Following the bath, some nurses and parents will apply an emollient to the skin. Yet, there is little consensus to date about the routine use of emollients for full-term newborns.45 One study reports improved skin parameters in healthy full-term infants when the skin care regime included “baby cream” emollient after bathing, and did not adversely affect bacterial skin colonization.35 Pilot studies have been initiated to determine whether routine emollient therapy immediately following the bath may benefit infants at risk for the development of atopic dermatitis,46 and larger trials are being proposed.
A large trial in pediatric intensive care units in 5 US hospitals reported a 36% reduction in bacteremia in patients receiving daily CHG bathing.62 This study utilized a cluster-randomization strategy by type of unit (cardiac, medical, or surgical); in each hospital there was 1 unit that used the CHG bathing, and 1 that used soap and water baths. They report results of both the “intention to treat” (ITT) and “per protocol” (PP) populations. The ITT group included all eligible patients (older than 2 months, ICU stay predicted to be >2 days). The PP group was half the size of the ITT group, with patients excluded for length of stay less than 2 days, if parents either refused to consent to CHG bath or were not available to give consent. In the ITT group, the risk of bacteremia did not differ compared with standard bathing practices, but the PP group (64% of the study population) showed significantly fewer infections. It is important to note that infants younger than 2 months were not enrolled due to the FDA exclusion of this population at the time of the study. The median time of treatment was 3 days, with a range of 1 to 119 days, and the average age was 4 to 6 years, but a small number of infants 3 months and older were included. One percent of the children experienced skin irritation.
Absorption of CHG was first reported in 1973; preterm and term infants had detectable amounts of CHG in the blood after an initial bath with CHG, and daily bathing.67 This finding was difficult to interpret because the samples were obtained via heel stick and therefore they may have been contaminated because CHG clings to the cells of the stratum corneum even after rinsing. A more recent study of CHG antisepsis for central-line placement in infants more than 1500 g found that 7 of the 10 infants who had levels obtained after initial skin preparation and weekly antisepsis with dressing changes had detectable CHG concentrations, ranging from 13 to 100 μg/L.68 In another study, 10 of the 20 premature infants (mean gestational age 28 weeks) had detectable levels of CHG, ranging from 1.6 to 206 μg/L after one limb was “washed” with 2% aqueous CHG before placement of a central venous catheter.69
Because of concerns about potential neurotoxicity, a laboratory study was undertaken by the National Institutes of Health.70 Neurotoxicity was assessed using an established in vitro model of neurite cells exposed to both CHG and HCP at levels seen with the highest levels detected in a newborn after topical exposure.67 They reported that CHG inhibited L1-mediated neurite growth, and concluded that it is important to determine whether the blood–brain barrier is permeable to CHG in premature infants. In addition to concerns of potential toxicity from absorption, the effect of antimicrobial cleansing on skin colonization with microorganisms and on the healthy microbiome of the skin in infancy is unknown.
1. Colwell A. To bathe or not to bathe: the neonatal question. Neonatal Netw. 2015; 34:216–219.
2. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal Skin Care: Evidence-based Clinical Practice Guideline. 3rd ed. Washington DC: AWHONN; 2013.
3. Demott K, Bick D, Norman R. Clinical Guidelines and Evidence Review for Post Natal Care: Routine Post Natal Care of Recently Delivered Women and Their Babies. London, England: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2006.
4. World Health Organization, United Nations Population Fund, UNICEF, The World Bank. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Geneva, Switzerland: WHO; 2013.
5. Behring A, Vezeau TM, Fink R. Timing of the newborn first bath: a replication. Neonatal Netw. 2003;22:39–46.
6. Varda KE, Behnke RS. The effect of timing of initial bath on newborn's temperature. J Obstet Gynecol Neonatal Nurs. 2000;29:27–32.
7. Penny-MacGillivray T. A newborn's first bath. When? J Obstet Gynecol Neonatal Nurs. 1996;25:481–487.
8. Bergstrom A, Byaruhanga R, Okong P. The impact of newborn bathing
on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial. Acta Paediatr. 2005;94:1462–1467.
9. Sobel H, Silvestri M, Mantaring J, et al. Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatr. 2011;100:1127–1133.
10. Nako Y, Harigaya A, Tomomasa T, et al. Effects of bathing
immediately after birth on early neonatal adaptation and morbidity: a prospective randomized comparative study. Pediatr Int. 2000;42:517–522.
11. Preer G, Pisegna JM, Cook JT, et al. Delaying the bath and in-hospital breastfeeding rates. Breastfeed Med. 2013;8:485–490.
12. Cooper BM, Holditch-Davis D, Verklan MT, et al. Clinical outcomes of late preterm infants evidence-based practice project. JOGNN. 2012;41:774–785.
13. Visscher M, Narendran V, Pickens W, et al. Vernix caseosa in neonatal adaptation. J Perinat. 2005;25:440–446.
14. Moraille R, Pickens W, Visscher M, Hoath S. A novel role for vernix caseosa as a skin cleanser. Biol Neonate. 2005;87:8–14.
15. Tollin M, Bergsson G, Kai-Larsen Y, et al. Vernix caseosa as a multi-component defence system based on polypeptides, lipids and their interactions. Cell Mol Life Sci. 2005;62:2390–2399.
16. Walker V, Akinbi H, Meinzen-Derr J, et al. Host defense proteins on the surface of neonatal skin: implications for innate immunity. J Peds. 2008;152:777–781.
17. Cole J, Brissette N, Lunardi B. Tub baths or sponge baths for newborn infants? Mother Baby J. 1999;4:39–43.
18. Anderson GC, Lane AE, Chang H. Axillary temperature in transitional newborn infants before and after tub bath. Appl Nurs Res. 1995;8:123–128.
19. Hylen A, Karlsson E, Svatberg L, et al. Hygiene for the newborn: to bathe or to wash? J Hyg. 1983;91:529–534.
20. Hennigsson A, Nystrom B, Tunnel R. Bathing
or washing babies after birth. Lancet. 1981;19:1401–1403.
21. Bryanton J, Walsh D, Barrett M, et al. Tub bathing
versus traditional sponge bathing
for the newborn. J Obstet Gynecol Neonatal Nurs. 2004;33:704–712.
22. Loring C, Gregory K, Gargan B, et al. Tub bathing
improves thermoregulation of the late preterm infant. J Obstet Gynecol Neonatal Nurs. 2012;41:171–179.
23. Gregory K. Microbiome aspects of perinatal and neonatal health. J Perinat Neonatal Nurs. 2011;25:158–162.
24. Dominguez-Bello M, Costello E, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Prac Natl Acad Sci USA. 2010;107:11971–11975.
25. Watson J, et al. Community-associated methicillin-resistant Staphylococcus aureus
infection among healthy newborns—Chicago and Los Angeles County. MMWR. 2006;55:329–332.
26. Dominguez-Bello M, De Jesus-Laboy K, Shen N, et al. Partial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer. Nat Med. 2016;22:250–253.
27. Medves J, O'Brien B. Does bathing
newborns remove potentially harmful pathogens from the skin? Birth. 2001;28:161–165.
28. Hoeger P, Enzmann C. Skin physiology of the neonate and young infant: a prospective study of functional skin parameters during early infancy. Pediatr Dermatol. 2002;19:256–262.
29. Yosipovitch G, Maayan-Metzger A, Merlob P, et al. Skin barrier properties in different body areas in neonates. Pediatrics. 2000;106:105–108.
30. Behrendt H, Green M. Patterns of Skin pH
From Birth Through Adolescence. Springfield, IL: Charles C. Thomas; 1970.
31. Fox C, Nelson D, Wareham J. The timing of skin acidification in very low birth weight infants. J Perinat. 1998;18:272–275.
32. Bornkessel A, Flach M, Arens-Corell M, et al. Functional assessment of a washing emulsion for sensitive skin: mild impairment of stratum corneum hydration, pH, barrier function, lipid content, integrity and cohesion in a controlled washing test. Skin Res Tech. 2005;11:53–60.
33. Gfatter R, Hackl P, Braun F. Effects of soap and detergents on skin surface pH, stratum corneum hydration and fat content in infants. Dermatology. 1997;195:258–262.
34. Lavender T, Bedwell C, Roberts SA, et al. Randomized, controlled trial evaluating a baby wash product on skin barrier function in healthy, term neonates. J Obstet Gynecol Neonatal Nurs. 2013;42:203–214.
35. Garcia Bartels N, Scheufele R, Prosch F, et al. Effect of standardized skin care regimens on neonatal skin barrier function in different body areas. Pediatr Dermatol. 2010;27:1–8.
36. Dizon M, Galzote C, Estanislao R, et al. Tolerance of baby cleansers in infants: a randomized controlled trial. Indian Pediatr. 2010;47:959–963.
37. Liaw J-J, Yang L, Yuh Y-S, Yin T. Effects of tub bathing
procedures on preterm infants' behavior. J Nurs Res. 2006;14:297–305.
38. Tapia-Rombo CA, Morales-Mora M, Alvarez-Vazquez E. Variations of vital signs, skin color, behavior and oxygen saturation in premature neonates after sponge bathing
. Possible complications. Rev de Investigación Clín. 2003;55:438–443.
39. Lee HK. Effects of sponge bathing
on vagal tone and behavioural responses in premature infants. J Clin Nurs. 2002;11:510–519.
40. Peters KL. Bathing
premature infants: physiological and behavioral consequences. Am J Crit Care. 1998;7:90–100.
41. Quinn D, Newton N, Piecuch R. Effect of less frequent bathing
on premature infant
skin. J Obstet Gynecol Neonatal Nurs. 2005;34:741–746.
42. Franck L, Quinn D, Zahr L. Effect of less frequent bathing
of preterm infants on skin flora and pathogen colonization. J Obstet Gynecol Neonatal Nurs. 2000;29:584–589.
43. da Cunha M, Procianoy R. Effect of bathing
on skin flora of preterm newborns. J Perinat. 2005;25:375–379.
44. Fern D, Graves C, L'Huillier M. Swaddled bathing
in the newborn intensive care unit. Newborn Infant
Nurs Rev. 2002;2:3–4.
45. Ervin E, Miller H. Emollient use in the term newborn: a literature review. Neonatal Netw. 2015;34:227–230.
46. Simpson E, Berry T, Brown P, et al. A pilot study of emollient therapy for the primary prevention of atopic dermatitis. J Am Acad Dermatol. 2010;63:587–593.
47. Nopper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ, Lane AT. Topical ointment therapy benefits premature infants. J Pediatr. 1996;128:660–669.
48. Lane AT, Drost SS. Effects of repeated application of emollient cream to premature neonates' skin. Pediatrics. 1993;92:415–419.
49. Edwards W, Connor J, Soll R Vermont Oxford Skin Care Study Group. The effect of prophylactic ointment therapy on nosocomial sepsis rates and skin integrity in infants with birth weights of 501–1000 g. Pediatrics. 2004;113:1195–1203.
50. Darmstadt GL, Saha SK, Ahmed AS, et al. Effect of skin barrier therapy on neonatal mortality rates in preterm infants in Bangladesh: a randomized, controlled, clinical trial. Pediatrics. 2008:121:522–529.
51. American Academy of Pediatrics & American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 8th ed. Elk Grove Village, IL: American Academy of Pediatrics & American College of Obstetricians and Gynecologists; 2013.
52. Centers for Disease Control and Prevention. Leads from the MMWR. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings. JAMA. 2006;260:462–465.
53. Sankar M, Paul V. Efficacy and safety of whole body skin cleansing with chlorhexidine in neonates—a systematic review. Pediatr Infect Dis J. 2013;32:e227–e234.
54. Mullany LC, Khatry SK, Sherchand JB, et al. A randomized controlled trial of the impact of chlorhexidine skin cleansing on bacterial colonization of hospital-born infants in Nepal. Pediatr Infect Dis J. 2008;27:505–511.
55. Darmstadt GL, Hossain MM, Choi Y, et al. Safety and effect of chlorhexidine skin cleansing on skin flora of neonates in Bangladesh. Pediatr Infect Dis J. 2007;26:492–495.
56. da Cunha ML, Procianoy RS, Franceschini DT, De Oliveira LL, Cunha ML. Effect of the first bath with chlorhexidine on skin colonization with Staphylococcus aureus
in normal healthy term newborns. Scand J Infect Dis. 2008;40:615–620.
57. Sankar MJ, Paul V, Kapil A, et al. Does skin cleansing with chlorhexidine affect skin condition, temperature and colonization in hospitalized preterm low birth weight infants? A randomized clinical trial. J Perinatol. 2009;29:795–801.
58. Climo M, Yokoe D, Warren D, et al. Effect of daily chlorhexidine bathing
on hospital-acquired infection. N Engl J Med. 2013;368:533–542.
59. Karki S, Cheng A. Impact of non-rinse skin cleansing with chlorhexidine gluconate
on preventions of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect. 2012;82:71–84.
60. Boonyasiri A, Thaisiam P, Permpikul C, et al. Effectiveness of chlorhexidine wipes for the prevention of multi-drug resistant bacterial colonization and hospital-acquired infections in intensive care unit patients: a randomized trial in Thailand. Infect Control Hosp Epidemiol. 2016;37:245–253.
61. Popovich KJ, Hota B, Hayes R, et al. Daily skin cleansing with chlorhexidine did not reduce the rate of central-line associated bloodstream infection in a surgical intensive care unit. Intensive Care Med. 2010;36:854–858.
62. Milstone A, Elward A, Song X, et al. Daily chlorhexidine bathing
to reduce bacteraemia in critically ill children a multicentre, cluster-randomised, crossover trial. Lancet. 2013;381:1099–1106.
63. Quach C, Milstone AM, Perpete C, et al. Chlorhexidine bathing
in a tertiary care neonatal intensive care unit: impact on central line-associated bloodstream infections. Infect Control Hosp Epidemiol. 2014;35:158–163.
64. Robertson A. Reflections on errors in neonatology: II. The “heroic” years, 1950 to 1970. J Perinat. 2003;23:154–161.
65. MMWR. Neuropathology in newborn infants bathed with hexachlorophene. MMWR. 1973;22:93–94.
66. Anderson J, Clockburn F, Forfar J, et al. Neonatal spongioform myelinopathy after restricted application of hexacholorophene skin disinfectant. J Clin Pathol. 1981;34:25–29.
67. Cowen J, Ellis S, McAinsh J. Absorption of chlorhexidine from the intact skin of newborn infants. Arch Dis Child. 1979;54:379–383.
68. Garland JS, Alex CP, Uhing MR, Peterside IE, Rentz A, Harris MC. Pilot trial to compare tolerance of chlorhexidine gluconate
to povidone-iodine antisepsis for central venous catheter placement in neonates. J Perinatol. 2009;29:808–813.
69. Chapman AK, Aucott SW, Milstone AM. Safety of chlorhexidine gluconate
used for skin antisepsis in the preterm infant. J Perinatol. 2012;32:4–9.
70. Milstone A, Bamford P, Aucott S, et al. Chlorhexidine inhibits L1 cell adhesion molecule mediated neurite outgrowth in vitro. Pediatr Res. 2014;75:8–13.
71. Hartz LE, Bradshaw W, Brandon DH. Potential NICU environmental influences on the neonate's microbiome. Adv Neonatal Care. 2015;15:324–335.