Neonatal & Infant Skin Care

Introduction
Preserving the skin integrity of the neonate is important to maintain the function of the skin, protect
against potential wounds and avoid skin disorders in the future.

Aim

Provide evidence based skincare to neonates

Identify those who may be at risk for alterations in skin integrity

Protect against potential skin breakdown caused by epidermal stripping, extravasation,

wound breakdown and excoriation
Implement interventions to promote and protect optimal skin function
Care for premature neonates in an environment that minimises Trans Epidermal Water
Loss and promotes Stratum Corneum barrier maturation
Minimize the potential for future skin sensitization

Definition of Terms
Preterm baby Less than 37 weeks gestational age
Term baby 37- 40 weeks gestational age
Neonate Less than 4 weeks age (post term)
Infant Young children, 1 month to 12 months age
TEWL Trans Epidermal Water Loss
Atopy Predisposition toward developing certain allergic hypersensitivity reactions
Emollient A substance that softens & moisturizes the skin
Erythema Redness of the skin
Stratum Corneum (SC) The outermost layer of the epidermis acting as a mechanical barrier
Xerosis Skin dryness

Vernix Waxy white substance on newborn skin

Rediwipes Absorbent disposable towels (available from Equipment Distribution Centre)

Assessment
Assess skin condition on admission and commencement of each shift (and at each nappy change as
needed). Be proactive. Observe and clean areas such as the neck, behind the ears, axillae and groin.
Dry, red or itchy skin is an indication that skin integrity may be impaired. If a pustular, vesicular or purulent
skin lesion is noted, communicate with the appropriate medical team for management.
Consider the following factors that may increase the risk of skin trauma and breakdown;

Prematurity

Vacuum or forcep extraction

Skin oedema, infection, thermal injury

Sedation or inability to mobilise

Use of endotracheal tubes, continuous positive airway pressure, nasogastric/orogastric

tubes Extracorporeal membrane oxygenation (ECMO)

Monitors, electrodes, probes

Surgical wounds, ostomies

Adhesive removal

Environmental humidification

Nappy rash

Nutritional status

Family history of atopy

Management
To maintain skin integrity and minimise heat loss consider the following -

Bathing

Ensure vital signs and temperature are stable before first bath

Consider universal precautions, wear gloves

Immersion bathing should be considered based on assessment of individual condition

Newborns may be bathed after 1 hour of age when appropriate care is taken to support
thermal stability. To minimise heat loss after first bath, immediately put a nappy and hat on and
wrap in warm blankets. When infant temperature is within normal limits (after approximately 10
minutes) dress and re wrap in dry warm blankets

Bath or sponge daily or more often as needed

Use warm water

Use a water depth deep enough to allow the infants' shoulders to be well covered

Maintain an adequately heated environment

pH neutral cleanser may be used if needed or plain water

Carefully dry the skin folds including armpits, groin, neck and behind the ears

Allow vernix to wear off with normal care and handling

Disinfect bath equipment before and after use

Examples of appropriate pH neutral cleansers: QV Wash, QV Gentle Cleanser, Hamilton Wash,

Cetaphil Gentle Skin Cleanser, Avene Trixera Cleansing Gel, Kenkay Body Wash, Dermaveen Baby Soap
Free Wash
Cord Care

Wash hands before handling umbilical cord

Keep cord area clean with water. No need for alcohol wipes

Cleanse with water and pH neutral cleanser if soiled with urine or stool

Keep nappy folded under the cord to facilitate drying

Identify signs of infection such as inflammation or an offensive odour

The cord usually separates from the baby 7 to 10 days after birth

Cord clamp may remain insitu until separation

Educate staff and families about normal mechanism of cord healing

Emollients

At the first sign of dryness, fissures or flaking, apply an emollient twice a day or as
needed

Emollients should be applied as a preventative therapy at least daily to newborns and

infants with a family history of atopy

Emollients should not be shared and always dispensed from a hospital pharmacy in
patient-specific containers

Spoon emollient on to paper towel prior to use (to maintain sterility of the container)

Emollients are safe to be used for infants under radiant heat or for infants receiving
treatment such as phototherapy

Emollients may interfere with the adherence of adhesives

Choose emollients without fragrances, dyes or preservatives

Examples of appropriate emollients: QV Cream, QV Kids balm, QV Intensive, Hydraderm Cream,

Cetaphil Cream, Aqueous cream, Avene Trixera Cream, Dermeze Ointment, Kenkay Extra Relief Cream,
Dermaveen Baby Moisturising Cream, Mustela Stelatopia Moisturising Cream
Nappy Area Care

Assess neonate for risk factors for skin breakdown. ie. loose stools, frequent stooling,
drug withdrawal, medications that alter stool frequency or composition. Monitor skin condition
closely

Change nappies frequently, usually every 3- 4 hours or when soiled

Use disposable nappies

Nappy wipes may cause irritation and should be reserved for healthy looking skin

Gently clean nappy area with water and Rediwipes or cotton wool

A pH neutral cleanser, sorbolene cream, aqueous Cream or olive oil may be used to help
cleanse the nappy area

To maintain skin integrity, apply a thick barrier cream that contains zinc oxide at every
nappy change

Complete removal of barrier ointments with nappy changes is not necessary, rather apply
another layer

Assess for presence of infection ie candida albicans, and need for topical antifungal

Do not use talcum powder

Do not use creams with fragrances or unnecessary additives such as tea tree oil

Allow as much "nappy off" time as possible

If the area is red, a mild hydrocortisone 1% ointment may need to be applied bd, prn e.g.
Sigmacort 1% ointment. A prescription is not needed for this

For further information see Nappy Rash Clinical Practice Guideline

Examples of appropriate barrier creams: 10% Olive Oil in Zinc Paste, Covitol, Desitin, Sudocream,
Bepanthan Nappy Ointment
Adhesives

Minimal use of adhesives on all neonates

Delay the removal of adhesive for at least 24hrs after application

Tape should be backed with cotton wool where possible

A semipermeable dressing should be used between the skin and adhesive to secure
nasogastric tubes, intravascular devices, nasal cannulas or central venous catheters

Barrier films should not be used on premature neonates or infants < 4 weeks of age (ie.
Smith & Nephew Skin Prep Protective Barrier Wipes, Convacare Protective Barrier Wipe, 3M
Cavilon No Sting Barrier Film )

Gently and slowly remove adhesives with warm water soaked cotton balls, peeling back
parallel to the skin surface. Avoid solvents

Solvents (ie. Convacare wipes) must not be used on premature neonates. If required to
aid adhesive removal on term neonates, the area should be rinsed with warm water immediately
after use

For transparent adhesives, stretch to release adherence

Use wraps such as stretchy gauze or Koban to anchor probes, electrodes or limbs to arm
boards

Use only gel electrodes

Examples of appropriate adhesives: Mepitac, Comfeel, Duoderm, Siltape, Transparent adhesive

dressings (Tegaderm), Hydrocolloids, Gel Electrodes, Silicone adhesives

Special Considerations for Premature Neonates

Ensure vital signs and temperature are stable before the first bath.
Neonates <1000g or < 32 weeks sponged in plain water only every 3-4 days.
Use soft materials such as cotton balls. Avoid rubbing. Consider immersion
bathing for stable infants >1800g

Emollients should not be part of routine care for infants 23-30 weeks'
gestation. TEWL may be reduced by other means ie. Humidity

No nappy wipes. Cotton wool and olive oil /water only to cleanse the
nappy area

No solvents for adhesive removal, toxicity may result from absorption

through the skin ie. Convacare wipes

For Further Neonatal & Infant skin Care Management see:

Environmental Humidty

Clinical management as per Environmental Humidity for Premature Neonates Clinical

Guideline

Extravasation Care

Clinical management as per Neonatal Extravasation Clinical Guideline

Wound Care

Clinical management as per Wound Care Clinical Guideline

Pressure Area Care

Assessment and clinical management as per Pressure Injury Prevention and

Management Clinical Guideline

Common Newborn Rashes

Erythema Toxicum Neonatorum

A common condition affecting as many as half of all full term newborn infants. Most prominent on day 2,
although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the
trunk and limbs. Palms and soles are not usually affected.
Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat
red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it
is unusual for an individual lesion to persist for more than a day.
Treatment: The infant is otherwise well and requires no treatment.

Neonatal Milia

Affects 40-50% of newborn babies. Few to numerous lesions.

Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin.
Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate
(Bohn nodules) or more widely on scalp, face and upper trunk.
Treatment: Lesions will heal spontaneously within a few weeks of birth.

Miliaria (Heat rash)

Arises from occlusion of the sweat ducts. In infants lesions commonly appear on the neck, groins and
armpits, but also on the face.
Clinical features: 1-3mm papules (vesicular or papular).
Treatment: Remove from heated humid environment or adjust incubator temperature. Cool bathing or
apply cool compresses. Topical steroids may be used to facilitate relief while the condition resolves.

Pityrosoprum folliculitis

Infantile acne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the
newborns' sebaceous glands cause inflammation and folliculitis.
Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops, commonly
affecting the cheeks, nose and forehead. This rash is not itchy.
Treatment: Will resolve within weeks without treatment or may be treated with ketoconozole shampoo
(eg. Sebizole shampoo) diluted 1:5 with water, applied with a cotton bud twice a day. Rinse off with water
after 10 minutes. Or apply Hydrozole cream bd to the affected areas until the rash has resolved.

http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal___Infant_Ski
n_Care/
The Royal Children's Hospital Melbourne