The skin is a dynamic organ with critical functions. It serves as a protective barrier against microbes and radiation, helps maintain hydration, regulates body temperature, and aids in sensory perception. At birth, newborn skin abruptly adapts from an aqueous intrauterine environment to dry, aerobic conditions. Gradual maturation of epidermal function continues throughout infancy. Skin care practices during the immediate neonatal period and in infancy can affect maturation and function of the epidermal barrier. This article reviews recent evidence-based recommendations for newborn and infant skin care.
Neonatal Skin Development
Best practices for newborn skin care are informed by our knowledge of fetal skin development and neonatal skin maturation after birth. Human skin is composed of three basic layers: the epidermis, dermis, and subcutaneous tissue. Skin layers and appendages including pilosebaceous units, eccrine ducts, apocrine glands, and nails are derived from embryonic mesoderm and ectoderm. Skin development begins in the fourth week of gestation with a basal cell layer covered by periderm. By 13 weeks of gestation, epidermal cells begin to stratify, and the structural development of the epidermis is complete by 34 weeks of gestation with organization of the epidermis into four recognizable layers: basal, spinous, granular, and stratum corneum.1 The upper-most layer, known as the stratum corneum and composed of a matrix of specialized corneocyte cells, proteins and lipids, is predominantly responsible for the skin barrier function.
In-utero, a white waxy layer known as vernix caseosa covers and protects fetal skin. Vernix caseosa consists of protein, water, shed lanugo hair, desquamating cells, and lipids synthesized by fetal sebaceous glands. This biological coating provides antibacterial and antioxidant benefits, and it protects the skin against amniotic fluid and enzymes as a physical barrier. It also acts as a lubricant in the birth canal during delivery and decreases transepidermal water loss (TEWL) after birth. A yellow discoloration of vernix may occur in hemolytic disease of the newborn, and a brownish discoloration of vernix may be seen with staining from meconium passage. Vernix caseosa is often removed shortly after birth; however, this practice remains controversial. Reduced erythema, improved skin hydration, and lower skin pH has been observed in newborns with retained vernix.2
At birth, skin has a neutral pH between 6.34 and 7.5 depending on anatomical site, and it progressively becomes more acidic in the first few weeks after delivery.3 For comparison, adult skin pH varies between 4.5 and 5.5. The acidic layer that develops within the stratum corneum barrier of the epidermis, termed the “acid mantle,” offers an important defense against bacterial and viral skin infections. Alkaline soap use during bathing may disrupt the skin pH and lower the antimicrobial properties of this important barrier.
First Neonatal Bath
The timing of the first bath for neonates is controversial. Bathing a newborn may lead to hypothermia and fetal distress. In some cultures, early bathing is traditional, whereas others delay bathing until after umbilical cord separation. With appropriate environmental controls, early bathing minutes after birth does not adversely affect healthy full-term and near-term newborn infants.4
Recent European guidelines based on expert consensus recommend wiping the neonate with a dry towel (leaving vernix caseosa in place as possible) and bathing after thermoregulatory stability is achieved.5 American evidence-based clinical practice guidelines from the Association of Women's Health and Obstetric Nurses agree that temperature stability should be ensured prior to the first bath and that the goal of the first bath is to remove blood and infectious products from the neonate, but not to fully remove vernix caseosa.6 Standard infection control precautions should be used by caregivers until the newborn is cleansed of blood and amniotic fluid. Removal of all vernix is not recommended as the vernix facilitates acid mantle formation and has natural moisturizing, antioxidant, and antimicrobial properties.2
Umbilical Cord Care
Natural drying of the umbilical cord is recommended. Application of isopropyl alcohol or triple dye to the cord has been associated with delayed cord separation and may cause necrosis or irritation of the surrounding skin.7–9 The umbilical cord area should be kept clean to avoid umbilical stump infection, and the diaper should be folded down below the umbilicus. When possible, the umbilical cord should be exposed to air. In some developing countries, the risk of serious morbidity and mortality from umbilical cord infections is high, and there may be a role for chlorhexidine application in routine umbilical cord care in these settings.10 Additionally, application of breast milk to the umbilical stump has been shown to reduce bacterial colonization and may be a useful adjunct to cord care in developing nations.11
Male Neonatal Circumcision Care
Male circumcision is the surgical removal of the foreskin from the penis. Circumcision can occur soon after birth or within a few years of life for religious and cultural reasons. Although circumcision remains controversial in some communities, there is some evidence that it may reduce the risk of phimosis, urinary tract infections, sexually transmitted diseases, and penile cancer.12 Possible postprocedural complications of circumcision include bleeding, infection, and meatal stenosis.
In preparation for circumcision, liquid disinfectant is applied to the skin. The procedure is done with local anesthesia, and comfort measures including swaddling, oral sucrose on a pacifier, and acetaminophen administration may additionally reduce the stress response. Immediately after the procedure, residual disinfectant should be removed with sterile water or saline from creases to prevent irritation. Postoperatively, the penis should be covered with petrolatum-impregnated gauze strips for 24 hours then petrolatum ointment is applied to any irritated or raw areas as needed during diaper care and after bathing until healed.6
Routine Newborn Bathing
Bathing term newborns more than 2 to 3 times per week is generally not necessary. Excessive bathing of infants may impair skin function by disrupting the acid mantle and altering the balance of cutaneous bacterial flora. Alkaline soaps containing surfactants may reduce hydration of the stratum corneum leading to dry and irritated skin.13 However, bathing newborns with mild skin cleansers (pH between 5.5 and 7) removes dirt and debris better than water alone, while preserving epidermal function and normal skin microbial colonization. Immersion tub bathing is preferred over sponge bathing, as babies are calmer and more comfortable partially submerged in tubs, and tub bathing results in less heat-loss; importantly, in large studies, immersion bathing prior to umbilical cord separation does not appear to increase risk of umbilical cord infection.14
Moisturizing Newborn Skin
Additional research is needed to define best practices regarding routine skin moisturization for term neonates. After a 10-minute water bath, the newborn stratum corneum is significantly less hydrated,15 which suggests that there is a role for moisturizer use after bathing. Skin moisturization is recognized to be a helpful treatment for infants affected by seborrheic dermatitis and atopic dermatitis. Importantly, starting daily skin moisturizer use early in infancy has been shown to reduce rates of atopic dermatitis among children at high risk for atopic disease based on family history.16,17 Skin emollients used in these primary prevention studies included petrolatum ointment, sunflower seed oil, liquid paraffin, hydrating gel, and hypoallergenic cream. Skin emollients for infants should ideally have neutral pH and contain limited additives (eg, fragrance-free and preservative-free). Emollients containing sodium lauryl sulfate, a commonly used emulsifier, should be avoided as it may adversely affect skin barrier function. As compared to creams and lotions, ointments such as petrolatum tend to contain fewer preservatives and additives. Additionally, vegetable oils rich in linoleic acid, such as sunflower seed and coconut oil, are inexpensive and are natural moisturizers shown to improve skin barrier function and offer anti-inflammatory benefits to the skin.18,19
Preterm Infant Skin Care
The skin of infants born before 34 weeks gestational age is anatomically and physiologically immature. The epidermal layer is thin and has increased permeability and TEWL. In addition, vernix caseosa is absent in preterm infants. After birth, premature skin quickly develops such that the skin of most preterm babies resembles that of a full-term baby by age 2 weeks,20 although very premature infants may have impaired epidermal barrier function for longer than 4 weeks after birth.21
Special attention should be exercised during skin care for premature infants. Warm sterile water alone should be used for bathing, and soft cotton cloth or cotton balls should be used to clean soiled skin.6 Swaddled bathing can help to maintain body temperature and reduce unnecessary stress to the infant.22 Importantly, less frequent bathing (every 4 days) did not increase the incidence of skin concerns in preterm infants.23 Focal bland emollient use on fissured, cracked, and scaly preterm skin can help promote skin healing; however, due to concern for increasing the risk of nosocomial infections in hospital settings, routine, preventive application of skin emollients is not currently recommended for preterm infants in industrialized nations.24 On the other hand, it is notable that in developing countries with limited health care resources, Darmstadt et al.19 found that routine application of petrolatum-based emollient or sunflower seed oil to preterm infant skin reduced nosocomial bloodstream infections and infant mortality rates.
As preterm skin is very fragile, adhesive use should be limited to the minimum required to secure critical tubes and lines. Silicone-based adhesives and hydrogel adhesives adhere well to wounds and cause minimal trauma when removed.6 Anetoderma of prematurity is a form of iatrogenic anetoderma (focal loss of dermal elastic tissue) that does not improve with time, which is associated with the use of monitoring leads in premature infants (born at 24 to 30 weeks gestation).25
Diapering and Diaper Area Care
Prolonged exposure to urine and feces causes a local increase in skin pH with resultant skin barrier dysfunction and skin irritation. Superabsorbent diaper technology has reduced the incidence of diaper dermatitis. Nonetheless, diapers should be changed promptly after urination or soiling, and diaper area skin should be kept clean and dry. Soft cloths or cotton balls may be used with water or a gentle cleanser to wash the diaper area. Alternatively, mild, pH-balanced, hypoallergenic wipes with well-tolerated preservatives may be used to clean the skin with each diaper change.5 Vigorous scrubbing should be avoided as it can damage the skin. Application of petroleum jelly or zinc oxide as a protective barrier to the diaper area is recommended with every diaper change.
Contact Allergens in Infant Skin Care Products
Allergic contact dermatitis (ACD) is a type IV hypersensitivity reaction that requires prior sensitization to a specific allergen. Many skin care products are marketed to parents as “natural,” “safe for babies,” and “doctor recommended;” however, these skin care products may contain additives that can cause skin irritation or contact allergies. A recent study scrutinizing skin care product specifically marketed for babies found that most specialized infant skin care products contain one or more common skin contact allergens.26 Products evaluated included wipes, diaper creams, soaps, moisturizers, shampoos, and sunscreens. Common skin allergens encountered included fragrance, betaines, propylene glycol, lanolin, neomycin, formaldehyde and formaldehyde derivatives, and methylchloroisothiazolinone, with fragrance and betaines being the most prevalent. Interestingly, products containing more potential allergens tend to be less expensive than products containing none of the screened allergens. Pediatricians, therefore, should consider educating parents on avoiding certain ingredients and could consider developing a product list for parents to help them identify safe and affordable options.
Yu et al.27 identified several allergens in commonly used baby wipes, diapers, and topical diaper preparations, including botanical extracts, alpha-tocopherol, fragrances, iodopropynyl butylcarbamate, propylene glycol, parabens, and lanolin. Preferably, baby wipes should be free of alcohol, fragrance, soap, essential oils, and detergents to avoid skin irritation of the diaper area.5
With a thinner epidermal layer, infants are more vulnerable to ultraviolet (UV) radiation than adults.28 Infants begin to develop pigmentary skin changes in response to UV exposure as early as the first summer of life.29 Excessive UV exposure increases the risk of sunburn, immunosuppression, premature skin aging, and skin cancers, including melanoma. Although sunlight exposure is required for the skin to produce active vitamin D, oral vitamin D3 supplementation replaces the need for vitamin D production in the skin; oral vitamin D3 supplementation with 400 IU per day is universally recommended by the American Academy of Pediatrics (AAP) for all breast-fed children as well as for infants consuming less than 1 L of formula per day.30
Sun protection recommendations for newborns focus on sun avoidance in addition to the use of shade structures and protective clothing. When outside, infants should wear wide-brimmed hats and tightly-woven cool clothing or specialized UV-protective clothing. In addition, families should seek shade and use umbrellas and stroller covers.
Because infants have a thinner epidermis and a high skin surface-area to bodyweight ratio, there is concern for potential systemic absorption of chemicals in sunscreen products. Therefore, application of sunscreen to infants younger than age 6 months is generally not recommended. However, the AAP recently revised its recommendation, stating that small amounts of sunscreen may be applied to sun exposed areas in young infants if sun exposure cannot be avoided.31
At birth, newborn skin transitions from aqueous intrauterine conditions to a dry external environment. Full-term infant skin is equipped to adapt promptly, whereas underdeveloped premature infant skin matures in an accelerated fashion but may require more than 4 weeks to achieve normal skin barrier function. Nevertheless, all infant skin function continues to develop over infancy, and considerations about newborn skin physiology and maturation affect recommendations for skin cleansing, skin moisturization, and sun protective measures.
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- Fluhr JW, Darlenski R, Taieb A, et al. Functional skin adaptation in infancy - almost complete but not fully competent. Exp Dermatol. 2010;19(6):483–492. doi:. doi:10.1111/j.1600-0625.2009.01023.x [CrossRef]
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- Blume-Peytavi U, Lavender T, Jenerowicz D, et al. Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care. Pediatr Dermatol. 2016;33(3):311–321. doi:. doi:10.1111/pde.12819 [CrossRef]
- Lund CH, Brandon D, Holden AC, Kuller J, Hill CM. Neonatal Skin Care: Evidence Based Clinical Practice Guideline. 3rd ed. Washington, DC: Association of Women's Health, Obstetric and Neonatal Nurses; 2013.
- Chamnanvanakij S, Decharachakul K, Rasamimaree P, Vanprapar N. A randomized study of 3 umbilical cord care regimens at home in Thai neonates: comparison of time to umbilical cord separation, parental satisfaction and bacterial colonization. J Med Assoc Thai. 2005;88(7):967–972.
- Dore S, Buchan D, Coulas S, et al. Alcohol versus natural drying for newborn cord care. J Obstet Gynecol Neonatal Nurs. 1998;27(6):621–627. doi:10.1111/j.1552-6909.1998.tb02631.x [CrossRef]
- Evens K, George J, Angst D, Schweig L. Does umbilical cord care in preterm infants influence cord bacterial colonization or detachment?J Perinatol. 2004;24(2):100–104. doi:10.1038/sj.jp.7211027 [CrossRef]
- Sankar MJ, Chandrasekaran A, Ravindranath A, Agarwal R, Paul VK. Umbilical cord cleansing with chlorhexidine in neonates: a systematic review. J Perinatol. 2016;36(suppl):S12–S20. doi:. doi:10.1038/jp.2016.28 [CrossRef]
- Ahmadpour-Kacho M, Zahedpasha Y, Hajian K, Javadi G, Talebian H. The effect of topical application of human milk, ethyl alcohol 96%, and silver sulfadiazine on umbilical cord separation time in newborn infants. Arch Iran Med. 2006;9(1):33–38.
- American Academy of Pediatrics. Male circumcision. Pediatrics. 2012;130(3):e756–785. doi:. doi:10.1542/peds.2012-1990 [CrossRef]
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