Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India

Figures & data

Table 1 Summary of Key Consensus Statements

1. Need for neonatal skin care recommendations for healthy full-term newborns

Neonatal skin care should be an integral part of routine newborn care within the hospital.^Citation4 Neonatal skin care is of utmost significance, starting from delivery to discharge from the hospital. Follow hand hygiene each time prior to handling neonates.^Citation4 Mothers should be trained and guided on evidence-based newborn skin care practices during their hospital stay, and as part of routine discharge advice.^Citation12,Citation13

2. Neonatal skin care at birth

Clean gloves need to be worn to handle the newborn.^Citation14 Remove blood, meconium, or amniotic fluid from the baby’s skin.^Citation14,Citation15 Leave the vernix intact. Do not scrub it off as it protects the skin and favors appropriate colonization.^Citation15–18 Use cotton swabs soaked in water boiled and cooled to an appropriate temperature to gently clean the skin and then gently dry the skin.^Citation14,Citation15 Establish skin-to-skin contact during the first hour after birth as it supports timely breastfeeding, thermoregulation, survival, establishment of a healthy skin microbiome, and mother-baby bonding.^Citation19–25

3. Bathing the newborn

The first bath should be given once the newborn has achieved cardiorespiratory and thermal stability; the ideal time-period may range between 6 and 24 hours after birth.^Citation15 For neonates born to an HIV-positive mother, the first bath should occur at the earliest.^Citation26 Keep the bath time short, lasting not more than 5–10 minutes.^Citation16,Citation18 The frequency of bathing should not exceed twice or thrice a week.^Citation16 Bathing should not occur immediately after feeding. Bathing should preferably be carried out 45 minutes to 1 hour following the last feed. The tub swaddle bath is considered the ideal modality of bathing.^Citation27,Citation28 However, the traditional method of placing the neonate between the knees is required to be explored, and may be recommended as an alternative. Use lukewarm water (at around 38°C) and maintain room temperature (between 26°C-28°C). Also, a mild gentle cleanser which has been demonstrated appropriate for newborns could be used.^Citation29,Citation30 The cleanser should be formulated to be pH neutral to mildly acidic and to not disturb the normal pH of the baby skin.^Citation15

4. Skin care practices within the hospital

Neonatal skin assessment should be a part of routine newborn care.^Citation18,Citation31 The skin should be assessed at the earliest following birth, on a continuous basis, or, at least once daily using valid and reliable tools; increase frequency, if needed. Umbilical cord care: Follow dry cord care. If cord gets soiled with urine or feces, it may be cleaned with water, or a mild cleanser.^Citation17,Citation20 Diaper area cleansing and care: Use a soft cloth, water, and a mild cleanser or disposable diaper wipes to gently clean the perianal area and buttocks after each diaper change.^Citation16 Appropriately formulated emollients for baby skin are recommended at the first signs of dryness, fissures or cracking of the skin and can be employed to maintain or enhance the skin barrier function.^Citation32–34 It may also be considered in high-risk infants to prevent occurrence of Atopic Dermatitis.^Citation33,Citation35,Citation36 Additionally, emollients may be applied on the scalp in newborns with cradle cap. Appropriately formulated baby oils can be lightly applied to the neonate skin before bath for transitory dryness only. Oils meant for cooking or sourced from the kitchen should not be used on the baby’s skin.^Citation16,Citation37

5. Recommendations at the time of discharge

Newborn skin care guidance should be a part of routine discharge advice. The mother should be instructed to assess the skin on a daily basis.^Citation12,Citation13 Parents should be guided for the management of common neonatal skin conditions, and seeking timely medical advice.^Citation12,Citation38 Do’s and Don’ts (Figure 1) should be included in the discharge summary.

6. Use of skin care products

Parents to consider products that are exclusively tested and/or certified for newborn use. Parents and caregivers must read and follow product instructions.

7. Recommendations for industry

Formulations prescribed for neonatal skin care should undergo rigorous quality control. The safety and efficacy of products should be evaluated in high-quality clinical trials. The formulation should contain preservatives and fragrances that have demonstrated safety and tolerability for newborns only.^Citation16 Formulations should not include ingredients that can be harsh and irritating to the neonatal skin and eyes, such as sodium lauryl sulfate.^Citation16 Manufacturers should support healthcare professionals and parents by making more detailed information about ingredient specification available on the websites.

Figure 1 Do’s and don’ts included in the discharge summary.

Table 2 Studies Comparing the Effect of Different Timings of the First Bath on Neonatal Thermoregulatory Outcome

Study	Method	Study Population	Intervention	Primary Outcomes
Kelly et al (2018)^Citation45	Quasi-experimental, mixed-model design	75 healthy newborns	3, 6, or 9 hrs after birth	No clinically significant differences in the neonatal thermoregulatory status as indicated by the axillary and skin temperatures
Behring et al (2003)^Citation46	Quasi-experimental	51 healthy newborns	1 hr vs 4–6 hrs after birth	Axillary temperatures as measured at four different times (pre-bath, immediately post-bath, one hour and two hours post-bath) did not differ significantly between the two groups
Varda et al (2000)^Citation47	Randomized, comparative study	80 healthy, full-term newborns	1 hr vs 2 hrs after birth	No significant differences in axillary temperatures between the two groups before the bath or at 10, 20, or 60 min post-bath
Alizadeh Taheri et al (2007)^Citation48	Randomized, comparative study	100 healthy newborns	1–2 hrs vs 4–6 hrs after birth	Rectal temperatures as measured at four different times (pre-bath, immediately post-bath, 30 min and 60 min post-bath) did not differ significantly between the two groups
Penny-MacGillivray et al (1996)^Citation49	Randomized, comparative study	100 healthy, full-term newborns	Immediately after initial assessment vs 4 hrs after birth	No significant differences (P<0.05) in rectal temperatures between two groups during the initial assessment examination, pre-bathing, immediately after bathing, 1 hr, or 2 hrs after bathing
Bergström et al (2005)^Citation50	RCT	249 non-asphyxiated newborns after vaginal delivery	1 hr vs 2 hrs after birth	Significantly increased risk of hypothermia (at 10 min and 30 min after bathing) in newborns bathed in the first hour after delivery
Nako et al (2000)^Citation51	Randomized, comparative study	187 healthy term and near-term newborn infants	Early bathing: 2–5 min after birth vs dry care	Rectal temperatures as measured at 20 min after intervention was significantly higher in the bath group than in the dry care (P=0.000022). No significant differences in respiratory rate, heart rate, blood pressure and oxygen saturation level between two groups
Sobel et al (2011)^Citation52	Observational assessment	481 mother–baby pairs	Early bathing	Delay’s thermoregulation and initiation of breastfeeding
Gözen et al (2019)^Citation53	Randomized, comparative study	73 healthy, full-term newborns	24 hrs vs 48 hrs after birth	Significantly higher body temperatures (P=0.008) and skin moisture levels (P=0.044) measured at 10 min post-bath in the infants bathed after 48 hrs vs after 24 hrs of birth
Brogan et al (2017)^Citation54	Retrospective experimental study	282 newborns	2–4 hrs after birth (sponge bathing) vs delayed immersion bath	Delayed immersion baths resulted in significant decrease in hypothermia (P=0.044) and increased parent satisfaction

Abbreviation: Hr, hour, RCT, randomized controlled trial.

Table 3 Studies Comparing Different Bathing Techniques for the First Bath

Study	Method	Study Population	Intervention	Primary Outcomes
Bryanton et al 2004^Citation61	RCT	102 healthy newborns	Tub vs sponge bathing	Tub-bathed infants had less temperature loss (P<0.001), were more content (P<0.001) vs sponge-bathed infants. Mothers rated their higher pleasure with tub bathing (P<0.001). No difference in cord healing or infection.
Loring et al 2012^Citation27	RCT	100 late-preterm infants	Tub vs sponge bathing after 24 hrs of delivery	Tub-bath had less variability in body temperature and were warmer at 10 and 30 min vs sponge-bath (P=0.024).
Çaka et al 2017^Citation28	Randomized trial	80 healthy newborns	Swaddled vs traditional tub bathing after 24 hrs of delivery	Swaddled bathed had significantly higher body temperatures just after the bath and 10 min after the bath were compared with tub-bathed (P=0.028). Heart rate was significantly lower with swaddled than the tub bath in the post-bath period (P=0.035). Less crying and agitation with swaddled bathing.
Çınar et al 2020^Citation62	Mixed methods research design	62 healthy newborns	Swaddled bathing vs tub bathing	No statistically significant difference in newborns’ body temperatures before and after bathing (P>0.05). Swaddled bathed infants had higher oxygen saturation (P=0.024), less crying duration, less face/forehead grimacing, and less unrest with higher maternal satisfaction.
Edraki et al 2014^Citation64	Randomized trial	50 premature infants	Swaddled vs conventional (sponge) bathing	Mean temperature loss was significantly less in the swaddle-bathed newborns compared to the conventionally-bathed newborns (P<0.001). Crying time was significantly less in swaddled bathed group (P<0.001).
Gaddam et al 2017^Citation66	Quantitative approach, True experimental comparative research design	60 preterm infants	Swaddled vs conventional (sponge) bathing	Mean temperature loss was less in the swaddle-bathed newborns compared to the conventionally-bathed newborns (P<0.001). Swaddle bathed infants cried less compared with conventionally bathed infants (P<0.001).
Sailer et al 2017^Citation63	Retrospective study	Sponge (n=15) and swaddle (n=21) bath comparison data	Swaddled vs sponge bathing	Delayed swaddle immersion bath resulted in a decrease of time, steps and crying in comparison to the sponge bath.

Abbreviation: RCT, randomized controlled trial.

Table 4 Neonatal Skin Condition Score (NSCS)

Score	Dryness
1	Normal, no sign of dry skin
2	Dry skin, visible scaling
3	Very dry skin, cracking/fissures
Score	Erythema
1	No evidence or erythema
2	Visible erythema, <50% body surface
3	Visible erythema, ≥50% body surface
Score	Breakdown
1	None evident
2	Small, localized areas
3	Extensive

Notes: Perfect score = 3; Worst score = 9. AWHONN Neonatal Skin COndition Score: used and adapted with permission AWHONN. Adapted from Lund CH, Osborne J. Validity and reliability of the neonatal skin condition score. J Obstet Gynecol Neonatal Nurs. 2004;33(3):320–327.³¹

Figure 2 Characteristics of an ideal cleanser* for infant skin.

Notes: *Water alone would be sufficient for newborn bathing unless concerns exist regarding the water quality. Mild cleansers are required for the removal of urine components, fecal enzymes and fat-soluble surface impurities, such as, fecal remnants.

Figure 3 Characteristics of an ideal emollient for infants.

Notes: TEWL, trans-epidermal water loss.

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