- Email: [email protected]
Diaper Dermatitis
CLINICIANS DISCUSS
Diaper Dermatitis Mary Brucker (Moderator) Stephanie McGuire Lisa Merrill Francine Rossing Kammi Sayaseng
Abstract: Diaper dermatitis in infants is commonly seen by clinicians in both primary care and acute care settings. The condition can cause significant discomfort for infants and distress for their parents and caregivers. Nursing for Women’s Health convened a group of nursing clinicians who work in a variety of settings to discuss the issues and challenges related to preventing and treating diaper dermatitis in both healthy term newborns and premature newborns. DOI: 10.1111/1751-486X.12233 Keywords: diaper candidiasis | diaper dermatitis | diaper rash | newborn skin care
FRANCINE ROSSING: I’m a NICU nurse. One of our biggest issues has to do with having products that we can use on our premature babies. We do see diaper dermatitis in our healthy newborns as well as our premature babies, and how we treat the two is different. A big issue is trying to get everyone on the same page regarding using the same products and keeping everything consistent.
BRUCKER: So you mean having some standards? ROSSING: Yes, we need standards, but there hasn’t been a lot of evidence-based practice for diaper dermatitis in premature babies. We’re in the process of trying to set up evidence-based standards to use in our hospital, but it’s challenging because there hasn’t been a lot of research done on diaper dermatitis in premature babies. LISA MERRILL: I can speak to the normal newborn/postpartum area when newborns spend those important first few hours or days with their moms in hospital. An issue I see is education for parents. If you look at the vast scope of education provided to parents in the immediate postpartum period, preventing diaper dermatitis may not be the primary focus of education at that time. However, in order to prevent diaper dermatitis, talking about good diaper hygiene, healthy skin and what to do when a baby starts to get some redness in the diaper
Mary Brucker, PhD, CNM, FACNM, is an adjunct assistant professor in the midwifery program at Georgetown University and she is editor of Nursing for Women’s Health. Stephanie McGuire, MS, APRN, NNPBC, is a neonatal nurse practitioner at Connecticut Children’s Medical Center in Hartford, CT. Lisa Merrill, MN, RN, is a clinical nurse specialist in the Women’s Health Program at the Women’s Hospital, Health Sciences Center in Winnipeg, Manitoba, Canada. Francine Rossing, RN, BS, WCC, is a neonatal nurse and wound certified nurse at Connecticut Children’s Medical Center in Hartford, CT. Kammi Sayaseng, DNP, RN, PNP-BC, IBCLC, is assistant professor at California State University, Fresno, and a pediatric nurse practitioner at Community Children’s Health Center in Fresno, CA. The authors report no conflicts of interest or relevant financial relationships. The views expressed in this discussion are solely those of the participants. The publication of this discussion was supported in part by an educational grant from Kimberly-Clark/Huggies®. The sponsor had no involvement in the discussion or in any part of the editorial process leading to its publication. Address correspondence to: [email protected].
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area is important. It can be stressful for families when they’re at home and they aren’t prepared to take even some simple steps with regard to newborn skin care. KAMMI SAYASENG: I’m a pediatric nurse practitioner and I work in an outpatient clinic that serves many low-income families. Diaper dermatitis is something I commonly see; in many cases the families are trying to save money on diapers and may not be changing the diaper frequently enough. STEPHANIE MCGUIRE: I think one of the biggest challenges for all of us is prevention. There are a variety of opportunities we need to capitalize on for both parental education and staff education. Prevention is key, because if you never get it then you never have to treat it. I was very taken with Kammi’s comments about the socioeconomic factors that play a role in the population she sees. That’s not something I see in the NICU, but I can see what a challenge it would be in the outpatient arena.
BRUCKER: Why is diaper dermatitis such an issue? What are the physiologic and other factors putting babies at risk? SAYASENG: In the past it was thought that it was the ammonia in urine that was breaking down the skin, but more recent studies show this isn’t entirely the case. Urine and feces can mix together to increase the pH of the skin, which can allow the enzymes in the stool to be more active and cause more irritation to the skin. Also prolonged exposure of the skin to wetness from urine collection and/or diarrhea in the diaper increases the risk.
BRUCKER: Why are babies in the NICU more vulnerable? ROSSING: Premature babies don’t have the layers and the thickness of the skin the same way healthy term babies do. The
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Opening photo © Rayes / Digital Vision / thinkstockphotos.com
MARY BRUCKER: Thank you all for joining us today. To begin, are there any general or overarching issues you see with regard to diaper dermatitis in your practice?
“A big issue is trying to get everyone on the same page regarding using the same products and keeping everything consistent” – Francine Rossing
third trimester is when the skin growth really develops and continues after the infant is born. Also, there is the issue of the vernix protecting the skin. For very premature infants, vernix may not even be present. Plus, premature babies may have other issues, such as short gut from necrotizing enterocolitis, which can result in more frequent stooling.
BRUCKER: Francine, you mentioned the importance of vernix. Does this have any implications as to the baby’s first bath? ROSSING: Yes. We don’t bathe our infants until we consider them stable. I know some articles have shown you’re not supposed to bathe for at least 6 hours after birth. We don’t bathe some of our premature infants for up to a month, depending on their issues and overall stability. We clean away blood and stool, but as far as vernix, we try to keep what we can intact. And, of course, as we’re changing diapers we’re cleaning gently using only water, but we’re not doing any kind of deep scrub with soap until they’re stable and their skin integrity is able to handle it.
BRUCKER: What about first bath for healthy, term babies? MERRILL: We also delay bathing for term babies for the same reason. We like to go as long as possible, but sometimes we encounter resistance from parents who are uncomfortable with that. We’d love to delay as long as 12 to 24 hours, but in reality if we can get to 6 hours of age that’s good.
stays in a wet diaper the skin is going to break down. So I really stress the need to change the diaper often and to air dry the skin when possible. For example, when the baby is asleep, keep the diaper on the baby very loosely or open to air. Also, it seems in Western cultures that there’s a big focus in the culture on everything being very “antiseptic” and people are using lots of antibacterial cleansing products, so I stress that too much cleaning can disrupt the normal flora of the skin and cause irritation to the skin. When babies have diaper rash, avoid using baby wipes as this tends to irritate the skin more. Use gentle and nonscented soap and water to clean the diaper area, paying special attention to the folds, and then pat dry the skin. Allow the diaper area to air dry before putting on the diaper. ROSSING: We tell parents that if they start to see any kind of redness they should not use any kind of commercial wipe and instead should use plain water and a soft cloth, as well as more frequent diaper changes. We also inform them that, with commercial products, even if something is marketed as being for a baby it might have ingredients that could be irritants, such as ingredients found in some scented baby wipes. Anything with any kind of alcohol in it can also be a problem. In the NICU we usually only use petroleum jelly unless there is redness noted; then we will move on to a commercial product such as Criticaid or Desitin and use these only on our older preterm and term babies.
MCGUIRE: You know, Lisa, I can’t help but wonder that with more and more acceptance of skin-to-skin contact immediately after birth if that will help extend the time to first bath.
Photo © Fuse / thinkstockphotos.com
MERRILL: Definitely, I completely agree. And now since we’re having such a major push toward doing skin-to-skin right away after birth, that’s changing the way both parents and staff think about it. I’d say that for the last 10 years we’ve been working on the delayed bathing and now it’s really starting to take hold because of the focus on immediate skin-to-skin contact. I’m really happy about that.
BRUCKER: I think we’ve established that diaper dermatitis is a major problem. I read somewhere that up to 20 percent of childhood dermatology visits are for the diaper area. So let’s go back to how to educate parents. What are the key points? SAYASENG: In the case of many of the families I see for whom finances are an issue, we try to get support that can help them. And I try to really drive home the point that if the baby
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For our premature babies, early on, we pretty much don’t allow anything but petroleum jelly. Once they’re older and at term or close to term, we would use more products.
SAYASENG: Once parents start to see redness that’s a different story, but for purely prevention purposes in our population, we recommend an emollient such as petroleum jelly or Vaseline. I caution parents against using anything too thick to clean or remove when it becomes soiled with the baby’s feces. Rubbing or cleaning too hard can further cause skin irritation or injury. If a baby has developed diaper dermatitis and has been prescribed a topical medication, I recommend the parents put the medication on first and then they can put a layer of emollient on top of that.
“One of the considerations that we have to make for the NICU population is whether or not there is a component of cow’s milk allergy. The stools in those babies can be more caustic, especially in the perianal area’” – Stephanie McGuire
BRUCKER: Is there any association between breastfeeding and diaper dermatitis? MERRILL: The published literature indicates that the stool of breastfed infants has a lower pH and, therefore, these infants may have a lower risk of developing diaper dermatitis than formula-fed infants. SAYASENG: I’m an international board-certified lactation consultant, so of course I promote breastfeeding. There may be some protection, but other factors, such as how often the diaper gets changed, will play a role as well. MCGUIRE: One of the considerations that we have to make for the NICU population is whether or not there is a component of cow’s milk allergy. The stools in those babies can be more caustic, especially in the perianal area. So we recommend to some breastfeeding mothers that they try a dairy-free diet for themselves, but honestly we haven’t seen many mothers able to sustain that for any length of time. Kammi, I would think in the outpatient world you may see this as well. SAYASENG: Definitely, yes. If indeed it is a true cow’s milk allergy that the baby has, then the mother would have to be on a strict diet omitting any kind of dairy products. The mother has to be very committed to breastfeeding and able to maintain this strict diet to continue with breastfeeding.
BRUCKER: Francine, you made the points that in your population you don’t use lanolin, correct?
BRUCKER: If a baby is in the middle of getting treatment for diaper dermatitis do you ever recommend that they go without a diaper for a while? Take a “diaper holiday”?
ROSSING: Correct, it’s not indicated for our population. We will have parents who bring in products they want to use, as they like to have some autonomy in their baby’s care. They feel like this is their child and they want to do things for their child, but we have to be careful about what products we let them use.
ROSSING: Yes, we put our babies’ bottoms to air. We keep the bedding covered and just try to let it dry by air. A lot of times that does improve the situation, but not necessarily quickly enough for all babies. If loose stools and more frequent stooling are occurring then air drying can really be more of a hindrance.
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Photo opposite page © Monkey Business Images / thinkstockphotos.com
BRUCKER: That’s good advice because so many of us grew up with the idea that alcohol was a perfect disinfectant, and we really didn’t know as much about the difference between “good” and “bad” bacteria back then, nor how irritating some disinfectant products can be. Any other advice for parents?
MERRILL: In our normal newborn population we also use petroleum jelly but generally only if there is some redness, or if it’s a higher risk baby. For example, babies at risk for symptoms of opiate withdrawal, because they’re more likely to have diarrhea and loose stools, so we start right away with a barrier cream, otherwise their skin tends to break down quickly. We start with petroleum jelly, but then sometimes we like to use a thicker paste, with zinc oxide, as a barrier, but we don’t wipe it off completely—just the parts that are soiled with stool.
BRUCKER: Do you make any recommendations about disposable versus cloth diapers? SAYASENG: Disposable diapers today are very good at trying to pull wetness away from the skin. The literature doesn’t seem to indicate much of a difference between the two. But I think it all still boils down to how often the wet or soiled diaper gets changed.
BRUCKER: What about when parents might be finding nonevidence-based information about diaper rash on the Internet or receiving it from well-meaning family members? For example, recommendations to use things such as cornstarch, coconut oil or honey? ROSSING: We let them know that cornstarch and any of the baby powders don’t protect the skin from the moisture, urine and feces. As far as everyday honey—I’m a wound certified nurse so I know there are products out there specifically for wounds that contain honey in them, but I would not suggest to anybody to go down to the corner store and buy a jar of honey and put it on the baby’s bottom. We tell parents you don’t want to risk your child’s skin for something that we’re not quite sure about. SAYASENG: I agree with Francine. We know now that cornstarch and powders can accumulate in the diaper area and can actually contribute to a candida infection. Plus there are inhalation risks for the baby with powders when the powder is being sprinkled on to the baby.
BRUCKER: What is the biggest misconception or point of confusion for parents in your experience?
“People need to understand that it can happen really quickly. If you have a baby who has a major bout of loose stools and diarrhea, it doesn’t take long for the skin to break down” – Lisa Merrill
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MCGUIRE: In the NICU, sometimes parents and families think the baby has diaper dermatitis because of a lack of care on our part. They think we haven’t changed the babies’ diapers enough, which is a very reasonable assumption to make, because basically that’s what we often say to parents—that you have to change the diaper frequently. Parent education is very important because NICU babies are more susceptible and at higher risk. Parents also need to know that once it occurs and because there has been skin injury, there is a risk for recurrence in the future, despite our best efforts. So it’s not necessarily a lack of care but sometimes just a baby’s predisposition to skin injury. MERRILL: I fully agree with that and I also think people need to understand that it can happen really quickly. If you have a baby who has a major bout of loose stools and diarrhea, it doesn’t take long for the skin to break down. I think parents of babies that go home from the normal newborn area are sometimes shocked when they experience diaper rash and they’re not prepared for that. So, again, it’s all about prevention and education and talking about it early on. Unfortunately, there are so many things to focus on with discharge education for parents that sometimes this topic might be at the bottom of the list when maybe it be more of a priority.
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BRUCKER: Let’s talk a little bit about differentiating between different types of dermatitis. SAYASENG: Candidal, or fungal, lesions tend to be in the fold with satellite lesions. If it’s directly at the area where the skin makes contact with the diaper and sparing the folds, that’s more likely to be a contact or irritant dermatitis.
BRUCKER: Is it different for the NICU population? MCGUIRE: There may be some less common contributors in our population, but generally that’s what we see. Another key point is that of all cases of diaper dermatitis, about 45 percent to 75 percent of kids will have a fungal component, and anything lasting more than 3 days is a significant consideration in terms of it being fungal, as well.
SAYASENG: I don’t see many people using cloth diapers either, but if someone is using them, an important point is to thoroughly rinse out all of the detergents that are used otherwise those detergents can become a contact irritant.
BRUCKER: Kammi, you mentioned you see a lot of contact dermatitis in your practice. How do you treat it, other than to remove the offending agent? SAYASENG: The main thing is to try to prevent it in the first place, but if contact dermatitis does develop, then I use topical corticosteroids. I start with the lowest dose and lowest potency possible, but I’ve had some severe cases where I’ve had to use higher potency.
BRUCKER: With bacterial dermatitis is one organism more common than another?
SAYASENG: In our outpatient population, we also see a lot of contact dermatitis. In my practice I probably see equal amounts of candidal dermatitis and contact dermatitis.
SAYASENG: I most frequently see Staph aureus, but sometimes Strep as well.
BRUCKER: How do you treat candidal dermatitis?
BRUCKER: What about treating the mom?
ROSSING: Topical antifungal ointments.
SAYASENG: If a breastfeeding mom is being treated with antibiotics we let her know there is a risk for loose stools in the baby and we encourage her to keep checking the diaper and changing it frequently. If there’s a candidal infection in the baby’s diaper area we have to check other areas such as the baby’s mouth and if we find it there then we need to check the mom’s nipple area and treat all areas involved accordingly.
SAYASENG: Yes, plus air drying is important to inhibit fungal growth.
BRUCKER: If a baby has a fungal infection and the parents are using cloth diapers are they supposed to wash the diapers in bleach or is that an old wives tale?
Photo © Steve Mcsweeny / thinkstockphotos.com
ROSSING: We don’t encounter a lot of people using cloth diapers.
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BRUCKER: Lisa, you recently authored a CNE article for Nursing for Women’s Health on diaper dermatitis. Did anything surprise you while researching and writing that? MERRILL: I was excited for the opportunity to author the article! I was really hoping that in doing the literature search I’d find some new magic strategy or solution for diaper dermatitis, but I guess what surprised me is that there wasn’t one. Despite all the advancements, we’re still really no further ahead in our prevention strategies. It’s still back to basics with air drying, barriers, gentle cleansing with water and plain cloths, and changing diapers frequently.
BRUCKER: To the group, are there any final thoughts you’d like to share? MCGUIRE: There are a variety of different factors that can affect the skin, and prevention and early intervention are really crucial to avoiding severe cases of diaper dermatitis, which I think all parents would like to avoid because it’s very uncomfortable for the babies and very distressing for the parents.
“If you can prevent any kind of problem in the first place, that’s the best outcome” – Kammi Sayaseng
petroleum jelly or Vaseline to protect the skin from urine and feces. Health care providers need to be able to recognize if the diaper dermatitis is candidal or contact or irritant dermatitis and treat appropriately.
BRUCKER: Thank you all for a great discussion.
Photo © iStock Collection / thinkstockphotos.com
MERRILL: There’s a nice acronym that’s helpful here, which was published by Boiko (1999). It’s ABCDE and it stands for Air, Barrier, Cleansing, Diapering and Education. This is very straightforward and helps to remind people about the key elements of diaper hygiene.
REFERENCE Boiko, S. (1999). Treatment of diaper dermatitis. Dermatologic Clinics, 17(1), 235-240.
ROSSING: Parents should be aware that frequent diaper changing can help prevent the issue, and should make sure diapers aren’t too tight, otherwise air can’t flow. Prevention is really key, but if dermatitis does develop it’s important to use just water to cleanse, and to use a barrier. SAYASENG: I agree that prevention is the best plan. If you can prevent any kind of problem in the first place, that’s the best outcome. We need to educate families on hygiene care, changing the diaper as soon as it becomes wet or soiled and using
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Diaper Dermatitis Mary Brucker (Moderator) Stephanie McGuire Lisa Merrill Francine Rossing Kammi Sayaseng
Abstract: Diaper dermatitis in infants is commonly seen by clinicians in both primary care and acute care settings. The condition can cause significant discomfort for infants and distress for their parents and caregivers. Nursing for Women’s Health convened a group of nursing clinicians who work in a variety of settings to discuss the issues and challenges related to preventing and treating diaper dermatitis in both healthy term newborns and premature newborns. DOI: 10.1111/1751-486X.12233 Keywords: diaper candidiasis | diaper dermatitis | diaper rash | newborn skin care
FRANCINE ROSSING: I’m a NICU nurse. One of our biggest issues has to do with having products that we can use on our premature babies. We do see diaper dermatitis in our healthy newborns as well as our premature babies, and how we treat the two is different. A big issue is trying to get everyone on the same page regarding using the same products and keeping everything consistent.
BRUCKER: So you mean having some standards? ROSSING: Yes, we need standards, but there hasn’t been a lot of evidence-based practice for diaper dermatitis in premature babies. We’re in the process of trying to set up evidence-based standards to use in our hospital, but it’s challenging because there hasn’t been a lot of research done on diaper dermatitis in premature babies. LISA MERRILL: I can speak to the normal newborn/postpartum area when newborns spend those important first few hours or days with their moms in hospital. An issue I see is education for parents. If you look at the vast scope of education provided to parents in the immediate postpartum period, preventing diaper dermatitis may not be the primary focus of education at that time. However, in order to prevent diaper dermatitis, talking about good diaper hygiene, healthy skin and what to do when a baby starts to get some redness in the diaper
Mary Brucker, PhD, CNM, FACNM, is an adjunct assistant professor in the midwifery program at Georgetown University and she is editor of Nursing for Women’s Health. Stephanie McGuire, MS, APRN, NNPBC, is a neonatal nurse practitioner at Connecticut Children’s Medical Center in Hartford, CT. Lisa Merrill, MN, RN, is a clinical nurse specialist in the Women’s Health Program at the Women’s Hospital, Health Sciences Center in Winnipeg, Manitoba, Canada. Francine Rossing, RN, BS, WCC, is a neonatal nurse and wound certified nurse at Connecticut Children’s Medical Center in Hartford, CT. Kammi Sayaseng, DNP, RN, PNP-BC, IBCLC, is assistant professor at California State University, Fresno, and a pediatric nurse practitioner at Community Children’s Health Center in Fresno, CA. The authors report no conflicts of interest or relevant financial relationships. The views expressed in this discussion are solely those of the participants. The publication of this discussion was supported in part by an educational grant from Kimberly-Clark/Huggies®. The sponsor had no involvement in the discussion or in any part of the editorial process leading to its publication. Address correspondence to: [email protected].
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area is important. It can be stressful for families when they’re at home and they aren’t prepared to take even some simple steps with regard to newborn skin care. KAMMI SAYASENG: I’m a pediatric nurse practitioner and I work in an outpatient clinic that serves many low-income families. Diaper dermatitis is something I commonly see; in many cases the families are trying to save money on diapers and may not be changing the diaper frequently enough. STEPHANIE MCGUIRE: I think one of the biggest challenges for all of us is prevention. There are a variety of opportunities we need to capitalize on for both parental education and staff education. Prevention is key, because if you never get it then you never have to treat it. I was very taken with Kammi’s comments about the socioeconomic factors that play a role in the population she sees. That’s not something I see in the NICU, but I can see what a challenge it would be in the outpatient arena.
BRUCKER: Why is diaper dermatitis such an issue? What are the physiologic and other factors putting babies at risk? SAYASENG: In the past it was thought that it was the ammonia in urine that was breaking down the skin, but more recent studies show this isn’t entirely the case. Urine and feces can mix together to increase the pH of the skin, which can allow the enzymes in the stool to be more active and cause more irritation to the skin. Also prolonged exposure of the skin to wetness from urine collection and/or diarrhea in the diaper increases the risk.
BRUCKER: Why are babies in the NICU more vulnerable? ROSSING: Premature babies don’t have the layers and the thickness of the skin the same way healthy term babies do. The
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Opening photo © Rayes / Digital Vision / thinkstockphotos.com
MARY BRUCKER: Thank you all for joining us today. To begin, are there any general or overarching issues you see with regard to diaper dermatitis in your practice?
“A big issue is trying to get everyone on the same page regarding using the same products and keeping everything consistent” – Francine Rossing
third trimester is when the skin growth really develops and continues after the infant is born. Also, there is the issue of the vernix protecting the skin. For very premature infants, vernix may not even be present. Plus, premature babies may have other issues, such as short gut from necrotizing enterocolitis, which can result in more frequent stooling.
BRUCKER: Francine, you mentioned the importance of vernix. Does this have any implications as to the baby’s first bath? ROSSING: Yes. We don’t bathe our infants until we consider them stable. I know some articles have shown you’re not supposed to bathe for at least 6 hours after birth. We don’t bathe some of our premature infants for up to a month, depending on their issues and overall stability. We clean away blood and stool, but as far as vernix, we try to keep what we can intact. And, of course, as we’re changing diapers we’re cleaning gently using only water, but we’re not doing any kind of deep scrub with soap until they’re stable and their skin integrity is able to handle it.
BRUCKER: What about first bath for healthy, term babies? MERRILL: We also delay bathing for term babies for the same reason. We like to go as long as possible, but sometimes we encounter resistance from parents who are uncomfortable with that. We’d love to delay as long as 12 to 24 hours, but in reality if we can get to 6 hours of age that’s good.
stays in a wet diaper the skin is going to break down. So I really stress the need to change the diaper often and to air dry the skin when possible. For example, when the baby is asleep, keep the diaper on the baby very loosely or open to air. Also, it seems in Western cultures that there’s a big focus in the culture on everything being very “antiseptic” and people are using lots of antibacterial cleansing products, so I stress that too much cleaning can disrupt the normal flora of the skin and cause irritation to the skin. When babies have diaper rash, avoid using baby wipes as this tends to irritate the skin more. Use gentle and nonscented soap and water to clean the diaper area, paying special attention to the folds, and then pat dry the skin. Allow the diaper area to air dry before putting on the diaper. ROSSING: We tell parents that if they start to see any kind of redness they should not use any kind of commercial wipe and instead should use plain water and a soft cloth, as well as more frequent diaper changes. We also inform them that, with commercial products, even if something is marketed as being for a baby it might have ingredients that could be irritants, such as ingredients found in some scented baby wipes. Anything with any kind of alcohol in it can also be a problem. In the NICU we usually only use petroleum jelly unless there is redness noted; then we will move on to a commercial product such as Criticaid or Desitin and use these only on our older preterm and term babies.
MCGUIRE: You know, Lisa, I can’t help but wonder that with more and more acceptance of skin-to-skin contact immediately after birth if that will help extend the time to first bath.
Photo © Fuse / thinkstockphotos.com
MERRILL: Definitely, I completely agree. And now since we’re having such a major push toward doing skin-to-skin right away after birth, that’s changing the way both parents and staff think about it. I’d say that for the last 10 years we’ve been working on the delayed bathing and now it’s really starting to take hold because of the focus on immediate skin-to-skin contact. I’m really happy about that.
BRUCKER: I think we’ve established that diaper dermatitis is a major problem. I read somewhere that up to 20 percent of childhood dermatology visits are for the diaper area. So let’s go back to how to educate parents. What are the key points? SAYASENG: In the case of many of the families I see for whom finances are an issue, we try to get support that can help them. And I try to really drive home the point that if the baby
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For our premature babies, early on, we pretty much don’t allow anything but petroleum jelly. Once they’re older and at term or close to term, we would use more products.
SAYASENG: Once parents start to see redness that’s a different story, but for purely prevention purposes in our population, we recommend an emollient such as petroleum jelly or Vaseline. I caution parents against using anything too thick to clean or remove when it becomes soiled with the baby’s feces. Rubbing or cleaning too hard can further cause skin irritation or injury. If a baby has developed diaper dermatitis and has been prescribed a topical medication, I recommend the parents put the medication on first and then they can put a layer of emollient on top of that.
“One of the considerations that we have to make for the NICU population is whether or not there is a component of cow’s milk allergy. The stools in those babies can be more caustic, especially in the perianal area’” – Stephanie McGuire
BRUCKER: Is there any association between breastfeeding and diaper dermatitis? MERRILL: The published literature indicates that the stool of breastfed infants has a lower pH and, therefore, these infants may have a lower risk of developing diaper dermatitis than formula-fed infants. SAYASENG: I’m an international board-certified lactation consultant, so of course I promote breastfeeding. There may be some protection, but other factors, such as how often the diaper gets changed, will play a role as well. MCGUIRE: One of the considerations that we have to make for the NICU population is whether or not there is a component of cow’s milk allergy. The stools in those babies can be more caustic, especially in the perianal area. So we recommend to some breastfeeding mothers that they try a dairy-free diet for themselves, but honestly we haven’t seen many mothers able to sustain that for any length of time. Kammi, I would think in the outpatient world you may see this as well. SAYASENG: Definitely, yes. If indeed it is a true cow’s milk allergy that the baby has, then the mother would have to be on a strict diet omitting any kind of dairy products. The mother has to be very committed to breastfeeding and able to maintain this strict diet to continue with breastfeeding.
BRUCKER: Francine, you made the points that in your population you don’t use lanolin, correct?
BRUCKER: If a baby is in the middle of getting treatment for diaper dermatitis do you ever recommend that they go without a diaper for a while? Take a “diaper holiday”?
ROSSING: Correct, it’s not indicated for our population. We will have parents who bring in products they want to use, as they like to have some autonomy in their baby’s care. They feel like this is their child and they want to do things for their child, but we have to be careful about what products we let them use.
ROSSING: Yes, we put our babies’ bottoms to air. We keep the bedding covered and just try to let it dry by air. A lot of times that does improve the situation, but not necessarily quickly enough for all babies. If loose stools and more frequent stooling are occurring then air drying can really be more of a hindrance.
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Photo opposite page © Monkey Business Images / thinkstockphotos.com
BRUCKER: That’s good advice because so many of us grew up with the idea that alcohol was a perfect disinfectant, and we really didn’t know as much about the difference between “good” and “bad” bacteria back then, nor how irritating some disinfectant products can be. Any other advice for parents?
MERRILL: In our normal newborn population we also use petroleum jelly but generally only if there is some redness, or if it’s a higher risk baby. For example, babies at risk for symptoms of opiate withdrawal, because they’re more likely to have diarrhea and loose stools, so we start right away with a barrier cream, otherwise their skin tends to break down quickly. We start with petroleum jelly, but then sometimes we like to use a thicker paste, with zinc oxide, as a barrier, but we don’t wipe it off completely—just the parts that are soiled with stool.
BRUCKER: Do you make any recommendations about disposable versus cloth diapers? SAYASENG: Disposable diapers today are very good at trying to pull wetness away from the skin. The literature doesn’t seem to indicate much of a difference between the two. But I think it all still boils down to how often the wet or soiled diaper gets changed.
BRUCKER: What about when parents might be finding nonevidence-based information about diaper rash on the Internet or receiving it from well-meaning family members? For example, recommendations to use things such as cornstarch, coconut oil or honey? ROSSING: We let them know that cornstarch and any of the baby powders don’t protect the skin from the moisture, urine and feces. As far as everyday honey—I’m a wound certified nurse so I know there are products out there specifically for wounds that contain honey in them, but I would not suggest to anybody to go down to the corner store and buy a jar of honey and put it on the baby’s bottom. We tell parents you don’t want to risk your child’s skin for something that we’re not quite sure about. SAYASENG: I agree with Francine. We know now that cornstarch and powders can accumulate in the diaper area and can actually contribute to a candida infection. Plus there are inhalation risks for the baby with powders when the powder is being sprinkled on to the baby.
BRUCKER: What is the biggest misconception or point of confusion for parents in your experience?
“People need to understand that it can happen really quickly. If you have a baby who has a major bout of loose stools and diarrhea, it doesn’t take long for the skin to break down” – Lisa Merrill
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MCGUIRE: In the NICU, sometimes parents and families think the baby has diaper dermatitis because of a lack of care on our part. They think we haven’t changed the babies’ diapers enough, which is a very reasonable assumption to make, because basically that’s what we often say to parents—that you have to change the diaper frequently. Parent education is very important because NICU babies are more susceptible and at higher risk. Parents also need to know that once it occurs and because there has been skin injury, there is a risk for recurrence in the future, despite our best efforts. So it’s not necessarily a lack of care but sometimes just a baby’s predisposition to skin injury. MERRILL: I fully agree with that and I also think people need to understand that it can happen really quickly. If you have a baby who has a major bout of loose stools and diarrhea, it doesn’t take long for the skin to break down. I think parents of babies that go home from the normal newborn area are sometimes shocked when they experience diaper rash and they’re not prepared for that. So, again, it’s all about prevention and education and talking about it early on. Unfortunately, there are so many things to focus on with discharge education for parents that sometimes this topic might be at the bottom of the list when maybe it be more of a priority.
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BRUCKER: Let’s talk a little bit about differentiating between different types of dermatitis. SAYASENG: Candidal, or fungal, lesions tend to be in the fold with satellite lesions. If it’s directly at the area where the skin makes contact with the diaper and sparing the folds, that’s more likely to be a contact or irritant dermatitis.
BRUCKER: Is it different for the NICU population? MCGUIRE: There may be some less common contributors in our population, but generally that’s what we see. Another key point is that of all cases of diaper dermatitis, about 45 percent to 75 percent of kids will have a fungal component, and anything lasting more than 3 days is a significant consideration in terms of it being fungal, as well.
SAYASENG: I don’t see many people using cloth diapers either, but if someone is using them, an important point is to thoroughly rinse out all of the detergents that are used otherwise those detergents can become a contact irritant.
BRUCKER: Kammi, you mentioned you see a lot of contact dermatitis in your practice. How do you treat it, other than to remove the offending agent? SAYASENG: The main thing is to try to prevent it in the first place, but if contact dermatitis does develop, then I use topical corticosteroids. I start with the lowest dose and lowest potency possible, but I’ve had some severe cases where I’ve had to use higher potency.
BRUCKER: With bacterial dermatitis is one organism more common than another?
SAYASENG: In our outpatient population, we also see a lot of contact dermatitis. In my practice I probably see equal amounts of candidal dermatitis and contact dermatitis.
SAYASENG: I most frequently see Staph aureus, but sometimes Strep as well.
BRUCKER: How do you treat candidal dermatitis?
BRUCKER: What about treating the mom?
ROSSING: Topical antifungal ointments.
SAYASENG: If a breastfeeding mom is being treated with antibiotics we let her know there is a risk for loose stools in the baby and we encourage her to keep checking the diaper and changing it frequently. If there’s a candidal infection in the baby’s diaper area we have to check other areas such as the baby’s mouth and if we find it there then we need to check the mom’s nipple area and treat all areas involved accordingly.
SAYASENG: Yes, plus air drying is important to inhibit fungal growth.
BRUCKER: If a baby has a fungal infection and the parents are using cloth diapers are they supposed to wash the diapers in bleach or is that an old wives tale?
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ROSSING: We don’t encounter a lot of people using cloth diapers.
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BRUCKER: Lisa, you recently authored a CNE article for Nursing for Women’s Health on diaper dermatitis. Did anything surprise you while researching and writing that? MERRILL: I was excited for the opportunity to author the article! I was really hoping that in doing the literature search I’d find some new magic strategy or solution for diaper dermatitis, but I guess what surprised me is that there wasn’t one. Despite all the advancements, we’re still really no further ahead in our prevention strategies. It’s still back to basics with air drying, barriers, gentle cleansing with water and plain cloths, and changing diapers frequently.
BRUCKER: To the group, are there any final thoughts you’d like to share? MCGUIRE: There are a variety of different factors that can affect the skin, and prevention and early intervention are really crucial to avoiding severe cases of diaper dermatitis, which I think all parents would like to avoid because it’s very uncomfortable for the babies and very distressing for the parents.
“If you can prevent any kind of problem in the first place, that’s the best outcome” – Kammi Sayaseng
petroleum jelly or Vaseline to protect the skin from urine and feces. Health care providers need to be able to recognize if the diaper dermatitis is candidal or contact or irritant dermatitis and treat appropriately.
BRUCKER: Thank you all for a great discussion.
Photo © iStock Collection / thinkstockphotos.com
MERRILL: There’s a nice acronym that’s helpful here, which was published by Boiko (1999). It’s ABCDE and it stands for Air, Barrier, Cleansing, Diapering and Education. This is very straightforward and helps to remind people about the key elements of diaper hygiene.
REFERENCE Boiko, S. (1999). Treatment of diaper dermatitis. Dermatologic Clinics, 17(1), 235-240.
ROSSING: Parents should be aware that frequent diaper changing can help prevent the issue, and should make sure diapers aren’t too tight, otherwise air can’t flow. Prevention is really key, but if dermatitis does develop it’s important to use just water to cleanse, and to use a barrier. SAYASENG: I agree that prevention is the best plan. If you can prevent any kind of problem in the first place, that’s the best outcome. We need to educate families on hygiene care, changing the diaper as soon as it becomes wet or soiled and using
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