The Need for Up-To-Date, Evidence-Based Multidisciplinary Guidelines for Baby Skin Cleansing a Supplement Developed and Produced by Waterwipes®
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A call for clarity and collaboration: The need for up-to-date, evidence-based multidisciplinary guidelines for baby skin cleansing A supplement developed and produced by WaterWipes® Contributors: Pixie McKenna, Cheryll Adams, Lucille Bradfield, Many Daly, Alexis Granite, Peter Hoeger, Evelyne Khoriaty, Emilia Jaśniewska, Marie Louise, Susan Mayou, Margaret Merrigan-Feenan, Cecile de Scally, Fauzia Paize, Fiona MacVane Phipps, Tina Wesley, Misty Williams. General Practitioner, Abstract In order to understand how to support UK/Ireland (Dr Pixie healthcare professionals (HCPs), parents McKenna); Institute In September 2020, an expert group of of Health Visiting UK 17 professionals with a special interest in and other caregivers to upskill in and (Cheryll Adams); Clinical infant skin cleansing from eight different deliver best practice on baby skin care, Nurse Manager, Cork countries was brought together by WaterWipes® convened a global advisory University Maternity board of 17 HCPs/experts from eight Hospital, Ireland WaterWipes®, to consider best practice (Lucille Bradfield); on baby skin cleansing and how to countries in September 2020. The advisers Director of Advocacy convey recommendations consistently represented a range of specialties, and Policymaking, to new parents. This international group including health visiting, midwifery, Irish Neonatal Health neonatal specialist nursing, neonatology, Alliance, Ireland (Mandy reviewed selected guidelines by leading Daly); Consultant bodies and discussed their own expert dermatology, paediatrics and patient Dermatologist, affiliated recommendations to consider the advice. advocates. This group of experts sought with Skin Health Alliance, A clear disconnect was found between the to consider the current guidance on US (Dr Alexis Granite); baby skin cleansing and whether these Paediatric Dermatologist, guidelines and expert recommendations. Children’s Hospital Therefore, this group of experts are calling reflect emerging evidence and their own Wilhelmstift, Hamburg, for updated guidelines on infant skin perceptions of best practice, as well as how Germany (Professor Peter cleansing that are informed by experiences to convey recommendations consistently to Hoeger); Consultant new parents. Paediatrician (family across the multidisciplinary team and care), UAE (Dr Evelyne reflect the latest scientific evidence, as well Khoriaty); Midwife, Baby as practical considerations of modern life. Sleep Consultant, owner Countries represented of Emilymed.pl, Poland They should also be regularly updated and (Emilia Jaśniewska); provide specific guidance that can then be Midwife, UK (Marie conveyed to parents and other caregivers. Louise); Skin Health Alliance Dermatologist, UK (Dr Susan Mayou); Introduction by Dr Pixie McKenna, Clinical Midwife Manager, Dublin, Ireland (Margaret GP and broadcaster, UK and Ireland Merrigan-Feenan); Lead Becoming a parent for the first time can Midwife Educator, spark a range of wonderful emotions, but Malaak Mama & Baby Care, UAE (Cecile de also bring with it waves of worry about Scally); Consultant this tiny, precious person. A baby’s skin is Neonatologist, Bliss, its interface with the rest of the world—an The 17 advisors cited 19 different guideline UK (Dr Fauzia Paize); organ that is vulnerable and exposed to the Senior Research Fellow – sources on infant skin cleansing. These Midwifery (now retired), environment—and can therefore become ranged from local protocols to global University of Salford, a focus of parental worry, especially given recommendations and from those directed UK (Dr Fiona MacVane that parents need to cleanse it frequently at HCPs in a specific role and speciality Phipps); Senior Neonatal and at the very least at each nappy change. Nurse, Bliss, UK (Tina to those suggested for use by HCPs in 1-13 Wesley); NICU Advanced The American Academy of Pediatrics (AAP) general. These guidelines are often Practice Partner, highlights this in its guidance on newborn contradictory, e.g. in the recommendation University of Arkansas care stating, ‘Parents often have questions of cloth and water vs cotton wool and for Medical Sciences, about skin and cord care’.1 Something so Arkansas, US water vs baby wipes for cleansing of the 2,7,9 (Misty Williams); simple can actually prove a major source napkin area, but can also lack granularity, Midwife France; Nurse of concern for new parents. There is the for example only discussing bathing and Portugal. inevitable question of ‘am I doing this right?’. not bottom cleansing or nappy changing.1 1 “Consistent guidelines are really other is the lack of a robust resource for reference. Doctors like to important. Implementing a nappy rash resource an evidence base when delivering advice. They like this algorithm has been of major benefit in to be both clear and current, whatever constitutes ‘best in class’ our hospital as it ensures that everyone advice. follows the same standard of care,” Tina Wesley, Senior Neonatal Nurse, Although the main source of advice may come via midwives, Bliss, UK health visitors, dermatologists and paediatricians, it is important that GPs are also aligned with their guidelines. There is nothing more confusing as a new parent than getting conflicting advice. “Preterm birth flips the paradigm of parenthood on its axis. Parents place “It makes us look unprofessional when we are contradicting each a piece of their heart in the care of other as HCPs and then it also causes the mother’s anxiety level neonatal staff who are often the only to go up. It undermines us all as professionals,” constant in the turbulent NICU journey. Circumstance necessitates families to Cecile de Scally, Lead Midwife Educator, place unconditional trust in their baby’s Malaak Mama & Baby Care, UAE caregivers but evidence-based science must be the ultimate determinant in HCPs feel let down by the leading bodies throughout ensuring that the highest quality care the world that they can normally rely upon to provide is provided for babies and this includes robust guidance protecting the integrity of their skin,” The World Health Organization (WHO) is committed to ‘improve Mandy Daly, Director of Advocacy and equity in health, reduce health risks, promote healthy lifestyles Policymaking, Irish Neonatal Health and settings, and respond to the underlying determinants Alliance, Ireland of health’14 and offers guidance on all aspects of health and wellbeing, including newborn care. However, given the variety in Furthermore, the dermatologists and local needs and resources, on the subject of baby skin care, the paediatricians present expressed a recommendations are generic (see Table 1).2 general preference for relying on their own experience and anecdotal evidence “Global guidelines would not be helpful, as the type of skin when discussing skin cleansing, rather care very much depends on local climatic conditions, availability than referring to guidelines. Drivers of of basic hygienic measures, and financial resources, which this behaviour included the fact that obviously vary,” infrequently updated guidelines do not always reflect the latest evidence. Professor Peter Hoeger, Paediatric Dermatologist, Children’s Hospital Wilhelmstift, Hamburg, Germany “With the limited published guidelines on skin cleansing in paediatrics, I opted The UK’s National Institute for Health and Care Excellence (NICE) is to create personalised algorithms for considered an authority and key source of evidence-based guidance my patients, based on data from clinical for HCPs across the multidisciplinary team. The advisers accustomed studies, personal experience and country to relying on NICE for this purpose were disappointed to note that, while the clinical guideline on postnatal care up to 8 weeks after birth considerations,” [CG37] was last updated in February 2015, the specific guidance on Dr Evelyne Khoriaty, Consultant infant skin care has not been updated since 2006.3 More up-to-date Paediatrician (family care), UAE guidance (September 2020) are available on the management of nappy rash; however, these are ‘largely based on expert opinion in review articles on nappy rash and infant skin care’.11 When parents or carers access a GP, it is “The NICE postnatal guidelines last being updated in 2006 is normally for an acute problem. As doctors, not good enough. HCPs have a responsibility to give up-to-date we are very good at dealing with day-to- day emergencies and medical advice but advice, so guidelines should be up-to-date,” often defer to other HCPs when it comes Marie Louise, Midwife, UK to dealing with something that we perceive to be simple such as skin care. Part of the reason for this is lack of knowledge and the 2 In the Republic of Ireland, guidelines on While the American Academy of Dermatology (AAD) offers tips baby skin cleansing from the Health and to new parents on bathing and nappy rash treatment, these again Safety Executive (HSE) are aimed at parents seem to be based on expert experience rather than being evidence- rather than HCPs. They are also some of based and are not formulated into guidelines for HCPs.12,13 the most conservative and restrictive, with only ‘plain water’ recommended for “There are no concrete dermatological guidelines for the care baby cleansing in the first 4 weeks of life, of infant skin in the US. It would make the most sense to have and cotton wool and water given as the guidelines that are across all specialties, as different HCPs come preferred method of choice for napkin area at things from different viewpoints,”