Cleansing the Neonatal Diaper Area: A Literature Review

Introduction

The skin of the neonatal diaper area is a unique environment that is exposed to a combination of hostile insults such as urine, faeces, occlusion and frequent cleansing. As a consequence, neonatal napkin dermatitis affects up to 25% of nappy-wearing infants within the first four weeks of life.¹

New parents are often torn between guidance from health professionals who tend to recommend using cooled boiled water and cotton wool balls or using baby wipes, which in turn differ in their ingredients. This literature review will examine our current understanding of neonatal skin, napkin dermatitis and evidence-based cleansing practices of the diaper area.

Neonatal skin structure

The structure and function of newborn skin transforms rapidly during the early weeks of development. Baby skin is prone to greater transepidermal water loss (TEWL) and reduced stratum corneum hydration resulting in a less effective skin barrier.²

Skin pH decreases during the first 1–4 days of life and continues further over the first three months. A higher skin pH in babies may reduce stratum corneum integrity and enhance susceptibility to mechanical trauma. Skin pH in the diaper area has been shown to be higher than in non-diaper areas in newborns vs day 14. ³

The unique environment of the diaper area and implications for newborn skin care

Routine skin care can introduce frictional forces and irritants from cleansing products and wipes.² Moreover, nappies themselves keep the skin in a humid occluded state.⁴

Effective neonatal diaper skin care

Diaper skin care requires adequately cleansing the skin of physiological irritants while maintaining barrier function and without causing physical injury, irritation and potential allergic contact dermatitis in response to exogenous chemicals.⁵

Diaper area cleansing practices – Cotton wool and water or wipes?

In the UK, the use of cotton wool and water is the general recommendation to parents by midwives and health visitors.6 However, to date, five studies have shown comparability or superiority of baby wipes over water and cloth/cotton balls to clean diapered skin.^7–12

There is a readiness among parents to adopt baby wipes¹³

Water alone may not cleanse sufficiently 

• Easier to pack
• Convenient
• Allow consistent water quality even when away from home

What is the impact of wipe formulation?

A recent, prospective study (The BaSICS study) compared the effects of three different branded baby wipes on the incidence and duration of moderate-t-osevere diaper dermatitis (nappy rash) from birth to eight weeks of age.¹² The study identified that babies cleansed with the brand with the fewest ingredients (containing only ultra pure water and fruit extract) had fewer days of clinically significant nappy rash. Suggesting that using wipes with minimal ingredients has an added benefit. ¹⁴

Duration of moderate-to-severe nappy rash in the BaSICS study compared with Brand 3 (brand with the fewest ingredients)¹⁴ 

The importance of water quality

In the UK, 60% of people live in hard water areas.15 Studies support a role for softened/ultra pure water in maintaining the skin barrier function compared with domestic tap water, particularly in neonates who are susceptible to atopic dermatitis.16–18 Mechanisms proposed to be behind this phenomenon include increased deposition of detergents on the skin, altered calcium signalling and a rise in skin surface pH, all of which can potentially have adverse effects on the skin barrier function.18

Properties of purified water16

• No bacteria/microorganisms
• No minerals such as magnesium and calcium, which contribute to hard water
• Lower pH than tap water (5 vs 7) 

Conclusions

• The use of wipes to cleanse the diaper/napkin area appears comparable or superior to water and cotton wool/cloth methods
• A recent study supports the use of wipes with minimal ingredients (ultra pure water and fruit extract only) in the prevention of napkin dermatitis 

References

1. Philipp R, et al. Br J Gen Pract 1997;47:493–497;
2. Chiou YB, Blume-Peytavi U. Skin Pharmacol Physiol 2004;17(2):57-66;
3. Visscher MO, et al. Clin Dermatol 2015;33(3):271-280;
4. Visscher M, Narendran V. Newborn Inf Nurs Rev 2014; 14(4):135–41;
5. Collier M. British Journal of Nursing 2016;25(20):26-32;
6. National Institute for Health and Care Excellence. Postnatal care up to 8 weeks after birth [CG37] [online] 2006. Last Accessed 01.09.21 - Available from: https://www.nice.org.uk/guidance/cg37;
7. Rodriguez KJ, et al. Pediatr Dermatol. 2020;37:447– 454;
8. Ehretsmann C, et al. J Eur Acad Dermatology Venereol 2001;15(Supplement 1):16-21;
9. Lavender T, et al. BMC Pediatrics 2012;12(59);
10. Adam R, et al. Pediatr Dermatol 2009;26(5):506-13;
11. Visscher M, et al. Neonatology 2009;96(4):226-234;
12. Garcia Bartels N, et al. Pediatr Dermatol 2012; 29:270-276;
13. Furber C, et al. J Obstet Gynecol Neonatal Nurs 2012;41(6):E13-25;
14. Price A, et al Pediatr Neonatol 2021;62(2):138-145;
15. Source: Thames Water UK;
16. Jabbar-Lopez ZK et al. BMJ Open 2019;9(8):e027168;
17. Tanaka A, et al. Acta Derm Venereol 2015;95:787-791;
18. Danby SG, et al. J Invest Dermatol 2018;138(1):68-77.