Newborn Skin


New born skin

Skin is the largest organ of the human body. Skin has many functions such as protective barrier and immunological functions (such as protection from ultraviolet rays, invasion of microbes and external antigens), thermoregulation, healing of wounds, synthesis of nutrients like Vitamin D, sensory and autonomic functions, and sociosexual functions[1]. Newborn skin is not the miniature of the adult skin [2], hence newborn and infant skin require special care.

Differences Between Adult And Term Or Preterm Newborn Skin
    • Newborn skin is 20 to 30% thinner than adult skin.
    • The skin of newborns is less hydrated and has reduced natural moisturizing factor compared to adults.
    • Body surface area to the weight ratio in a term neonate is up to 5 times that of an adult and in preterm, it is 7 times that of an adult [3].
    • The stratum corneum of a preterm baby is thinner than that of a term baby.
    • At birth pH of newborn skin is slightly acidic (6.4) whereas the adult skin has acidic pH from 5 to 5.5. Alkaline pH (in some baby wipes and soap) predisposes newborns to diaper dermatitis and favors colonization of Staphylococcus aureus and Candida albicans.

The skin of the newborn undergoes structural and functional modifications from birth to almost the first year of life as an adaptation from the intrauterine wet world to the extrauterine dry environment. The structural and functional immaturity of the skin of a preterm baby results in increased transepidermal water loss, susceptibility to mechanical trauma, microbial invasion, and percutaneous absorption of toxins. In order to reduce the morbidity associated with immature skin barrier, optimum care for the skin of a newborn is essential.

Cleansing of newborn skin

Cleansing is a process of removal of dirt, sebum, microorganisms, exfoliated corneum cells from the skin surface. Water removes the water-soluble dirt leaving the fat-soluble particles.


Cleansers are surface-active substances that emulsify the fat-soluble particles and convert them into the water-soluble matter which can be washed off in the water. Today a wide variety of soaps, special soaps, and liquid cleansers are available in the market.

Cleansers are classified into three categories namely true soaps, syndet bars and combars.

Soaps are fatty acids derived from animal fat or vegetable fat processed with sodium or potassium hydroxide by saponification. True soaps are composed of long-chain fatty acid-alkali salts with a pH between 9 and 10. The high alkaline nature causes dissolution of lipids from the skin surface, disruption of the acid mantle and stratum corneum barrier and raises the pH of the skin. The use of soap particularly in diseased skin may cause dryness and irritation of the skin resulting in redness and itching.

Syndets or synthetic detergents are synthetically derived organic quaternary ammonium compounds or polymerized or sulfonated fatty acids. They have a pH of 5.5 to 7. They are less likely to produce dryness and irritation of the skin.

Combars are composed of alkaline soaps to which surface-active agents with a pH of 9 and 10 are added. They are milder cleansers than true soaps.

Other variants – Soapless cleansers are lotions that are primarily composed of either glycerine or propylene glycol and cetyl/stearyl alcohols and they can be wiped off without using water. Liquid cleansers with the appropriate blend of anionic, non-ionic, and amphoteric surfactants are available. They are milder in nature and do not disrupt the skin barrier or acid mantle.

An ideal skin cleanser is one that is mild and has minimal interaction with skin and removes all unwanted materials from the skin. It should not affect the acid mantle of the skin surface. It should be colorless and fragrance-free and should not irritate the skin or eyes.


Shampoos that are available in the market are soapless and consists of principal surfactant for detergent and foaming power, secondary surfactants to improve and condition the hair and additives to complete the formulation and special effects. Formaldehyde is the most common preservative used in shampoos and does not cause any side effects due to the short contact. Baby shampoos should be ideally fragrance free and should not cause eye irritation. Medicated shampoos with ketoconazole, tar, zinc pyrithione, salicylic acid are available for special hair conditions.

Care of the newborn skin

Gentle cleansing

Maintenance of hydration and moisturization

Protection from irritants

Prevention of friction and maceration in the body fold

Vernix caseosa [4]

It is a naturally occurring complex, lipid-rich substance coating the skin surface of the newborn. It is a chalky white material with shed epithelial cells, sebum, and sometimes lanugo hair. Preterm babies have very little vernix compared to term babies and post-term babies may not have vernix. Vernix is highly beneficial. It is a natural cleanser and moisturizer with anti-infective, antioxidant, and wound healing properties. It helps in the development of acid mantle and supports normal bacterial colonization. WHO guidelines mention that vernix should not be removed at the time of birth.

Bath of the newborn

WHO guidelines mention that the initial bath for term newborn should be given 6 hours after birth. Any term baby who weighs more than 2.5 kgs could be given bath 6 hours after birth. In term IUGR babies only a sponge bath is to be given until the baby’s weight crosses 2.5 kgs. There are some studies that have advocated bath after fall of the umbilical cord. Bathing makes the baby calmer and quieter than washing with a cloth or sponge. The tactile stimulation that occurs during bathing provides a pleasurable experience for the baby and promotes the bonding between the baby and the parent or the caregiver.

How to give a bath to newborn

Bath to newborn and infant should be given in a warm room. The temperature of the bathwater should not exceed 37°C. Check the temperature of the water before placing the baby in the bath If a tub bath is given the depth of the water should be 5 cm up to the hip of the baby. Bathtubs may be a potential source of infection hence they must always be disinfected. Bath duration should not exceed 5 minutes in order to prevent over hydration of the skin which may lead to easily fragility of the skin and decrease the threshold for injury.

Routine bathing of newborns and infants does not cause any harm. Daily baths are more preferable and during winter and in the hilly regions babies may be given a bath once in 2-3 days.



The use of alkaline soaps during the neonatal period should be avoided. If possible, liquid cleansers with acidic or neutral pH may be used which will not affect the skin barrier function or acid mantle. Syndets and mild soaps may be used in infantBath 

Care of the diaper area [5]

The skin in the diaper area of newborn and infant is exposed to excessive hydration, occlusion, friction, and maceration. Fecal ureases catalyze the breakdown of urea to ammonia, which increases the pH of the skin surface. pH increase will contribute to the activity of fecal enzymes, proteases, ureases, and lipases which are highly irritant to the skin. Water and wet cloth are the gold standards for cleansing the nappy area. Mothers should be advised to use only cloth napkins which should be changed frequently. It is important to keep the area dry. After defecation moistened cloths or cotton balls soaked in lukewarm water can be used for cleaning the area. In case diapers are used, barrier creams containing zinc oxide and petroleum-based preparation could be used. Cloth napkins are to be washed with a mild detergent in warm water and dried in sunlight. Use of antiseptics to be avoided as a routine.

Care of the umbilical cord 

The umbilicus should be kept dry and clean. The cord should be kept exposed to air. The cord can fall anywhere between 3 to 13 days. Do not apply anything on the cord or the wound after the cord gets fallen unless. If there is a purulent discharge or bloodstain discharge from the site, consult your pediatrician.

Care of the scalp 

The cradle cap of the scalp is common in newborns. Mineral oil can be applied to the crusts and removed after two to three hours. Baby shampoos that are free from fragrance could be useful in removal of crusts and scales. The pH of the shampoos should be close to that of tears and should not cause irritation to the eyes. Baby’s hair wash is to be given after the cord falls with a frequency of twice a week after that.

Use of baby powders

Mothers should be advised to smear the powder on the hands and then gently apply it to the newborn skin. Accidental inhalation of powders could happen if used with puffs.

Care of the skin of the preterm baby 

Preterm babies have immature barrier function which results in increased transepidermal water loss, impaired thermoregulation, increased percutaneous absorption, and susceptibility to trauma. There is the acceleration of permeability barrier maturation following birth hence within 2 to 3 weeks postnatally babies develop competent barriers. But in preterm born at 22 to 25 weeks, it takes 8 weeks to mature. In the preterm babies, the acid mantle develops over 2 to 8 weeks after birth. Practice gentle and minimal handling of the preterm babies. Mother or health care workers should follow strict hand hygiene measures. A sponge bath with water is to be given until the baby weighs 2.5 kgs after which a regular bath is advised with a mild cleanser. Micropore adhesives may be used to secure IV cannulas and while removing the adhesives use gauze pieces soaked with warm water. Gentle application of emollients will help reduce the dryness and maintain the barrier function. Emollients also decrease the risk for invasive infections in preterms by preventing access to deeper tissues and the bloodstream through skin portals of entry.


Emollients are lipid-containing substances that soften the skin and prevent transepidermal water loss. They help in the restoration of the skin barrier and thus retard further damage. Emollients contain hydrocarbon oils like petrolatum, mineral oils, paraffin, squalene. Fatty acids like lanolin acid, stearic acid, and fatty alcohol like lanolin alcohol and cetyl alcohol are also used as emollients. Regular use of emollients is indicated in preterm babies. Emollients could be used in term babies with cleansers induced dryness.

Massage – Touch therapy

Touch is considered absolutely essential for the growth and development of a neonate. Lack of appropriate touch results in poor growth of the infant delayed attachment to a parent and psychological disturbances. Systematic application of touch is termed as massage. Massage promotes circulation, suppleness, and relaxation of the different areas of the body and tones up the muscles. Massage results in the promotion of mother-infant bonding.

Benefits of massage
    • Stimulates secretion of the hormones that stimulate food absorption such as insulin [6].
    • Increased weight gain by increasing secretion of insulin and insulin-like growth factor 1.
    • Improve bone mineralization.
    • Helps in the development of optimal behavioral and motor responses.
    • Babies become more active and alert.
Oil massage

Oil massage is traditionally practiced in India [7,8]. The oil enhances skin barrier function, acts as a source of warmth and nutrition, and increases weight gain. Infants also showed less stress behavior and lower cortisol levels following massage. Very low birth weight preterm neonates who were given oil massage showed better weight gain. Coconut oil, sunflower oil are being used for massages. Mustard oil has recently been discouraged due to irritant and allergic contact dermatitis potential. Sunflower oil enhances the skin barrier function. Some studies have shown that olive oil can cause erythema and disruption of skin barrier function. During summer one has to avoid oil massage when the baby has miliaria rubra. Oil massage should be given before bath during summer and after bath during winter.

Massage is ideally given by the mother, father, grandparents, or caregivers. It could be started after the 10th day of life in a well-baby. Massage is to be given to babies when they are alert and active, preferably 1 to 2 hours after a feed. Massage is to be done in a warm room. The mother or the caregiver has to cut their nails and remove the rings and watch. Strokes should be gentle and firm and not jerky. These gentle strokes should be given from head to foot. As the baby may not lie still, one should work with and not against the movements. A full body massage will take 15 minutes.

Comfortable signs of a baby enjoying massage are happy vocal sounds like cooing, easy breathing pattern, bright-eyed look, ability to focus and take in surroundings comfortably, and enjoying stretching, sucking, clasping their own hands or feet.

Things to be avoided
    • Pressing the nipple of the baby to remove milk or decrease breast bud swelling can lead to local inflammation and abscess formation hence should be avoided.
    • Pouring oil in the nose should be avoided.
    • Avoid applying kajal to the inner border of eyelids (Preferably avoid kajal application to the eye).


    1. Archer CB. Functions of the skin. Burns T, Breathnach S, Cox N, Griffiths C, Eds. Textbook of dermatology. 8th edn. West Sussex: Wiley Blackwell 2010; pp 4.1– 4.11.
    2. Madhu R. Skin care for New born. Indian Journal of Practical Pediatrics 2014;16(3):309-315.
    3. Paller AS, Mancini AJ, Eds.Cutaneous disorders of the newborn, Eds. Hurwitz Clinical Pediatric Dermatology. 4th edn. Philadelphia, Elsevier Saunders 2011; pp10-36.
    4. Hoath SB, Pickens WL, Visscher MO. Biology of Vernix caseosa. Int J of Cosmetic Sci 2006:28:319-333.
    5. Adam R. Skin Care of the Diaper Area. Pediatr Dermatol 2008; 25(4): 427-433.
    6. Field T, Diego M, Hernandez-Reef M, Dieter JN, Kumar AM, Schanberg S, Kuhn C. Insulin and Insulin-like growth factor-1 increased in Preterm infants following massage therapy. ) Dev Behav Pediatr 2008; 29(6):463-466.
    7. Dhar S, Banerjee R, Malakar R.Oil massage in babies: Indian perspectives. Indian Journal of Paediatric Dermatology 2013; 14:1-3.
    8. Danby SG, AlEnezi T, Sultan A, Lavender T, Chittock ), Brown K, et al. Effect of olive and sunflower seed oil on the adult skin barrier: Implications for neonatal skin care. PediatrDermatol 2013; 30:42 50.

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