the skin to recover.
Vernix caseosa is a white biofilm that covers the baby in utero to provide insulation, acts as an emollient, and minimizes friction at delivery (Blackburn 2013). It is composed of water, sebaceous secretions, and desquamated skin cells; is rich in triglycerides, fatty acids, ceramides, cholesterol and unsaponified fat; and has microbial properties (Blackburn 2013, Ness et al 2013, Sarkar et al 2010, Trotter 2013). Afsar (2009b) and Ness et al (2013) consider it has an important hydration, thermoregulation and bacterial and wound protection function and should not be removed. Sarkar et al (2010), however, suggest the function of vernix caseosa after birth is debatable. Visscher et al (2011) suggest that when vernix caseosa is not removed there is a significant increase in skin hydration at 24 hours than when it is removed. They also found the pH of the stratum corneum was more acidic when vernix caseosa was not removed. Trotter (2013) agrees vernix caseosa should not be removed, rather it should be left to be absorbed naturally. Ness et al (2013) concur, suggesting it should not be removed until the baby is bathed.
Some babies, particularly when postmature, have dry skin which can crack. Although there is a temptation to rub in substances such as emollients or olive oil in an attempt to ‘moisturize’ the skin, Trotter (2004) cautions against this practice as she suggests the dry layer will peel off within a few days revealing a healthy layer of skin underneath, which will regain its protective barrier in 2–4 weeks. It may therefore be advisable to avoid the use of emollients or creams on the skin during the first 2–4 weeks. Blume-Peytavi et al (2009) disagree and suggest the use of an emollient on a dry skin can help protect the integrity of the stratum corneum and consider it may be of benefit in babies at risk of developing atopic dermatitis. Ness et al (2013) support this view suggesting topical emollients not only protect the stratum corneum but can also potentially enhance the maturation and repair of the skin barrier. They advise using an emollient with a physiological balance of lipids (3 : 1 : 1 : 1 molar ration of cholesterol, ceramides, palmitate and linoleate) and to avoid using lanolin alcohol due to the risk of sensitivity occurring. They also advise against the use of mustard oil, which is used in some of the developing countries, due to its effect of slowing the recovery of the skin barrier and increasing TEWL but suggest sunflower oil has been shown to accelerate the skin barrier recovery (Ness et al 2013). Sunflower oil has low levels of oleic acid and also has high levels of linoleic acid, which Cooke et al (2011) recommend, as it can repair/enhance the skin barrier. Trotter (2013) agrees on the use of sunflower oil but recommends no skin care products for the first month and avoiding nut oils because of the risk of sensitization. Olive oil is used as a traditional emollient in some countries and cultures, e.g. Turkey (Erenel et al 2010) but Trotter (2013) and Cooke et al (2011) caution against the use of olive oil, as it is high in oleic acid which can damage the skin barrier. Hugill (2014) warns it may be implicated in the development of atopic eczema and other skin conditions.
Skin cleansers/bath additives
There is a lot of debate around the use of skin cleansers and bath additives, the effect they have on skin pH and the risk of absorption creating an allergic or irritant reaction. Current skin care practices for babies vary among populations, tradition, ethnicity and culture (Blume-Peytavi et al 2009). NICE (2014) advise that cleansing agents should not be added to bath water, or medicated wipes or lotions used when cleaning the baby during the first 2–4 weeks. Trotter (2013) cautions against using anything that contains sulphates SLS/SLES, parabens, phthalates, artificial colours, and perfume. Brennan (2010) agrees, arguing that because the newborn skin is thinner and metabolizes chemicals differently, the skin surface area : weight ratio is higher and because the liver and kidneys are immature the baby is at increased risk for a toxic reaction. Blume-Peytavi et al (2012) suggest the risk is small as the German Cosmetic Toiletry, Perfumery and Detergent Association report an average of one adverse effect per million products sold and the American Food and Drug Administration report they receive one to three adverse effect reports per million products sold. However, it is possible that this is underreported.
The purpose of skin cleansing is to clean the skin without changing the pH, affecting the skin microbiota or removing the surface lipids that protect the skin (Hugill 2014). Water is effective at removing much of the matter that has accumulated on the baby’s skin but may not remove it all, particularly where there is faecal soiling; thus parents may want to use a cleanser or bath additive at times (Furber et al 2012, Garcia-Bartels et al 2012, Lavender et al 2012, Lavender et al 2013). Furber et al (2012) found that parents allocated to a ‘water only’ group for cleansing of the genital and perianal area were less likely to clean the baby’s skin when only urine was in the nappy than parents allocated to use of a wipe, which is concerning. However, when diaper dermatitis (DDM) (nappy rash) was present, those using wipes were more likely to change to water only but parents using just water were unlikely to change to using wipes to eliminate the DDM. Thus in some situations, e.g. DDM, parents may prefer the use of water only.
Lavender et al (2012) advise that the pH of tap water is 7.9–8.2 which compromises the acidic environment of the skin. Lavender et al (2013) also suggest water may increase the pH of skin to 7.5 which will increase skin protease activity and inhibit lipid synthesis leading to a breakdown of the skin barrier. Blume-Peytavi et al (2009) suggest that washing with tap water alone can have a drying effect on the skin which may be heightened in areas of hard water. Hard water can have an effect on the development of dermatitis (Hugill 2014) thus bathing babies in hard water may increase the risk of eczema occurring. Adam et al (2009) are concerned that water has no buffering capacity, which means it is unable to neutralize external influences to maintain the pH level and that it does not solubilize lipophilic substances.
Liquid cleansers are designed to interact with surface ‘soil’ and remove harmful substances such as faecal enzymes without damaging the skin (Blume-Peytavi et al 2009). Many also contain an emollient. The bulk of the cleanser is comprised of surfactants which act to decrease the surface tension between water and air and also have a foaming action which assists with the removal of fat-soluble substances (Sarkar et al 2010). Surfactants however can have a deleterious effect on the barrier function of the baby’s skin and may increase the skin pH. Trotter (2006) cautions the use of surfactants also have a risk of trauma occurring to the skin surface which can result in allergic and/or irritant dermatitis. Sarkar et al (2010) advise that the higher the foaming power, the higher the risk of skin damage as excessive lipids can be removed from the stratum corneum. However, products being developed now may be less damaging to the skin than just using water.
Soap may have an alkali or acid/neutral pH. Syndets are synthetic detergents with a pH that is acidic or neutral, the lauryl sulphate of traditional soap has been replaced with natural fats and oils. Ness et al (2013) and Sarkar et al (2010) suggest syndets are milder and less irritating than traditional soaps and that they do not alter the skin pH or alter the microflora. They further suggest that a moisturizer be added to avoid excessive dryness. Traditional alkali soaps have a pH around 10, alter the skin pH and affect the barrier function in terms of TEWL, and are drying and irritant to the skin (Blume-Peytavi et al 2009, Furber et al 2012, Ness et al 2013). Blackburn (2013) and Sarkar et al (2010) suggest it takes at least 1 hour for the pH to return to its pre-wash level whereas Blume-Peytavi et al (2012) advise 30 minutes. Thus the best advice is to not use alkaline soap.
Baby wipes are popular with many parents but may contain chemicals that are irritant to the baby’s skin. Trotter (2013) suggests that wipes should not be used during the first month of life and if they are to be used, they should be free from alcohol, parabens, phthalates, artificial colours, and perfumes. Furber et al (2012) consider that the modern, high-quality wipes used today are not associated with a higher incidence of DDM in healthy newborns. In support of this view, Garcia-Bartels et al (2012) found that neither baby wipes nor water hampered hydration and that wipes did not harm the acid mantle barrier during the first 4 weeks. Lavender et al (2012) tested wipes with a pH of 4.9 and found the hydration effects on the buttocks to be the same as using water and cotton wool. They found no evidence of differences on skin pH, TEWL, erythema, and microbial skin contaminants.
Although shampoo is not necessary it is often used during bathing. Ness et al (2013) recommend the shampoo does not contain cocamidopropyl betaine and MIDA-laureth sulphate, as they are allergens. To reduce the risk further of developing irritant dermatitis, Sarkar et al (2010) advise using the minimal time of contact between the shampoo and the scalp and using a shampoo that is free from fragrance and anti-infective agents. Trotter (2013) suggests that shampoo should not be used for the first year of life.
Ness et al (2013) recommend that if using a cleanser, use it sparingly and only on soiled areas and ensure it is completely rinsed off. It seems sensible that if cleansers, wipes, or soaps are to be used, they should have a neutral/acidic pH, with no perfume or dye added and be specifically designed for babies (never use an adult product).
Blume-Peytavi et al (2012) suggest that routine bathing poses no risk to the baby and is superior to washing or sponge bathing. However the timing of the first bath is contentious and varies between different traditions and cultures. It is important that the baby is healthy and has thermal stability. Ness et al (2013) do not advocate bathing shortly after birth but suggest it should be delayed until the cardio-respiratory status has been stable for 2–4 hours, and not within the first 6 hours of life because of the risk of hypothermia, respiratory distress, increased oxygen consumption, unstable vital signs, and behavioural disruption. Sarkar et al (2010) argue bathing should be delayed 2–6 hours after birth provided the baby weighs >2500 gm. The World Health Organization (WHO 2013) suggest bathing should be delayed for 24 hours but if the baby has to be bathed, he should be at least 6 hours old. Trotter (2013) advises the bath is delayed until the cord has separated so that the microorganisms at the base of the cord are not disturbed, which she suggests may hamper the natural processes involved with cord separation. Blume-Peytavi et al (2012) found that bathing immediately after birth does not appear to affect cord healing and separation but also advise that there is no clear evidence about the effect of regular bathing on cord separation.
Parents should be involved as much as possible with the care of their baby and be given the opportunity to bath their baby if they choose to, or be shown how to bath their baby if they have not had prior experience. Parents with little or no experience of handling babies may not feel confident to bath them initially; thus it is important that the midwife considers the needs of the parents and supports them accordingly. A concern of parents may be that they may drop the baby in the water. If they express this concern, the midwife should ask them what they would do if this happened. Invariably the response will be ‘I’d pick the baby up’. This can then lead to a discussion of how to bath the baby safely and help the parents recognize what they would do if something unexpected occurred.
It is not necessary to bath babies every day, nor is it necessary to wash the baby’s hair with each bath. For some parents, daily bathing may be an easier and more pleasurable option than washing the baby. Immersing a baby in water, may cause the superficial layers of the skin to hydrate and thicken with an associated reduction in cellular cohesion. Thus, skin that is overhydrated from frequent or prolonged bathing becomes more fragile increasing the risk of trauma occurring to it (Hale 2007). Blume-Peytavi et al (2009), Lavender et al (2013) and Sarkar et al (2010) recommend that immersion in the bath should last no longer than 5 minutes.
While there is no right or wrong way to bath a baby, it is important to adhere to certain principles: