- Email: [email protected]
Newborn skin care
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37 (2013) 3–7
Available online at www.sciencedirect.com
www.elsevier.com/locate/semperi
Newborn skin care Jonathan A. Dyer, MDn Dermatology and Child Health, University of Missouri, Columbia, MO
artic le info
abstract Many organ systems undergo significant and rapid changes during the transition from an
Keywords:
intrauterine to an extrauterine environment, especially those which serve as interfaces
Neonate
between the infant and the external environment. Historically the skin care methods
Vernix
employed during and after this period of rapid physiologic change have been derived from
Skin Care
individual anecdotal experience or cultural tradition, rather than evidence-based or
Embryology
pathomechanistically derived data. While research in this area has historically been limited, it is increasing in scope and volume, and recent work has shed light on the changes experienced by the cutaneous organ during this period of transition. This increased understanding has driven new recommendations in skin care protocols for newborn infants and neonates. & 2013 Elsevier Inc. All rights reserved.
Introduction The transition from an intrauterine to extrauterine environment requires rapid and ongoing physiologic and anatomic changes in multiple organ systems, including the skin. In a way the skin exhibits some parallels with the lung. In the warm, hydrated, elevated hydrostatic pressure of the relatively frictionless and sterile intrauterine environment, the barrier function of the skin is not taxed to any degree. Yet with the sudden exposure to the desiccated, oxygenated, harsh extrauterine environment teeming with microorganisms and fraught with wide fluxes in temperature and humidity, the skin must bolster evolving barrier mechanisms for present and future survival. While this transition for the skin is not as dramatic or immediate as that experienced by the pulmonary system, it is vastly important and in those infants born without an effective cutaneous barrier, management in the immediate neonatal period can be quite difficult. The changes that begin at birth continue into the first years of life. How to care for the skin during this critical period in development has received scant attention from an investigative perspective in years past. A review in 2005 looking for
prospective studies addressing skin care for the term newborn found no qualifying or relevant studies in the literature, highlighting the great deficiency in data that exists regarding routine skin care of what represents the largest group of infants.1 Many of the protocols used or recommendations made in caring for newborn skin are derived as much from tradition and hearsay as from evidence-based decision making.2. The Association of Women’s Health, Obstetric and Neonatal Nurses has produced guidelines specific to newborn skin care based on available evidence in the literature, although these focus especially on premature or otherwise compromised neonates.3. More recent work has advanced our understanding of cutaneous biology during this period of transition and has provided insights and direction into how best to care for infants at this important stage of development.
Anatomy/structure Fetal skin development commences at 4–5 weeks of gestation with coverage of the initial fetal ectoderm by the periderm. Proliferation of the periderm cells is followed at 8 weeks gestation by the formation of an intermediate layer between
n Correspondence address. Departments of Dermatology and Child Health, University of Missouri, 1 Hospital Dr., Room MA111D, Columbia, MO 65212. E-mail address: [email protected]
0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2012.11.008
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the periderm and the ectoderm within which the stratum corneum (SC) forms. Near the end of the second trimester, with maturation of the epideremis into clearly stratified layers, the periderm is shed and contributes to the vernix caseosa.4 A detectable epidermal permeability barrier first appears in the immediate area of the pilosebaceous unit. Keratinization of the interfollicular epidermis begins between 22 and 24 weeks of age, which is also the limit of premature infant viability.4 The extremely compromised skin barrier of premature infants born at or before 22–24 weeks gestation contributes to their high rate of mortality. The epidermis and dermis exhibit clear architectural arrangement by 4 months gestation but the SC present is atretic and minimally functional. Additionally the subcutaneous fat of the fetus is minimal.5 The highly compromised barrier at this age is evidenced by the greatly increased (over tenfold) transepidermal water loss (TEWL) in premature infants (24 weeks or earlier) compared to a normal term infant.5 Rapid skin maturation occurs over the first 2 weeks of postnatal life in premature infants and can take up to 4 weeks in the most premature.5 Until then the infant is susceptible to significant fluid and electrolyte shifts as well as hypothermia due to the poor barrier function of the underdeveloped skin. Maturation of the SC occurs in the third trimester and the epidermis is largely mature by 34 weeks of age.6 At this point a lipid bilayer is present as well as the full complement of mature epidermal layers. Additionally the subcutaneous fat is fully developed and the SC is completely keratinized, more functional, and similar to that seen in adult skin. The vernix caseosa develops (cephalocaudad) to cover the fetus in the 3rd trimester and may protect the epidermis from amniotic fluid while promoting epidermal cornification and SC formation.7 Vernix caseosa is the cheesy white covering of the newborn term infant and is mixture of variety of substances including protein (10%), lipid (10%), and water (80%). Vernix is unique to humans and likely serves a variety of important roles, many of which have only recently been appreciated. Vernix is 80% water; however most of the water is contained in the water rich corneocytes which are embedded in a thick, amorphous, hydrophobic lipid matrix. This leads to vernix having a surface tension very similar to petrolatum rather than water.7,8. However, rather than being completely occlusive like ointment, vernix has a much higher TEWL, the likely result of the vernix lipids not being arranged in a lamellar fashion.9 Some have suggested that vernix structurally recapitulates the outermost SC layer in normal extrauterine skin.10 It is likely that the vernix lipids are produced by both the SC and the sebaceous glands. Ceramides and cholesterol typically arise from the SC while triglycerides, wax esters, sterol esters, squalene, and phospholipids originate from sebum. Fatty acids present in vernix include oleic, linoleic, and long chain fatty acids. Linoleic acid activates peroxisome proliferator-activated receptor-a (PPARa) which can increase the rate of formation of the epidermal barrier. Additionally linoleic acid also has anti-inflammatory properties which could be helpful for premature infants.7 Vernix is highly cellular, and vernix corneocytes are unique in that they lack desmosomal attachments and exhibit
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sparse keratin filament networks that have little tonofilament orientation.11,8 The protein component of vernix includes a variety of identified proteins with known functions, such as lysozyme, lactoferrin, UGRP-1, and cystatin A (recently identified as defective in exfoliative ichthyosis12). Some of the proteins represent antimicrobial peptide families, such as the cathelicidins (LL-37) and the a-defensins (human neutrophil peptides 1–3). Vernix also contains other proteins with anti-microbial functions such as calprotectin (calgranulins A, B, and C), secretory leukocyte protease inhibitor (SLPI), and psoriasin among others.13 Vernix contains a variety of cytokines including IL1a, IL1b, TNFa and IL67 which have been shown to accelerate the formation of the stratum corneum and the permeability barrier function of the epidermis during gestation.14,15 Vernix also has high concentrations of free amino acids (FAAs) especially asparagine and glutamine. Vernix likely plays a variety of important roles both in utero and in aiding the transition of skin to the outside world in the postpartum period. Amniotic fluid is known to increase in turbidity during the third trimester which may reflect the effects of increasing levels of pulmonary surfactant on the vernix. This detached vernix is swallowed by the fetus. Glutamine may act as a trophic factor for the developing fetal gut and thus high levels of glutamine in shed vernix may aid in its development. Vernix also likely works to prevent infection, both in utero and after birth. Surfactant protein D (a collectin family member) and other antimicrobial particles in vernix (see above) may prevent colonization in utero and control or direct skin colonization by commensal flora in the immediate neonatal period.7 An additional observation is that the appearance of the vernix and SC change the electrical properties of fetal skin, creating a skin surface with high impedance, which may effectively electrically isolate the fetus in utero. This may be important for the developing fetal autonomy.16 Vernix has also been shown to function as a skin cleanser.17 The amount and distribution of vernix varies greatly depending on a variety of factors including gestational age, delivery mode, race, and meconium exposure.18 Vernix is uniquely suited to aid the transition of the skin from the relatively high hydrostatic pressure, hydrated, intrauterine environment19 to the relatively desiccated, low pressure, extrauterine climate (relative humidity between 20% and 40%).18 Slow stratum corneum drying is necessary for filaggrin proteolysis and natural moisturizing factor (NMF) production. NMF production is best between 80% and 95% relative humidity and the presence of vernix on the skin appears to create roughly that10 Wound healing studies suggest that wounds heal best with a semipermeable barrier rather than completely permeable or impermeable barrier, very similar to that created by vernix on the skin.10 In rats, high humidity (100%) immediately after birth blocks filaggrin proteolysis suggesting that decreased humidity is an important signal stimulating the adaptation of the skin to the extrauterine environment. Vernix is also a source of free amino acids (FAA) which bind water and can facilitate adaptation from the intrauterine to the extrauterine atmosphere.7 Retention of vernix leads to much higher levels of FAA on neonatal skin 24 h after birth than if vernix is
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removed. Without vernix the FAA levels are very low at birth and, though they increase early in life, they continue to remain below adult levels. Retention of the vernix after birth does not affect neonatal temperature maintenance but does lead to higher skin hydration and lower skin pH and erythema.18,20 Additionally it has been hypothesized that vernix may be a source of pheromones which could facilitate maternal fetal bonding.10 Newborn skin demonstrates reasonable barrier function immediately after birth (lower TEWL); however adaptation of newborn skin to the extrauterine environment is an ongoing process during the first year of life. Corneocyte hydration (measured using skin capacitance) drops rapidly over the first postnatal day and then gradually increases over the following weeks, often exceeding the moisture accumulation rate of adult skin by several months of age. After this there is a steady decrease in SC hydration to adult levels by 12 months of age. The water holding capacity of the skin also increases during this time.6 Barrier integrity (via TEWL) remains somewhat low during this period. Newborn skin is drier than the skin of older (1, 2, and 6 months) infants and maternal skin. It is important to recognize that TEWL tends to vary based on body site as well. On the palms, soles, and forearm TEWL decreases or is stable and doesn’t reach adult levels for approximately 12 months. In contrast the forehead, abdomen, and upper leg reach adult TEWL levels rapidly, often within the first week of life.21 The acid mantle of the skin (slightly acidic skin surface pH between 5 and 5.5) develops gradually after birth. The pH of newborn skin is higher than that seen in adults, newborn skin pH averages 6 and decreases over the first 1–2 months of life to adult levels.6,21 Sebum levels increase to adult levels by DOL 7 and then decline to quite low levels by 6 months of age where they remain until puberty.6,21,22 The morphologic features of neonatal skin that contribute to its unique physiology are being elucidated. In addition to increased resting TEWL, neonatal SC has higher water content and absorbs/desorbs water faster than adult skin.21 Recently differences between newborn and adult skin in dermal papillary density/distribution have been described using in vivo imaging methods. Specifically, newborn skin exhibit one dermal papilla to one ‘‘island’’ between reticular surface markings. In contrast adult skin has many more papilla per ‘‘island’’ with no clear order or pattern as well as significant variation in dermal papilla size and distribution. Additionally the stratum corneum appears 30% thinner in infants and the suprapapillary epidermis 20% thinner in infants. In aggregate these architectural differences may contribute to the higher TEWL in neonatal SC.23 Infant corneocytes are also smaller and exhibit a higher turnover rate than adult corneocytes. Dermal differences have also been described. Specifically, the borders between the papillary and reticular dermis are not distinguishable using confocal laser scanning microscopy in neonatal skin as they are in adults, due to thinner collagen fiber bundles in the upper reticular dermis.23 The adaptation process of neonatal skin varies depending on body site and based on the exposures that particular site experiences. For example, areas covered by a diaper adapt at a different rate than areas left uncovered.24
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Care of newborn skin The ultimate goal of investigative efforts to better understand the anatomy and physiology of newborn skin is the development of more informed regimens to care for it, replacing the haphazard and anecdotal methods of the past with newer, evidence-based ones.2 While long term prospective studies have yet to be done shorter term studies suggest benefits from this approach. While large trials have not been performed, in the immediate newborn period most current protocols suggest gentle toweling of the infant and leaving any vernix that is present in place (unless there is a risk of transmission of disease via maternal blood products on the vernix surface25,26). The use of vernix on normal adult skin leads to increased SC water binding capacity compared to controls and vernix appears to supply FAA that contribute to this.27 Vernix appears ideally suited to facilitate the transition of the skin from the intrauterine to the extrauterine environment and allowing it to remain on the infants’ skin and dry naturally appears beneficial without any negative sequelae.26 A variety of studies examining infant skin care regimens have been published although it can be difficult to compare between widely different regimens and protocols. In addition to recent guidelines on infant skin care published by several organizations a recent review of the literature focused on neonatal skin care provides an excellent overview of the majority of studies published to date.21 Investigation of types of bathing regimens suggest that there is no evidence of negative effects, either in infant vital signs or overall morbidity, from bathing versus dry care immediately after birth.28 Bathing appears most beneficial with water at the appropriate temperature (100.4 1F) to prevent heat loss and maximize infant comfort,21,28,29 and tub bathing appears somewhat more calming than sponge baths or cloth washing.29 When a bathing routine is initiated at day 7 of life the skin barrier and its adaptation to the environment do not appear to exhibit any negative consequences.21,30 The effect of various washing agents on newborn skin has been studied to a limited degree. Previous works demonstrated that alkaline soaps can increase skin pH in infants,21,31 interfering with the development and function of the acid mantle.21 In contrast the use of mild liquid cleansers or syndets (synthetic detergents) appears similar to the use of plain water and allows more rapid acidification of the SC.21,32 Daily use of syndets does not appear to cause negative outcomes.21 Bacterial colonization of newborn skin occurs in the first 2–3 days after birth.21,32 Cleansing regimens did not appear to affect either the type or amount of microbes present on infant’s skin.32 Bathing normal term newborns after birth does not appear to negatively affect either skin microflora colonization or umbilical cord healing.21,32 In addition to the recently published guidelines on newborn skin care,25,26 recently a consensus conference of European Dermatologists and pediatricians on newborn skin care resulted in the recommendation for simple clear water cleansing initially after birth, with further bathing based on the infant’s parents’ cultural practices.33 A summary of these
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Table 1 – Evidence-Based Skin Care Protocol for the Well, Term, Newborn – 2012 Immediately after birth gently dry the infant If any blood or meconium – gently remove If at risk due to maternal blood borne pathogens then more aggressive cleansing Cleansing should be gentle using warm water – avoid use of harsh cleansers Leave vernix as intact as possible Wrap the infant to conserve heat and/or allow skin to skin contact with the mother Allow vernix to dry and peel naturally. Further skin cleansing should use plain water or only mild cleansers/syndetsa if necessary and be followed immediately by application of an appropriate moisturizer.b Frequency of skin cleansing based on culture and need. 1–2 times/week if necessary is reasonable. Full bathing appears better tolerated, especially after cord separation than sponge/cloth bathing. With time bathing frequency may increase due to need with increased activity and dirt exposure. Diaper creams: Avoid those with strong fragrances or those containing common sensitizers such as Balsam of Peru, dyes, or numerous preservatives. The thicker zinc oxide pastes usually work better. Lanolin is a potential sensitizer but is commonly included in such creams and hard to avoid. Avoid the use of topical antibiotic ointments unless directed by a physician. Infant clothing/fabrics: Avoid laundry detergents containing fragrances or dyes. Consider an extra rinse to ensure complete detergent removal at the end of the wash cycle. Liquid detergents often dissolve more easily in the washer. Avoid the use of dryer sheets or fabric softeners. a Cleansers: The ideal cleanser is pH neutral, fragrance-free (no masking fragrance), dye free, relatively preservative free, and very gentle. Avoid any with high pH, fragrance, or dyes. b Moisturizers: The ideal moisturizer is relatively thick, pH neutral to slightly acidic, fragrance-free (no masking fragrances), dye free, relatively preservative free, and very gentle. Avoid any with high pH, fragrance, or dyes.
recommendations was used to generate the Newborn Skin Care Protocol included in Table 1. While many of the above studies have examined the effect of cleansers used on newborn and infants’ skin, there is very little data on the effect of various moisturizing agents on neonatal skin development. Yet, neonatal SC hydration is significantly decreased after a 10 min water soak followed by towel drying and exposure to 30–45% relative humidity for 15 min.34 Further investigation directed at the best methods and agents for moisturizing newborn skin are greatly needed. Recently the preliminary data from a multicenter parallel group randomized control trial exploring the effect of skin care routine on the development of eczema in a high risk population found that early institution of a gentle skin care routine that included routine use of an emollient such as sunflower seed oil, Cetaphil cream, or Aquaphor ointment led to greatly reduced odds of eczema development in the emollient group as compared to untreated controls.35 While preliminary, prospective data such as this will be important in the future for further refining evidence-based guidelines for neonatal skin care.
dermatitis is one of the most common skin disorders of children affecting up to 20% of children. While there are clear genetic factors which predispose to AD and clear roles for environmental triggers in AD development, skin care has long been championed as a way to control the flares of the condition. Recent striking preliminary data suggests that early intervention with aggressive skin care routines may impact the incidence of AD, validating existing recommendations espoused by dermatologists. With further incorporation of neonatal skin care principles and earlier interventions it will be very exciting to see whether the incidence of AD development can be decreased further. While caring for the skin of a normal newborn would seem to be straightforward, the drastically wide variety of practices and products that exist suggest otherwise. However, better understanding of the unique attributes of neonatal skin and the challenges it faces adapting to terrestrial life, will likely motivate a return to a simpler approach to newborn skin care, hopefully leading to improved skin health and potentially decreased skin disease during infancy and childhood.
r e fe ren c e s
Conclusions The care of newborn skin is widely varied, influenced by individual training, anecdotal experiences, regional customs, and individual patient’s cultures. Yet the skin of all newborns experiences the same demands as it transitions from intrauterine to extrauterine existence. Developing skin care protocols that incorporate a better understanding of the anatomy and physiology of newborn skin and investigating outcomes in terms of newborn skin health and disease in a prospective fashion will allow the evidence-based refinement of skin care regimens and recommendations. This growing knowledge in how to best care for newborn skin hopefully will decrease the rates of certain pediatric skin diseases. For example, atopic
1. Walker L, Downe S, Gomez L. Skin care in the well term newborn: two systematic reviews. Birth. 2005;32(3):224–228. 2. Siegfried EC. Neonatal skin and skin care. Dermatol Clin. 1998;16(3):437–446. 3. Lund CH, Kuller J, Lane AT, Lott JW, Raines DA, Thomas KK. Neonatal skin care: evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. Association of Women’s Health, Obstetric and Neonatal Nurses/National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30(1):30–40. 4. Nieland ML, Parmley TH, Woodruff JD. Ultrastructural observations on amniotic fluid cells. Am J Obstet Gynecol. 1970; 108(7):1030–1042.
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5. Shwayder T, Akland T. Neonatal skin barrier: structure, function, and disorders. Dermatol Ther. 2005;18(2):87–103. 6. Fluhr JW, Darlenski R, Lachmann N, Baudouin C, Msika P, De BC, et al. Infant epidermal skin physiology: adaptation after birth. Br J Dermatol. 2012;166(3):483–490. 7. Visscher MO, Utturkar R, Pickens WL, LaRuffa AA, Robinson M, Wickett RR, et al. Neonatal skin maturation–vernix caseosa and free amino acids. Pediatr Dermatol. 2011;28(2):122–132. 8. Pickens WL, Warner RR, Boissy YL, Boissy RE, Hoath SB. Characterization of vernix caseosa: water content, morphology, and elemental analysis. J Invest Dermatol. 2000; 115(5):875–881. 9. Rissmann R, Groenink HW, Weerheim AM, Hoath SB, Ponec M, Bouwstra JA. New insights into ultrastructure, lipid composition and organization of vernix caseosa. J Invest Dermatol. 2006;126(8):1823–1833. 10. Hoath SB, Pickens WL, Visscher MO. The biology of vernix caseosa. Int J Cosmet Sci 2006;28(5):319–333. 11. Agorastos T, Hollweg G, Grussendorf EI, Papaloucas A. Features of vernix caseosa cells. Am J Perinatol. 1988;5(3): 253–259. 12. Blaydon DC, Nitoiu D, Eckl KM, Cabral RM, Bland P, Hausser I, et al. Mutations in CSTA, encoding Cystatin A, underlie exfoliative ichthyosis and reveal a role for this protease inhibitor in cell–cell adhesion. Am J Hum Genet. 2011;89(4): 564–571. 13. Tollin M, Jagerbrink T, Haraldsson A, Agerberth B, Jornvall H. Proteome analysis of vernix caseosa. Pediatr Res. 2006;60(4): 430–434. 14. Jiang YJ, Lu B, Crumrine D, Man MQ, Elias PM, Feingold KR. IL1alpha accelerates stratum corneum formation and improves permeability barrier homeostasis during murine fetal development. J Dermatol Sci. 2009;54(2):88–98. 15. Jiang YJ, Lu B, Crumrine D, Elias PM, Feingold KR. IL-6 stimulates but is not essential for stratum corneum formation and permeability barrier development during gestation. Exp Dermatol. 2010;19(8):e31–e36. 16. Wakai RT, Lengle JM, Leuthold AC. Transmission of electric and magnetic foetal cardiac signals in a case of ectopia cordis: the dominant role of the vernix. caseosa. Phys Med Biol. 2000;45(7):1989–1995. 17. Moraille R, Pickens WL, Visscher MO, Hoath SB. A novel role for vernix caseosa as a skin cleanser. Biol Neonate. 2005;87(1): 8–14. 18. Visscher MO, Narendran V, Pickens WL, LaRuffa AA, Meinzen-Derr J, Allen K, et al. Vernix caseosa in neonatal adaptation. J Perinatol. 2005;25(7):440–446. 19. Raghunath M, Hennies HC, Ahvazi B, Vogel M, Reis A, Steinert PM, et al. Self-healing collodion baby: a dynamic phenotype explained by a particular transglutaminase-1 mutation. J Invest Dermatol. 2003;120(2):224–228. 20. Visscher MO, Taylor T, Narendran V. Neonatal intensive care practices and the influence on skin condition. J Eur Acad Dermatol Venereol. 2012http://dx.doi.org/10.1111/j.1468-3083. 2012.04470.x.10-3083 %20. 21. Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia BN. Skin care practices for newborns and infants: review of
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the clinical evidence for best practices. Pediatr Dermatol. 2012;29(1):1–14. Fluhr JW, Darlenski R, Taieb A, Hachem JP, Baudouin C, Msika P, et al. Functional skin adaptation in infancy – almost complete but not fully competent. Exp Dermatol. 2010;19(6): 483–492. Stamatas GN, Nikolovski J, Luedtke MA, Kollias N, Wiegand BC. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatr Dermatol. 2010;27(2):125–131. Visscher MO, Chatterjee R, Munson KA, Pickens WL, Hoath SB. Changes in diapered and nondiapered infant skin over the first month of life. Pediatr Dermatol. 2000;17(1):45–51. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. Association of Women’s Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30(1):41–51. National Guideline Clearinghouse N. Neonatal Skin Care, 2nd ed. Evidence-based clinical practice guideline. Agency for Healthcare Research and Quality (AHRQ). Visscher MO, Barai N, LaRuffa AA, Pickens WL, Narendran V, Hoath SB. Epidermal barrier treatments based on vernix caseosa. Skin Pharmacol Physiol. 2011;24(6):322–329. Nako Y, Harigaya A, Tomomasa T, Morikawa A, Amada M, Kijima C, et al. Effects of bathing immediately after birth on early neonatal adaptation and morbidity: a prospective randomized comparative study. Pediatr Int. 2000;42(5):517–522. Bryanton J, Walsh D, Barrett M, Gaudet D. Tub bathing versus traditional sponge bathing for the newborn. J Obstet Gynecol Neonatal Nurs. 2004;33(6):704–712. Garcia BN, Mleczko A, Schink T, Proquitte H, Wauer RR, Blume-Peytavi U. Influence of bathing or washing on skin barrier function in newborns during the first four weeks of life. Skin Pharmacol Physiol. 2009;22(5):248–257. Gfatter R, Hackl P, Braun F. Effects of soap and detergents on skin surface pH, stratum corneum hydration and fat content in infants. Dermatology. 1997;195(3):258–262. Garcia BN, Scheufele R, Prosch F, Schink T, Proquitte H, Wauer RR, et al. Effect of standardized skin care regimens on neonatal skin barrier function in different body areas. Pediatr Dermatol. 2010;27(1):1–8. Blume-Peytavi U, Cork MJ, Faergemann J, Szczapa J, Vanaclocha F, Gelmetti C. Bathing and cleansing in newborns from day 1 to first year of life: recommendations from a European round table meeting. J Eur Acad Dermatol Venereol. 2009; 23(7):751–759. Visscher MO, Chatterjee R, Ebel JP, LaRuffa AA, Hoath SB. Biomedical assessment and instrumental evaluation of healthy infant skin. Pediatr Dermatol. 2002;19(6):473–481. Simpson E. Abstracts of the Annual Meeting of the Society for Investigative Dermatology. May 9–12, 2012. Raleigh, North Carolina, USA. J Invest Dermatol. 2012;132(Suppl 1): S1-180.S1-180.
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Available online at www.sciencedirect.com
www.elsevier.com/locate/semperi
Newborn skin care Jonathan A. Dyer, MDn Dermatology and Child Health, University of Missouri, Columbia, MO
artic le info
abstract Many organ systems undergo significant and rapid changes during the transition from an
Keywords:
intrauterine to an extrauterine environment, especially those which serve as interfaces
Neonate
between the infant and the external environment. Historically the skin care methods
Vernix
employed during and after this period of rapid physiologic change have been derived from
Skin Care
individual anecdotal experience or cultural tradition, rather than evidence-based or
Embryology
pathomechanistically derived data. While research in this area has historically been limited, it is increasing in scope and volume, and recent work has shed light on the changes experienced by the cutaneous organ during this period of transition. This increased understanding has driven new recommendations in skin care protocols for newborn infants and neonates. & 2013 Elsevier Inc. All rights reserved.
Introduction The transition from an intrauterine to extrauterine environment requires rapid and ongoing physiologic and anatomic changes in multiple organ systems, including the skin. In a way the skin exhibits some parallels with the lung. In the warm, hydrated, elevated hydrostatic pressure of the relatively frictionless and sterile intrauterine environment, the barrier function of the skin is not taxed to any degree. Yet with the sudden exposure to the desiccated, oxygenated, harsh extrauterine environment teeming with microorganisms and fraught with wide fluxes in temperature and humidity, the skin must bolster evolving barrier mechanisms for present and future survival. While this transition for the skin is not as dramatic or immediate as that experienced by the pulmonary system, it is vastly important and in those infants born without an effective cutaneous barrier, management in the immediate neonatal period can be quite difficult. The changes that begin at birth continue into the first years of life. How to care for the skin during this critical period in development has received scant attention from an investigative perspective in years past. A review in 2005 looking for
prospective studies addressing skin care for the term newborn found no qualifying or relevant studies in the literature, highlighting the great deficiency in data that exists regarding routine skin care of what represents the largest group of infants.1 Many of the protocols used or recommendations made in caring for newborn skin are derived as much from tradition and hearsay as from evidence-based decision making.2. The Association of Women’s Health, Obstetric and Neonatal Nurses has produced guidelines specific to newborn skin care based on available evidence in the literature, although these focus especially on premature or otherwise compromised neonates.3. More recent work has advanced our understanding of cutaneous biology during this period of transition and has provided insights and direction into how best to care for infants at this important stage of development.
Anatomy/structure Fetal skin development commences at 4–5 weeks of gestation with coverage of the initial fetal ectoderm by the periderm. Proliferation of the periderm cells is followed at 8 weeks gestation by the formation of an intermediate layer between
n Correspondence address. Departments of Dermatology and Child Health, University of Missouri, 1 Hospital Dr., Room MA111D, Columbia, MO 65212. E-mail address: [email protected]
0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2012.11.008
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the periderm and the ectoderm within which the stratum corneum (SC) forms. Near the end of the second trimester, with maturation of the epideremis into clearly stratified layers, the periderm is shed and contributes to the vernix caseosa.4 A detectable epidermal permeability barrier first appears in the immediate area of the pilosebaceous unit. Keratinization of the interfollicular epidermis begins between 22 and 24 weeks of age, which is also the limit of premature infant viability.4 The extremely compromised skin barrier of premature infants born at or before 22–24 weeks gestation contributes to their high rate of mortality. The epidermis and dermis exhibit clear architectural arrangement by 4 months gestation but the SC present is atretic and minimally functional. Additionally the subcutaneous fat of the fetus is minimal.5 The highly compromised barrier at this age is evidenced by the greatly increased (over tenfold) transepidermal water loss (TEWL) in premature infants (24 weeks or earlier) compared to a normal term infant.5 Rapid skin maturation occurs over the first 2 weeks of postnatal life in premature infants and can take up to 4 weeks in the most premature.5 Until then the infant is susceptible to significant fluid and electrolyte shifts as well as hypothermia due to the poor barrier function of the underdeveloped skin. Maturation of the SC occurs in the third trimester and the epidermis is largely mature by 34 weeks of age.6 At this point a lipid bilayer is present as well as the full complement of mature epidermal layers. Additionally the subcutaneous fat is fully developed and the SC is completely keratinized, more functional, and similar to that seen in adult skin. The vernix caseosa develops (cephalocaudad) to cover the fetus in the 3rd trimester and may protect the epidermis from amniotic fluid while promoting epidermal cornification and SC formation.7 Vernix caseosa is the cheesy white covering of the newborn term infant and is mixture of variety of substances including protein (10%), lipid (10%), and water (80%). Vernix is unique to humans and likely serves a variety of important roles, many of which have only recently been appreciated. Vernix is 80% water; however most of the water is contained in the water rich corneocytes which are embedded in a thick, amorphous, hydrophobic lipid matrix. This leads to vernix having a surface tension very similar to petrolatum rather than water.7,8. However, rather than being completely occlusive like ointment, vernix has a much higher TEWL, the likely result of the vernix lipids not being arranged in a lamellar fashion.9 Some have suggested that vernix structurally recapitulates the outermost SC layer in normal extrauterine skin.10 It is likely that the vernix lipids are produced by both the SC and the sebaceous glands. Ceramides and cholesterol typically arise from the SC while triglycerides, wax esters, sterol esters, squalene, and phospholipids originate from sebum. Fatty acids present in vernix include oleic, linoleic, and long chain fatty acids. Linoleic acid activates peroxisome proliferator-activated receptor-a (PPARa) which can increase the rate of formation of the epidermal barrier. Additionally linoleic acid also has anti-inflammatory properties which could be helpful for premature infants.7 Vernix is highly cellular, and vernix corneocytes are unique in that they lack desmosomal attachments and exhibit
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sparse keratin filament networks that have little tonofilament orientation.11,8 The protein component of vernix includes a variety of identified proteins with known functions, such as lysozyme, lactoferrin, UGRP-1, and cystatin A (recently identified as defective in exfoliative ichthyosis12). Some of the proteins represent antimicrobial peptide families, such as the cathelicidins (LL-37) and the a-defensins (human neutrophil peptides 1–3). Vernix also contains other proteins with anti-microbial functions such as calprotectin (calgranulins A, B, and C), secretory leukocyte protease inhibitor (SLPI), and psoriasin among others.13 Vernix contains a variety of cytokines including IL1a, IL1b, TNFa and IL67 which have been shown to accelerate the formation of the stratum corneum and the permeability barrier function of the epidermis during gestation.14,15 Vernix also has high concentrations of free amino acids (FAAs) especially asparagine and glutamine. Vernix likely plays a variety of important roles both in utero and in aiding the transition of skin to the outside world in the postpartum period. Amniotic fluid is known to increase in turbidity during the third trimester which may reflect the effects of increasing levels of pulmonary surfactant on the vernix. This detached vernix is swallowed by the fetus. Glutamine may act as a trophic factor for the developing fetal gut and thus high levels of glutamine in shed vernix may aid in its development. Vernix also likely works to prevent infection, both in utero and after birth. Surfactant protein D (a collectin family member) and other antimicrobial particles in vernix (see above) may prevent colonization in utero and control or direct skin colonization by commensal flora in the immediate neonatal period.7 An additional observation is that the appearance of the vernix and SC change the electrical properties of fetal skin, creating a skin surface with high impedance, which may effectively electrically isolate the fetus in utero. This may be important for the developing fetal autonomy.16 Vernix has also been shown to function as a skin cleanser.17 The amount and distribution of vernix varies greatly depending on a variety of factors including gestational age, delivery mode, race, and meconium exposure.18 Vernix is uniquely suited to aid the transition of the skin from the relatively high hydrostatic pressure, hydrated, intrauterine environment19 to the relatively desiccated, low pressure, extrauterine climate (relative humidity between 20% and 40%).18 Slow stratum corneum drying is necessary for filaggrin proteolysis and natural moisturizing factor (NMF) production. NMF production is best between 80% and 95% relative humidity and the presence of vernix on the skin appears to create roughly that10 Wound healing studies suggest that wounds heal best with a semipermeable barrier rather than completely permeable or impermeable barrier, very similar to that created by vernix on the skin.10 In rats, high humidity (100%) immediately after birth blocks filaggrin proteolysis suggesting that decreased humidity is an important signal stimulating the adaptation of the skin to the extrauterine environment. Vernix is also a source of free amino acids (FAA) which bind water and can facilitate adaptation from the intrauterine to the extrauterine atmosphere.7 Retention of vernix leads to much higher levels of FAA on neonatal skin 24 h after birth than if vernix is
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removed. Without vernix the FAA levels are very low at birth and, though they increase early in life, they continue to remain below adult levels. Retention of the vernix after birth does not affect neonatal temperature maintenance but does lead to higher skin hydration and lower skin pH and erythema.18,20 Additionally it has been hypothesized that vernix may be a source of pheromones which could facilitate maternal fetal bonding.10 Newborn skin demonstrates reasonable barrier function immediately after birth (lower TEWL); however adaptation of newborn skin to the extrauterine environment is an ongoing process during the first year of life. Corneocyte hydration (measured using skin capacitance) drops rapidly over the first postnatal day and then gradually increases over the following weeks, often exceeding the moisture accumulation rate of adult skin by several months of age. After this there is a steady decrease in SC hydration to adult levels by 12 months of age. The water holding capacity of the skin also increases during this time.6 Barrier integrity (via TEWL) remains somewhat low during this period. Newborn skin is drier than the skin of older (1, 2, and 6 months) infants and maternal skin. It is important to recognize that TEWL tends to vary based on body site as well. On the palms, soles, and forearm TEWL decreases or is stable and doesn’t reach adult levels for approximately 12 months. In contrast the forehead, abdomen, and upper leg reach adult TEWL levels rapidly, often within the first week of life.21 The acid mantle of the skin (slightly acidic skin surface pH between 5 and 5.5) develops gradually after birth. The pH of newborn skin is higher than that seen in adults, newborn skin pH averages 6 and decreases over the first 1–2 months of life to adult levels.6,21 Sebum levels increase to adult levels by DOL 7 and then decline to quite low levels by 6 months of age where they remain until puberty.6,21,22 The morphologic features of neonatal skin that contribute to its unique physiology are being elucidated. In addition to increased resting TEWL, neonatal SC has higher water content and absorbs/desorbs water faster than adult skin.21 Recently differences between newborn and adult skin in dermal papillary density/distribution have been described using in vivo imaging methods. Specifically, newborn skin exhibit one dermal papilla to one ‘‘island’’ between reticular surface markings. In contrast adult skin has many more papilla per ‘‘island’’ with no clear order or pattern as well as significant variation in dermal papilla size and distribution. Additionally the stratum corneum appears 30% thinner in infants and the suprapapillary epidermis 20% thinner in infants. In aggregate these architectural differences may contribute to the higher TEWL in neonatal SC.23 Infant corneocytes are also smaller and exhibit a higher turnover rate than adult corneocytes. Dermal differences have also been described. Specifically, the borders between the papillary and reticular dermis are not distinguishable using confocal laser scanning microscopy in neonatal skin as they are in adults, due to thinner collagen fiber bundles in the upper reticular dermis.23 The adaptation process of neonatal skin varies depending on body site and based on the exposures that particular site experiences. For example, areas covered by a diaper adapt at a different rate than areas left uncovered.24
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Care of newborn skin The ultimate goal of investigative efforts to better understand the anatomy and physiology of newborn skin is the development of more informed regimens to care for it, replacing the haphazard and anecdotal methods of the past with newer, evidence-based ones.2 While long term prospective studies have yet to be done shorter term studies suggest benefits from this approach. While large trials have not been performed, in the immediate newborn period most current protocols suggest gentle toweling of the infant and leaving any vernix that is present in place (unless there is a risk of transmission of disease via maternal blood products on the vernix surface25,26). The use of vernix on normal adult skin leads to increased SC water binding capacity compared to controls and vernix appears to supply FAA that contribute to this.27 Vernix appears ideally suited to facilitate the transition of the skin from the intrauterine to the extrauterine environment and allowing it to remain on the infants’ skin and dry naturally appears beneficial without any negative sequelae.26 A variety of studies examining infant skin care regimens have been published although it can be difficult to compare between widely different regimens and protocols. In addition to recent guidelines on infant skin care published by several organizations a recent review of the literature focused on neonatal skin care provides an excellent overview of the majority of studies published to date.21 Investigation of types of bathing regimens suggest that there is no evidence of negative effects, either in infant vital signs or overall morbidity, from bathing versus dry care immediately after birth.28 Bathing appears most beneficial with water at the appropriate temperature (100.4 1F) to prevent heat loss and maximize infant comfort,21,28,29 and tub bathing appears somewhat more calming than sponge baths or cloth washing.29 When a bathing routine is initiated at day 7 of life the skin barrier and its adaptation to the environment do not appear to exhibit any negative consequences.21,30 The effect of various washing agents on newborn skin has been studied to a limited degree. Previous works demonstrated that alkaline soaps can increase skin pH in infants,21,31 interfering with the development and function of the acid mantle.21 In contrast the use of mild liquid cleansers or syndets (synthetic detergents) appears similar to the use of plain water and allows more rapid acidification of the SC.21,32 Daily use of syndets does not appear to cause negative outcomes.21 Bacterial colonization of newborn skin occurs in the first 2–3 days after birth.21,32 Cleansing regimens did not appear to affect either the type or amount of microbes present on infant’s skin.32 Bathing normal term newborns after birth does not appear to negatively affect either skin microflora colonization or umbilical cord healing.21,32 In addition to the recently published guidelines on newborn skin care,25,26 recently a consensus conference of European Dermatologists and pediatricians on newborn skin care resulted in the recommendation for simple clear water cleansing initially after birth, with further bathing based on the infant’s parents’ cultural practices.33 A summary of these
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Table 1 – Evidence-Based Skin Care Protocol for the Well, Term, Newborn – 2012 Immediately after birth gently dry the infant If any blood or meconium – gently remove If at risk due to maternal blood borne pathogens then more aggressive cleansing Cleansing should be gentle using warm water – avoid use of harsh cleansers Leave vernix as intact as possible Wrap the infant to conserve heat and/or allow skin to skin contact with the mother Allow vernix to dry and peel naturally. Further skin cleansing should use plain water or only mild cleansers/syndetsa if necessary and be followed immediately by application of an appropriate moisturizer.b Frequency of skin cleansing based on culture and need. 1–2 times/week if necessary is reasonable. Full bathing appears better tolerated, especially after cord separation than sponge/cloth bathing. With time bathing frequency may increase due to need with increased activity and dirt exposure. Diaper creams: Avoid those with strong fragrances or those containing common sensitizers such as Balsam of Peru, dyes, or numerous preservatives. The thicker zinc oxide pastes usually work better. Lanolin is a potential sensitizer but is commonly included in such creams and hard to avoid. Avoid the use of topical antibiotic ointments unless directed by a physician. Infant clothing/fabrics: Avoid laundry detergents containing fragrances or dyes. Consider an extra rinse to ensure complete detergent removal at the end of the wash cycle. Liquid detergents often dissolve more easily in the washer. Avoid the use of dryer sheets or fabric softeners. a Cleansers: The ideal cleanser is pH neutral, fragrance-free (no masking fragrance), dye free, relatively preservative free, and very gentle. Avoid any with high pH, fragrance, or dyes. b Moisturizers: The ideal moisturizer is relatively thick, pH neutral to slightly acidic, fragrance-free (no masking fragrances), dye free, relatively preservative free, and very gentle. Avoid any with high pH, fragrance, or dyes.
recommendations was used to generate the Newborn Skin Care Protocol included in Table 1. While many of the above studies have examined the effect of cleansers used on newborn and infants’ skin, there is very little data on the effect of various moisturizing agents on neonatal skin development. Yet, neonatal SC hydration is significantly decreased after a 10 min water soak followed by towel drying and exposure to 30–45% relative humidity for 15 min.34 Further investigation directed at the best methods and agents for moisturizing newborn skin are greatly needed. Recently the preliminary data from a multicenter parallel group randomized control trial exploring the effect of skin care routine on the development of eczema in a high risk population found that early institution of a gentle skin care routine that included routine use of an emollient such as sunflower seed oil, Cetaphil cream, or Aquaphor ointment led to greatly reduced odds of eczema development in the emollient group as compared to untreated controls.35 While preliminary, prospective data such as this will be important in the future for further refining evidence-based guidelines for neonatal skin care.
dermatitis is one of the most common skin disorders of children affecting up to 20% of children. While there are clear genetic factors which predispose to AD and clear roles for environmental triggers in AD development, skin care has long been championed as a way to control the flares of the condition. Recent striking preliminary data suggests that early intervention with aggressive skin care routines may impact the incidence of AD, validating existing recommendations espoused by dermatologists. With further incorporation of neonatal skin care principles and earlier interventions it will be very exciting to see whether the incidence of AD development can be decreased further. While caring for the skin of a normal newborn would seem to be straightforward, the drastically wide variety of practices and products that exist suggest otherwise. However, better understanding of the unique attributes of neonatal skin and the challenges it faces adapting to terrestrial life, will likely motivate a return to a simpler approach to newborn skin care, hopefully leading to improved skin health and potentially decreased skin disease during infancy and childhood.
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Conclusions The care of newborn skin is widely varied, influenced by individual training, anecdotal experiences, regional customs, and individual patient’s cultures. Yet the skin of all newborns experiences the same demands as it transitions from intrauterine to extrauterine existence. Developing skin care protocols that incorporate a better understanding of the anatomy and physiology of newborn skin and investigating outcomes in terms of newborn skin health and disease in a prospective fashion will allow the evidence-based refinement of skin care regimens and recommendations. This growing knowledge in how to best care for newborn skin hopefully will decrease the rates of certain pediatric skin diseases. For example, atopic
1. Walker L, Downe S, Gomez L. Skin care in the well term newborn: two systematic reviews. Birth. 2005;32(3):224–228. 2. Siegfried EC. Neonatal skin and skin care. Dermatol Clin. 1998;16(3):437–446. 3. Lund CH, Kuller J, Lane AT, Lott JW, Raines DA, Thomas KK. Neonatal skin care: evaluation of the AWHONN/NANN research-based practice project on knowledge and skin care practices. Association of Women’s Health, Obstetric and Neonatal Nurses/National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. 2001;30(1):30–40. 4. Nieland ML, Parmley TH, Woodruff JD. Ultrastructural observations on amniotic fluid cells. Am J Obstet Gynecol. 1970; 108(7):1030–1042.
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