From the Journals

Warmth and moisture help keep preterm neonates’ skin healthy



Tub bathing, emollients, and even plastic dressings can protect the fragile skin of preterm infants during the first few crucial weeks of extrauterine life.

Ayan Kusari

Ayan Kusari

The skin of premature infants is very fragile and can take up to 4 weeks to become cornified. Until then, it’s apt to rapidly lose water and heat, putting babies at risk of hypothermia, dehydration, and electrolyte imbalances, Ayan Kusari and his colleagues wrote in Pediatric Dermatology.

The team examined evidence-based skin care in these tiny patients, extracting recommendations from a meta-analysis of 68 studies.

“There are a number of unifying features that distinguish preterm skin from term skin,” wrote Mr. Kusari, a clinical research associate at the Rady Children’s Hospital–San Diego, and his associates. “Preterm skin is thinner, making preterm neonates more susceptible to skin infections and caustic agents. The vernix caseosa is typically thicker in preterm neonates [though thinner in extremely preterm neonates]. Accordingly, there are a number of general principles that can guide skin care for most preterm neonates.”


The team identified eight studies of bathing preterm neonates and concluded that a daily bath isn’t necessary.

“Colonization by pathogenic bacterial strains, size of the total bacterial population, and incidence of skin infection do not vary between preterm infants bathed every 2 days and preterm infants bathed every 4 days in all studies,” the authors wrote.

These less frequent baths appear to decrease the risk of temperature variability, and tub baths are preferable to sponge baths. “In sponge bathing, wet skin is more exposed to ambient air, which is typically colder than body temperature. Physiological and behavioral parameters in preterm infants are often disrupted during sponge bathing. In contrast, tub bathing results in less variability in body temperature and warmer temperatures after bathing,” Mr. Kusari and his associates found.

However, premoistened baby wipes appeared beneficial, lowering skin pH, which might help “facilitate acid mantle development, infection control, and barrier repair,” they wrote.


Seven studies and one meta-analysis examined the use of emollients in preterm infants; there was agreement that emollients do improve skin condition. Plant-based emollients appeared superior to petrolatum-based products.

“In developing countries where oil massage of infants and children is traditional, there appears to be a clear benefit to massage with some oils. In developed countries, research has emphasized petrolatum-based creams and ointments, whose benefits are tempered by the increased risk of serious infections with some products,” Mr. Kusari and his colleagues wrote.

Sunflower seed oil was particularly beneficial in studies carried out in developing countries. A mixture of 70% lanolin and 30% olive oil proved better than olive oil alone. Coconut oil also displayed positive impact on skin condition.

“In contrast, multiple studies show an increased risk of sepsis with the application of petrolatum ointment to preterm neonates,” they noted.

In one study, following the adoption of a new skin care protocol involving regular application of petrolatum‐based ointments for extremely low-birth-weight neonates, researchers in Texas observed a significant, 200% increase in the incidence of systemic candidiasis. A study in Saudi Arabia replicated this finding. The largest study of a petrolatum-based ointment on premature babies was conducted in Vermont and found a statistically significant increase in infection with coagulase-negative staphylococcus (CoNS). “This ... study appears to be the driving force in a Cochrane Database meta-analysis, which concludes that topical emollients are associated with increased CoNS infection in preterm neonates,” the authors wrote.

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