DOI: 10.1111/pde.13714

Pediatric
Dermatology

Neonatal skin care: Developments in care to maintainneonatal barrier function and prevention of diaper dermatitis
Oliver Burdall BSc, MRCh, MRCS1 | Liam Willgress DipHE1 | Nina Goad BA Hons2
1

Norfolk and Norwich University Hospitals
NHS Foundation Trust, Norfolk, UK
2

Skin Health Alliance, London, UK

Correspondence
Nina Goad, BA Hons, Skin Health Alliance,
London, UK.
Email: nina@bad.org.uk

Abstract
Background: Understanding the importance of the barrier function of the skin ofpreterm and term neonates is crucial in effective neonatal skin and diaper care. This
literature search aimed to review the development of different practices in neonatal
care to maintain skin barrier function, in turn preventing diaper dermatitis.
Methods: We performed two quantitative literature searches of English language

Funding information
Funding was provided by the Skin HealthAlliance.

studies: an initial literature search of studies published in the last 5 years was
conducted using Cinahl, Medline, Embase, British Nursing Index, and DelphiS, followed by a second search of publications from 1990 to 2017 using the National
Institute of Clinical Excellence Health Databases Advanced Search using key
words, synonyms, and Boolean phrasing. Titles and abstracts were reviewed forrelevance.
Results: One hundred ten studies were analyzed for the purpose of this review;
however, data are of variable quality. Guidance can be drawn from the existing literature relating to best practice options for diaper area cleansing methods, diaper typeselection, and use of barrier creams. More research is required into the benefit orotherwise of diaper‐free time.
Conclusions: Super‐absorbent diapers reduce moisture at skin level and reduce
diaper dermatitis. Barrier creams carry benefit both in prevention and cure but
do not provide a substitute for frequent diaper changes. The literature does notdemonstrate superiority of one cleansing method over another, but neither theuse of wipes nor water increases diaper dermatitis prevalence. Further studies
are required to explore the potential benefit of diaper‐free time, taking due consideration of the practicalities, particularly for vulnerable neonates within the
Intensive Care setting.
KEYWORDS

contact dermatitis, diaper cleansing, diaper dermatitis, neonatal, skin barrier

1 | INTRODUCTION

affecting the same area, according to features of impacted skinintegrity (ulceration, scaling), rash (papules, edema), and redness

Diaper dermatitis is a broad term used to describe inflammatory(spotty, continuous).2 Methods used to evaluate the severity ofchanges of variable severity in the skin of the diaper area,

diaper dermatitis include clinical evaluation using standardized

namely the lower abdomen, buttocks, perianal, and perineal

scoring systems, and noninvasive measurements of stratum cor-areas.1 Clinical studies generally assess the presence of diaper

neum hydration, skin surface pH, transepidermal water loss, anddermatitis, as distinct from other skin disorders potentiallysebum levels.

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The majority of diaper dermatitis is irritant contact dermatitis,3
with no single causative factor; rather, the skin is subject to a com-“diaper (nappy and napkin) dermatitis (rash).” Titles and abstracts
were reviewed for relevance.

plex interplay of potentially damaging factors.1,4 Neonates with diaper dermatitis demonstrate behavioral changes such as increased
crying, agitation, and changes in eating and sleeping patterns, which

3 | RESULTS

suggest emotional and physical distress.5 The negative impact can
extend beyond the affected individual, with studies highlighting par5

One hundred ten papers were identified as relevant to our topic

ental guilt in response to diaper dermatitis in their charges. This has

and analyzed. Included papers focused on diaper dermatitis as dis-

prompted warning that health care providers educating parents on

tinct from atopic or other forms or contact dermatitis, and on

diaper care should not imply poor parenting, which might affect thepediatric subjects. The selected papers included one Cochraneemotional well-being of parents.6

review, two other systematic reviews, eight randomized control

Within the literature, there is considerable variation in reported

trials, four nonrandomized comparative studies, and seven non-frequency of diaper dermatitis, in part due to study methodology

comparative, observational studies. The remaining papers com-variation and differences in the age of studied cohorts. Estimations

prised partial reviews, single expert opinion, or nonresearch-based

range from 25% of infants to the majority of children being affectededucational pieces. The results are organized into relevant clinical

1,7,8,9,10

to some degree before the age of 2 years.

A US survey of

482 neonatal units looking at extremely low birthweight babies

categories: diaper types, wash products, barrier creams, andcleansing (wipes vs water).

found that an average of 21% suffered skin breakdown during thefirst week of life. The authors also identified reduced rates in centersthat had skin care protocols that limited adhesives and liberally used

4 | TYPES OF DIAPERS

11

barrier cream.

Neonatal skin, especially in the diaper area, is subject to the

The Cochrane review (2006) pointed to the paucity of evidence

stresses of urine, feces, friction, microbes, and chemicals that canwhen looking specifically at types of diapers and their impact on dia-

contribute to compromised barrier function, leading to dermatitis,

per dermatitis incidence. Although the papers reviewed foundinfection, and pain. Effective neonatal skin care for the diaper area

increased diaper dermatitis rates within the populations of infants

therefore aims to maintain barrier function by cleansing the skin ofusing cloth diapers versus disposable, absorbent diapers, the 28

physiologic irritants and reducing excess moisture, without causing

studies identified were heterogeneous, methodologically flawed, andphysical injury, irritation, and potential allergic contact dermatitis inwith low patient numbers. Therefore, though the data within the9

response to exogenous chemicals. The goal of this study was toreview were indicative of benefits of the higher absorbency product,

determine the most appropriate practice for neonatal skin care in

the authors were unable to categorically conclude benefit.12

maintaining barrier function and preventing diaper dermatitis,through a comprehensive review of current literature.

A number of studies, including those reviewed in the Cochrane
process, do, however, indicate that super‐absorbent diapers reducethe moisture at skin level and so reduce diaper rash when compared
to cloth alternatives.

2 | METHODOLOGY

Monterosso et al13 compared neonates who were given cloth
napkins with or without absorbent pads inside. They then measured

Two independent literature searches were performed by two of thethe neonates’ temperature and incubator temperatures required toauthors. An initial literature search of English language papers pub-

maintain their core body temperatures. They found that the babies

lished in the last 5 years was conducted using Cinahl, Medline,with absorbent pads had higher mean core temperatures and lower

Embase, British Nursing Index, and DelphiS, alongside a search of

incubator temperatures. Although the clinical significance of the small

current clinical trials, gray literature, with title, abstracts, and refer-change, 0.04°C, is arguable, this is in keeping with studies that haveence lists reviewed. Search terms used included variations of “neona-shown increased liquid uptake from absorbent diapers. Dutta et al14tal,” “nappy care,” and “barrier function.” However, due to thecompared cloth napkins to absorbent diaper pads for the measure-

limited number of papers found, the decision was made to perform ament of urine output in neonates by pouring known volumes of liquid

second literature search.

into the napkins. They found a 26% deficit with the absorbent pads

The second literature search of English language papers pub-compared to the 12.1% deficit of simple cloth napkins on their own.

lished after 1990 was through the National Institute of ClinicalMany of the studies looking at diaper types comprised partial

Excellence Health Databases Advanced Search; this includes thereviews aimed at education and often single clinician opinions, pub-

PubMed, Medline, British Nursing Index, Health Management Infor-

lished in low impact factor journals, often with the same authorshipmation Consortium Exerpta Medical Database, Cumulative Index toon multiple papers. Despite the low evidence level, however, they

Nursing Allied Health Literature, and Allied and Complimentary

are very consistent. Almost all describe reduced rates of diaper der-Medicine databases. Search terms used included variations ofmatitis with strict cleaning regimes and frequent diaper changes.

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BURDALL ET AL.

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Kamat and Malkani15 specifically reviewed papers looking at dia-peaks at around the age of 9‐12 months;20 therefore, findings in thisper use in a lower-income country setting. Although the studies

age group may help guide our understanding of the condition more

involved were low quality, the results suggested increased spread ofgenerally.

Clostridium Difficile and other communicable pathogens around nurs-

A similar randomized study by the same group attempted toeries that used cloth diapers when compared to disposable diapers,

establish the ideal washing regimen for preservation of skin function.

which is of great importance in both low‐income settings and neona-

Sixty‐four term neonates, under 48 hours old, were divided accord-

tal units anywhere in the world where pathogens can spread very

ing to parent preference into bathing with washing gel; bathing andeasily between vulnerable infants.

barrier cream; bathing, washing gel, and cream; and washing with

The inclusion of super‐absorbent gels (reducing skin moisture),water only. The patients that received barrier cream or washing gelpetrolatum‐based lotions (improving skin integrity), and breathable

with the basic wash twice weekly had significantly lower TEWL on

outer layers (reducing local humidity) into thinner diapers with a bet-

the front, abdomen, and upper leg as well as higher stratum corneum

ter fit to the body's contour has seemingly led to a reduction in thehydration and significantly lower skin pH when compared topresence of erythema and severity of diaper dermatitis.16 It is diffi-

water-only care.21

cult to quantify precisely any declines in the incidence and severityof the condition, as the advent of modern diapers also maps withthe development of newer cleansing products and their wider adop-

6 | DIAPER AREA CLEANSING PRACTICES

6tion into skincare regimens. Nonetheless, it is widely recognizedthat modern disposable diaper technology has successfully reduced

The majority of the evidence around diaper skin care relates to thesome of the main negative impacts of overhydration, increased pH,

comparative effects of cleansing skin with cotton wool/cloth andfriction, and other variables on skin integrity.3 However, while mod-water, versus commercially available wipes (also known as wet wipes

ern diapers undoubtedly meet the hygiene needs of infants, theor diaper wipes). Earlier generations of wipes contained ingredients

occlusive nature of diaper wearing (regardless of type) concomitantly

linked to skin irritation, such as high levels of alcohol, certain fra-increases local humidity, hydration, and pH,17 factors implicated in

grances, and (now limited) preservatives.4,22 Most modern wipes

diaper dermatitis.

constitute manmade fibers and include water, synthetic detergents,
emollients, pH stabilizers/adjusters, and preservatives, and many arealcohol and fragrance‐free.6 However, there is variation between

5 | BARRIER CREAMS AND WASH
PRODUCTS

brands. Disposable wipes differ from one another in terms of theactual structure of the wipe (usually soft cloth substrates) and also
the added constituents, which may include skin conditioning ingredi-

The positive effects of barrier cream are reproduced for treatment

ents, such as dimethicone and glycerin and preservatives to prevent

as well as prevention. A nonrandomized study of 63 newborns sepa-

microbial growth. pH values of the different brands of wipes canrated into breast milk or barrier cream treatment groups found novary.

difference in mean number of clinical improvement days but identi-

Lavender et al22 compared 280 term infants, who were randomly

fied that the postlesion score of the barrier cream group was statisti-

assigned to diaper area care either with wipes, or with cotton wool

cally significantly lower (P = 0.002), suggesting some improvements

and water, from age 48 hours to 4 weeks. Wipes were shown to be

in infants receiving barrier cream.18 Although Rowe et al19 foundequivalent to water and cotton wool in terms of skin hydration,

limited research data in their systematic review, they concluded

transepidermal water loss (TEWL, g⁄m2⁄h; mean 17.8 vs 19.0,

that barrier creams were an effective component of infant skinP = 0.49, 95% CI −3.9 to 1.2), skin surface pH (5.93 vs 5.65) andmanagement.

erythema, and presence of microbial skin contaminants/irritants.

Increased liquid removal from the skin also removes irritants,

Maternal‐reported diaper dermatitis during the course of thesuch as the ammonia in the urine, and so reduces dermatitis and4 weeks was higher in the water group, but this was not reflected in

improves skin function. Two comparative studies on infant diaper

midwife‐reported diaper dermatitis at 4 weeks. The authors con-dermatitis rates measured transepidermal water loss (TEWL), skincluded that wipes had an equivalent effect on skin hydration when

hydration, and pH and found significantly worse results in skincompared to cotton wool and water.

affected by diaper dermatitis.20,21 One study randomized 89, 9‐

In a study of infants by Garcia‐Bartels et al, also in the firstmonth‐old infants into three groups: plain wash cloths only, wash

4 weeks postpartum, 44 healthy, full‐term neonates were again ran-

cloths with diaper cream, and wet wipes (baby wipes) with diaper

domly assigned to skin care with wipes or water‐moistened wash-

cream. Although dermatitis rates were the same across the threecloth at each diaper change, equivalent to approximately eightgroups, the actual TEWL and pH were improved, in the presence oftimes in every 24 hours.17 In addition to the measurement of20

Though the age

TEWL, skin hydration, and skin pH assessed in the Lavendergroup involved in this study would not be categorized as neonates,

study,22 levels of the pro‐inflammatory cytokine interleukin‐1a (IL‐there is an absence of comparable evidence relating to infants in

1a, suggested to influence fetal skin barrier maturation) were mea-

the first weeks of life. Furthermore, incidence of diaper dermatitis

sureddiaper dermatitis, with the diaper barrier creams.

on

days

2,

14,

and

28

postpartum.

Microbiological

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Pediatric
Dermatology

BURDALL ET AL.

colonization was evaluated at baseline and on day 28. All childrenof 5.5, or a rayon and polyester cloth and water, which was theused the same diapers. Bathing was standardized with regard to

standard mode of cleansing at the time of the study within thefrequency, and no additional skin care or wash products were used.

NICU. Measurements of skin condition including skin erythema,

The wipes group had significantly lower TEWL values on the but-skin rash (diaper dermatitis), TEWL, and pH within the diaper area

tock (median 9.60) compared to the water group (11.15) on day

and at control sites were determined daily for up to 14 days. Per-28, potentially indicating a more advanced barrier function in theineal erythema and TEWL were significantly lower for both types

wipes group in the diaper area (higher TEWL values may be indica-of wipes compared to the cloth and water method. The lower pH

tive of compromised skin barrier function). TEWL remained stablewipe produced a significantly lower skin pH than the higher pH

on nondiapered areas of skin in both groups. There was nowipe and the cloth and water method. The authors concluded that

increase in diaper dermatitis in either group. Skin pH, hydration,

both wipes are appropriate for use on medically stable NICU

and microbiological colonization were comparable in both groups.

patients, including both full and preterm infants, and provide more

IL‐1a levels were higher in diapered skin compared to nondiapered

normalized skin condition and barrier function versus the cloth andskin areas but were comparable for both the wipes and water

water standard. Lower pH wipes may facilitate acid mantle devel-groups. These findings suggest that the skin barrier matures at dif-

opment and therefore assist in colonization, infection control, andferent rates according to body site but is not influenced by diaper

barrier repair.23

cleansing technique. The authors therefore conclude that neither
option harms skin barrier maturation.17
The

aforementioned,

subsequent

Recommendations from a European Roundtable Meeting on Best
Practice Healthy Infant Skin Care, published in 2009 and reviewed ininfants

2016, recommend that wipes should contain pH buffers to maintain(9 months ± 8 weeks)20 saw the addition of barrier cream application

study

of

older

slight acidity of the skin and should be free of potential irritants such

twice daily to the wipes group and a third group in which diaper

as alcohol, fragrance, essential oils, soap, and harsh detergents (eg,cream was applied twice daily after cleansing with water‐moistened

sodium lauryl sulfate) and they should contain well‐tolerated preser-

washcloths (plain wash cloths only, wash cloths with diaper cream,

vatives. Drying can be achieved through air‐drying or gentle patting

and wet wipes with diaper cream).20 This time, on diapered skin,with a dry towel or dry cotton balls to avoid scrubbing that can

TEWL values were reduced in the water and diaper cream groupcause barrier disruption.4

only but remained stable in the wipes and barrier cream group andthe water only group. However, interestingly, in the same group
TEWL was lower in nondiapered skin also but again remained stable

7 | DISCUSSION

in the two other groups, for unexplained reasons. Although dermatitis rates were the same across the three groups, the actual TEWL

Diaper rash is a potentially severe and ongoing problem despite

and pH were improved, in the presence of diaper rash, with the dia-

modern diaper technology, with reported incidence ranging fromper barrier creams.20 Importantly, the incidence of diaper dermatitis

25% within the first 4 weeks of life to as much as 100% at somewas comparable in all groups. TEWL was higher in areas of skinpoint in infancy.1,4,6,8,24 The results demonstrate that any practiceaffected by diaper dermatitis than in unaffected skin, indicating thatthat keeps urine and feces away from the skin and that reduces thehigher TEWL is indeed a marker of compromised barrier function.

abrasion will reduce the incidence of diaper dermatitis. The best way

No correlation was found between bacterial and mycologic coloniza-of doing this has to be put into the context of what is practicaltion and diaper care regimen. This study confirms previous findings

within the social circumstances of the family.

that cleansing with wipes or water does not influence diaper der-Super‐absorbent diapers have been shown to reduce the mois-

matitis occurrence, and though this study is in older infants, it isture at skin level and so reduce diaper rash when compared to cloth

worthy of note as it reflects the aforementioned findings in neonates

alternatives.14,21 In alignment with the more recent research, super‐and suggests that these findings extend beyond the first few weeks

absorbent disposable diapers or pads are therefore recommendedof life.

where logistically or financially available.

It may be argued that guidelines for diaper care of preterm

A survey of practice of the care of over 1800 infants in the Uni-

infants in neonatal intensive care unit (NICU) environments are par-ted States showed lower rates of diaper dermatitis with higher fre-ticularly imperative to minimize risk of diaper dermatitis and barrier

quency of diaper changes and longer diaper‐free time.25 In the

disruption in this already vulnerable group. However, a study into

context of community care of a newborn, diaper‐free time is notthis group, outlined below, showed similar results to those in term

often practical. In the neonatal care of an intensive care premature

neonates, with regard to a comparable or even favorable effect onchild with highly immature skin, this may be the best mode of man-TEWL values and skin condition from wipes compared to water andagement, although our search did not identify a study comparing dia-

washcloths/cotton wool.

per use to diaper free time in the care of such children. While data

In the one study identified in our search of cotton wool versus

regarding TEWL vary according to study and age group, no adverse

wipes among NICU patients, 130 infants (gestational age 23‐

effects of using modern wipes versus water for diaper area cleans-

41 weeks, at enrollment 30‐51 weeks) were randomly assigned toing, in terms of increased diaper dermatitis, have been demonstrated

be diaper cleansed using either wipes with pH of 4, wipes with pH

in the literature. However, longer observation periods and a broader

PediatricDermatology

BURDALL ET AL.

cross section of ages would allow for greater insight into the pathophysiology of diaper dermatitis.

8 | CONCLUSION
Diaper dermatitis is best managed by prevention. Current evidence
suggests that super‐absorbent diapers and barrier creams are effective for prevention and treatment of diaper dermatitis. There is alack of data supporting the superiority of wipes over water, or viceversa, in terms of cleaning practices, but neither method seems tobe associated with higher incidence of diaper dermatitis.17,20,22,23
Modern disposable diaper technology has successfully reduced someof the main negative impacts of overhydration, increased pH, friction, and other variables on skin integrity.

ORCID
Nina Goad

http://orcid.org/0000-0002-6038-2018

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How to cite this article: Burdall O, Willgress L, Goad N.
Neonatal skin care: Developments in care to maintainneonatal barrier function and prevention of diaper dermatitis.
Pediatr Dermatol. 2019;36:31–35.
https://doi.org/10.1111/pde.13714