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Mechanism for Prevention of Infection in Preterm Neonates by Topical Emollients: A Randomized, Controlled Clinical Trial

Darmstadt, Gary L. MD, MS*; Ahmed, Saifuddin PhD; Ahmed, ASM Nawshad Uddin MB BS, FCPS; Saha, Samir K. PhD§

The Pediatric Infectious Disease Journal: November 2014 - Volume 33 - Issue 11 - p 1124–1127
doi: 10.1097/INF.0000000000000423
Original Studies

Background: Topical applications of emollients such as sunflower seed oil and Aquaphor have been shown to reduce the incidence of bloodstream infections and mortality of preterm infants in resource-poor settings. The causal mechanism for prevention of infection through cutaneous portals of entry is not well understood.

Methods: We examined the relationship between skin condition score as a measure of skin barrier integrity and risk for bloodstream infection, and the effect of emollients on that relationship. Data for this study come from a randomized controlled trial of the impact of topical emollient therapy on nosocomial infections in 491 preterm infants <33 weeks gestational age at Dhaka Shishu Hospital, Bangladesh. Latent growth trajectory model with random-coefficient and multivariable logistic regression were utilized.

Results: Rate of deterioration of skin condition was significantly lower (P < 0.05) in both emollient arms compared with the untreated control group. Adjusted odds ratio of skin score for infection was 1.32 (95% confidence interval: 1.06–1.65). Emollients reduced the incidence of infection only when the skin had no signs of deterioration [Aquaphor incidence rate ratio: 0.43 (95% confidence interval: 0.19–0.97) and sunflower seed oil incidence rate ratio: 0.46 (95% confidence interval: 0.21–0.99)].

Conclusion: Skin condition deteriorated progressively after birth and compromised skin condition increased the risk of infection. Emollients preserved skin integrity and thus prevented infection in preterm neonates. To optimize benefits of emollients for the prevention of bloodstream infection, use of emollients should begin immediately after birth when the skin is still intact.

From the *Global Development Division, Bill and Melinda Gates Foundation, Seattle, WA; Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Department of Neonatology; and §Department of Microbiology,Dhaka Shishu (Children) Hospital, Dhaka, Bangladesh.

Accepted for publication May 15, 2014.

This study was supported by the Thrasher Research Fund; the Office of Health, Infectious Diseases and Nutrition, Global Health Bureau, United States Agency for International Development (award HRN-A-00-96-90006-00); Save the Children/USA through a grant from the Bill & Melinda Gates Foundation and the Society for Pediatric Dermatology. SSO was provided by Omega Nutrition. Aquaphor Original Emollient Ointment was donated by Beiersdorf. The funders had no role in study design, study conduct, data analysis or interpretation, manuscript preparation or the decision to publish the article. The opinions expressed herein are those of the authors and do not necessarily represent the views of their institutions or the sponsors.

The authors have no other funding or conflicts of interest to disclose.

Address for correspondence: Gary L. Darmstadt, MD, MS, Global Development Division, Bill and Melinda Gates Foundation, PO Box 23350, Seattle, WA. E-mail: gary.darmstadt@gatesfoundation.org.

© 2014 by Lippincott Williams & Wilkins, Inc.