The Infant Skin Barrier: Can We Preserve, Protect, and Enhance the Barrier?

Table 5

Emollient therapy in healthy, full-term, or premature neonates (0–4 weeks old) or infants (1–6 months old) on skin barrier function: literature review†.

Healthy, full-term infants
Study	Cohort	Treatment	Study duration	Endpoints/; measurements	Primary outcome(s)
Garcia Bartels et al. [19]	64 healthy, full-term neonates (gestation ≥37 weeks aged ≤48 hours)	Body wash; body wash with emollient use after bathing; water alone, followed by emollient after bathing	8 weeks	TEWL, SC hydration, skin surface pH, sebum, NSCS, and bacterial colonization	Wash with emollient improved skin condition; in some cases, lower TEWL and higher SC hydration were observed; no adverse events
Garcia Bartels et al. [146]	44 healthy, full-term infants (≥37 weeks gestation) aged 3–6 months old	Lotion was applied after a swimming lesson once weekly or no treatment	5 weeks	TEWL, SC hydration, skin surface pH, and sebum	Reduced TEWL in both groups; site-specific differences in the treatment group were observed
Lowe et al. [147]	10 healthy, full-term neonates (0–4 weeks old; gestation ≥36 weeks) with a family history of allergic disease	Emollient consisting of ceramides, cholesterol, and free fatty acids at a 3 : 1 : 1 ratio and 2% petrolatum (applied once daily)	6 weeks	TEWL, SC hydration, skin surface pH, and sebum	Emollient use reduced TEWL
Simpson et al. [20]	22 full-term infants (≥37 weeks gestation) considered to be at high risk for developing atopic dermatitis	Oil-in-water, petrolatum-based emollient cream	Up to 2 years	TEWL and skin capacitance	Skin barrier measurements remained within normal range; only three participants developed atopic dermatitis
Premature Infants
Beeram et al. [18]	54 infants (≤27 weeks gestation)	Petrolatum-based emollient applied every 6 hours or no treatment	2 weeks	Fluids, electrolytes, bilirubin, and sepsis	The petrolatum-based emollient led to a significant reduction in the need for fluids; it also led to better urine output, more stable electrolytes, and lower bilirubin values
Brandon et al. [141]	69 infants (<33 weeks gestation)	Polymer, liquid-based film (applied twice) or petrolatum-based emollient (twice-daily application)	2 weeks	Total fluid intake, TEWL, and neonatal skin condition	Both treatments were well tolerated; both led to a decrease in TEWL
Darmstadt et al. [28, 100, 148]	497 premature infants (≤72 hours old; gestation ≤33 weeks)	Sunflower seed oil or petrolatum-based emollient (3 times daily for 14 days, then twice daily until hospital discharge) or no treatment	≥14 days	Survival rate and rate of nosocomial infection	Sunflower seed oil and petrolatum-based emollient reduced mortality by 25–30%; sunflower seed oil reduced nosocomial infection rates by a statistically significant margin
Lane and Drost [16]	34 neonates (29–36 weeks gestation)	Twice-daily application of a water-in-oil emollient; no treatment	16 days	TEWL, NSCS, and quantitative microbiology	Emollient decreased dermatitis of the hands (days 2–11), feet (days 2–16), and abdomen (days 7–11); no changes in microbial flora
Nopper et al. [17]	60 neonates (<33 weeks gestation)	Petrolatum-based emollient (applied twice daily); no treatment	2 weeks	Temperature, TEWL, fluid intake, weight analysis, skin condition, microbiology, and blood/urine analysis for cerebrospinal fluid cultures	Emollient use led to statistically significant decrease in TEWL; significant improvement in infant skin condition on days 7 and 14; less colonization of the axilla on days 2, 3, 4, and 14; statistically significant reduction of positive findings in blood and cerebrospinal fluid

TEWL: transepidermal water loss, SC: stratum corneum, NSCS: neonatal skin condition score.
†Studies published between 1 January 1960 and 1 June 2012 were identified by searching peer-reviewed literature indexed in PubMed. The titles and abstracts of indexed publications listed in PubMed were searched using the following words: “newborn OR neonat∗ OR infant∗” (group 1), “emollient OR lotion OR cream OR topical” (group 2), and “skin” (group 3). These three groupings were connected using the Boolean operators “AND”. The titles and abstracts were also searched using the word “vitro” and the Boolean operator “NOT”. Finally, only the titles of PubMed-indexed publications were searched using a fifth group of words and were connected to the search string using the Boolean operator “NOT”: “injury OR wound OR burn OR damage OR eczema OR dermatitis OR psoriasis OR disease∗ OR pain OR hemangioma∗ OR syndrome OR sepsis OR antisepsis.” Review articles, publications that were printed in a language other than English were also excluded. Although our search generated 220 publications, only 9 (summarized in Table 5) met the search criteria described above.