Sharon Trotter RM BSc

• Stratum Corneum
• Stratum Granulosum
• Stratum Spinosum

The latter of these is at the junction of the Epidermis and Dermis and is where the renewal of the Basal Cells is carried out. Basal cells constantly divide and are called Keratinocytes. They can be thought of as the bricks in a wall, with the mortar between, made up of lipids (fat cells).
It is this barrier, which allows the retention of fluids within the Epidermal cells, which remain plump and therefore prevent the introduction of micro organisms, chemicals and allergens. When intact, this 'wall' regulates temperature, acts as a barrier to infection, balances water/electrolytes, stores fat and insulates against the cold. The skin is also a large tactile area, for the interpretation of stimuli.
The Stratum Corneum itself is made up of 10-20 microscopic layers in an adult and the term infant. In premature infants, this number drops to between 2-3 layers. In extremely premature infants, of less than 23 gestational weeks, this layer may be virtually non-existent. ( Holbrook 1982, Nonato 1998). Consequently, the risk to these babies is even higher.
Babies are born with an alkaline skin surface, with an average pH of 6.34 (Peck & Botwinick 1964). However, within days, the pH has fallen to about 4.95 (acid). This is known as the 'Acid Mantle' and is the skins protector. The development of this 'Acid Mantle' happens within days irrespective of gestational age, which is probably a direct result of the skins exposure to air, instead of amniotic fluid (Harpin & Rutter 1983, Evans & Rutter 1986). However, The Stratum Corneum is still much thinner in the pre-term infant, especially in the 23-33 week age range. Therefore it would seem sensible to take extra care during this period to avoid any undue damage.
The introduction of Baby Bath products, wipes and creams etc, along with the exposure to urine and faeces, could disrupt this delicate protective barrier and lead to problems, including eczema, or allergic reactions (Peck and Botwinick 1964, Berg et al 1986, Cetta et al 1991). [back to top]

The Physiology of Cord Care

• Uniformity of Care practices nationally.
• Overall improved skin integrity.
• Reduced bathing using little or no products.
• Increased emollient use.
• No increase in infection rates.
• Identification of risk factors, leading to early introduction of appropriate treatment. (Lund et al 2001b)
  The guidelines implemented by Lund (2001b) were primarily aimed at premature or sick neonates in the acute hospital setting. With this in mind, the author has written a new set of guidelines, aimed at the healthy term infant, with some reference to premature and sick infants. [A Specific Policy, within the Neonatal Unit (NNU) will be introduced separately]. Collaboration between midwifery, medical and paediatric staff has led to the approval of these guidelines within Ayrshire and Arran Acute Hospital Trust (AAAHT).

A colourful and informative fold-out leaflet has also been designed for parents which includes the following advice:
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• Before and after carrying out any baby-care, especially cord care, it is important to wash hands thoroughly.
• First baths will now be carried out using plain water and cotton wool. This will help to protect the delicate skin while it is vulnerable to germs, chemicals and water loss. A baby comb can be used to gently remove any debris from thick hair after delivery. Please bring a baby comb into hospital with you.
• It is best to leave the delicate area around the eyes untouched. If it does become sticky, please notify a member of staff and they will advise you. The ears and nose should also be left alone and cotton buds should be avoided.
• Vernix (the white sticky substance that covers your baby's skin in the womb) should always be left to absorb naturally. This is nature's own moisturiser.
• Premature babies skin is even more delicate, so it is important to withhold all products for a period of 6-8 weeks, as their skin takes longer to mature. The staff in the Neonatal Unit (NNU) will be happy to advise you.
• If your baby is overdue, his/her skin may well be dry and cracked. This is to be expected, as the protective vernix has all been absorbed. Don't be tempted to use any creams or lotions as this may do more harm than good. The top layer of the babies skin will peel off over the next few days, leaving perfect skin underneath. This will now need 2-4 weeks to develop its naturally protective barrier.
• Cord care for the Healthy Term Baby: Keep this area clean and dry. The best way to achieve this is to leave the area alone. After the 1st bath in plain water, pat dry with a clean towel and fold back the nappy, at each change, until the cord separates. In the first few days, it is advisable to top'n'tail your baby to allow the cord to dry out. Wet Cotton wool can be used if the area becomes soiled, otherwise leave alone. There is no need to use any wipes or powders. The cord clamp will be removed by a member of staff in hospital or by your Community Midwife, if you are at home. If the cord or surrounding area does become red or smelly, notify a member of staff. This advice is based on the World Health Organization (WHO) recommendations published in 1999.
• Cord Care for the Sick or Premature Baby: This may differ slightly, due to the increased risk of infection. Antiseptic solutions and/or powders may be used for the first few days. Otherwise cord care should be the same as for any other baby. Be guided by staff in the NNU and they will advise you on the best possible care for your baby.
• Continue with plain water for 2-4 weeks before gradually introducing baby products. By this time the skins natural barrier will have developed. These products should be free from colours and perfumes and used sparingly.
• Baby wipes should also be avoided for 2-4 weeks. Once introduces, try to use ones, which are mild and free from alcohol and perfume.
• Shampoo is not necessary when your baby is under a year old. Once you have introduced baby products, simply rinse your baby's hair in the bath water solution.
• A thin layer of barrier cream can be used, if required, on the nappy area.
• If after a few weeks you wish to use a moisturiser, choose products that are emollient based. These will not dry out the skin, but they will give it some protection.
• Wash all baby clothes and bedding in non-biological washing powder. Fabric conditioners, if used, should be mild and free from colours and perfumes.
• Feeding: Breastfeeding is obviously the best choice for your baby as it gives some protection against allergies developing. However, whether you breastfeed or bottle-feed, remember to take care when introducing a mixed diet. This should not be attempted before four months of age, but can safely be left until six months, as recommended by the World Health Organization (WHO). Avoid any wheat (gluten) based products for the first six months as these could trigger an allergic response in the baby's immature digestive system. Stick to rice-based cereals instead. Cows milk should not be given as a drink until a year old. However, milk in cooking and milk products (yoghurts and fromage frais) can be introduced from six months. Eggs are best left until 9 months. Nuts should be avoided for at least the first year, but can present a choking hazard until the age of five. The Dietician will be happy to advise you further, if necessary. [back to top]

The Premature or Sick Infant

The reasons behind change of practice for these vulnerable infants are due to the higher risks of nosocomial (hospital acquired) infection, the increased number of carers and the infants compromised immune system.

Research Update

Although the work of Carolyn Lund (Lund et al 1999a, 1999b, 2001a, and 2001b) and the Association of Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses (AWHONN/NANN) provides the benchmark for best practice in neonatal skincare, there are many worthy projects ongoing in the UK.
Prof. Michael Cork (Cork et al 2003a, 2003b) has looked into the adverse effects of emollient use and targeted health education by specialist dermatology nurses. This is vital if the care and treatment of skin conditions, especially eczema, is to be effective.
Prof. Jean Golding and the ALSPAC study team (Lack et al 2003) have researched the link between arachis (peanut) oil used in skin treatments and the subsequent development of peanut allergies in children. In light of this research, and considering the availability of products that include ingredients derived from nuts and/or nut oils, further investigation is indicated. They have also looked at the prevalence of food allergy and intolerance in the under sevens (Northstone K et al 2002).
Although these studies are not directly related to the neonate, they do highlight the importance of evidence-based guidelines that are easy to follow and are implemented with support from qualified staff. They also emphasize the need for great care when choosing products for treatment and dietary advice, all of which have the potential to harm as well as heal. [back to top]