PROTECTION OF THE NAPPY AREA & PREVENTION OF NAPPY RASH

Nappy rash is a common condition among infants (*) and one that resonates with both health visitors and mothers alike.






Publication: Community Practitioner
Author: Hempel, Sandra
Date published: December 1, 2011

Nevertheless, many mothers appear not to be receiving the most up-to-date advice about how to help prevent their baby from developing the condition. Most health visitors (57 per cent) recommend that mothers use nappy cream only when signs of nappy rash appear, while over three-quarters (78 per cent) do not recommend using any product for prevention, according to a survey. (2) Yet new evidence shows that regular use of a cream improves skin barrier function. (3) This can help to stop the cycle of factors that lead to nappy rash becoming established. See article 1: The science of nappy skin

The main function of the outer skin layer, or stratum corneum (SC) is to keep the loss of water from the cells (transepidermal water loss or TEWL) to a minimum while at the same time acting as a barrier, preventing toxic substances and organisms from entering the body.(') Any damage to the SC risks compromising these two vital functions^1) which makes protection esssential.

Nappy creams provide a lipid film over the surface of the skin and/or supply lipids that can penetrate the SC, mimicking the effects of the normal intercellular lipids. (4) Lipids are a group of fatty acids or their derivatives, insoluble in water, that include oil and wax. They are naturally present in the skin and play a major role in maintaining the skin's function as a barrier.

Ideally, a nappy cream contains lipids similar to those naturally present in the SC, such as cholesterol, free fatty acids and ceramides,(5) forming a strong, long-lasting lipid shield that protects the skin while preventing excessive TEWL.(')

A review by a leading paediatric dermatologist at Great Ormond Street Hospital concluded that positive action was needed in order to prevent nappy rash.(') This should comprise of gentle cleansing, the careful selection of nappies, changing the nappy as soon as possible after defaecation, and the application of a suitable barrier preparation, at every change.

A barrier preparation could be used either to reinforce normal skin whose SC was under stress from outside and was, therefore, at risk of damage - i.e. the prevention of nappy rash - or in an attempt to restore the function of an already damaged SC, as a treatment. But if healthcare professionals and parents followed the routine of changing the baby as soon as possible after the nappy was soiled, gentle cleansing and then following up with a suitable barrier preparation then the result would be a decrease in the incidence and severity of the condition, the author concluded.(')

At the same time the specialist called for controlled clinical trials to evaluate the use of barrier preparations on baby skin.(') Now a relevant study has been published. The research team responsible for the new evidence say that while full-term healthy newborns have an anatomically well-developed skin, their epidermal barrier function is distinctly different from that of adults and is prone to dermatitis and infection, (3) adding that appropriate skin care is of particular interest in newborns to maintain the natural adaptation of the skin barrier. While skin care regimens varied and were based on tradition in many countries, the influence of commercially available topical baby products on skin barrier function had not been scientifically investigated during the neonate period, the team say.

They therefore compared the results of three skin care regimens with water alone on the skin barrier function of 64 infants. The babies, all under 48 hours old, were randomly assigned to receive twice-weekly bathing with wash gel; bathing and cream; bathing with wash gel and cream, or bathing with water over a period of eight weeks. The researchers measured several skin parameters including TEWL, SC hydration, skin pH and sebum (the fluid that lubricates the skin) on day two and at weeks two, four and eight of life on the front (uncovered skin), abdomen, thigh and buttocks. (3)

TEWL is a key indication of skin barrier function - a lower TEWL indicates a more effective skin barrier. (6) After eight weeks, TEWL was lower at all the skin sites tested in babies treated with twice- weekly bathing and the application of cream compared with bathing with water, indicating that applying cream helps to keep skin more hydrated and healthy than using water alone. (3)

Clearly more research is required in this important area. To best advise mothers, health visitors need hard evidence about the skincare regimen that will best protect the particularly vulnerable skin in the nappy area and help to prevent a distressing condition that can lead to infection. Researchers now do appear to be turning their attention to this topic. More work is currently underway that will add to the body of knowledge and translate into evidence-based practice to help ensure infant nappy skin stays healthy and intact. In particular a randomised, assessor-blinded, controlled study comparing the effectiveness of infant skin-cleansing products with that of water is soon to be published.

1 . Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current Medical Research and Opinion 2004;20(5):645-9.

2. Healthcare Professional Audit, Durdle Davis, November 2009.

3. Bartels, N.C, Scheufeie, R. et al. Effect of Standardized Skin Care Regimens on Neonatal Skin Barrier Function in Different Body Areas. Pediatric DermatologyVol.27No.l 1-8,2010.

4. Clark C, Hoare C. Making the most of emollients. Pharm J 2001;266:227-9

5. Darmstadt GL, Dinulos JG. Neonatal skin care. Pediatr Clin North Am 2000;47(4):757-82

6. Pinnagoda J, Tupker RA, Agner TA et al. Guidelines for transepidermal water loss (TEWL)measurements: a report from the Standardization Group of the European Society of Contact Dermatitis. Contact Dermatitis 1990;22:164-178.

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