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 latestevidence. 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,” 9 cleansing in the first 2–4 weeks. Dr Alexis Granite, Consultant Dermatologist, affiliated with Skin Health Alliance, US Guidelines from the US on infant skin cleansing also fell short of HCP expectations. Guidelines from AAP have not been updated since 2012 and provide only very broad recommendations, without discussion of napkin area cleansing specifically.
Table 1. Summary of key English language guidelines on newborn cleansing
Region Guideline Audience Recommendations on cleansing Last Evidence- (includes relevant text only) updated based?
Global WHO: Pregnancy, HCPs • Wash the face, neck, underarms daily 2015 Described childbirth, • Wash the buttocks when soiled. Dry thoroughly as such, but postpartum references not and newborn • Bath when necessary: cited care—A guide for ° Ensure the room is warm, no draught essential practice ° Use warm water for bathing (3rd edition)2 ° Thoroughly dry the baby, dress and cover after bath • Use cloth on baby’s bottom to collect stool. Dispose of the stool as for woman’s pads. Wash hands UK NICE: Postnatal HCPs • Cleansing agents should not be added to a baby’s bath water nor 2006 Yes care up to 8 should lotions or medicated wipes be used. The only cleansing agent weeks after birth3 suggested, where it is needed, is a mild non‑perfumed soap UK NICE: Nappy HCPs • Use water, or fragrance- and alcohol-free baby wipes; dry gently after 2020 No rash11 cleaning; avoid potential irritants such as soaps and bubble bath Republic HSE: Caring for Parents • Most experts recommend you use plain water when washing your baby 2018 No— suggestion of Ireland your baby’s skin9 for the first 4 weeksor so that it is based • Use cotton wool and water to clean your baby’s skin on expert opinion • Try not to use baby wipes until your baby is 2 to 4 weeks old US AAP: Care of the HCPs • The newborn infant does not require frequent bathing 2012 No— appear to 1 well newborn • Cleansers should be mild and the child should have sponge baths until be based on the umbilical cord detaches expert opinion US AAD: How to Parents • Bathing your baby is simple and only needs to happen two to three times 2019 No— appear to bathe a newborn: a week, as long as the diaper area is thoroughly cleaned during each be based on Tips from diaper change expert opinion 12 dermatologists • The first thing to remember is to start off with sponge baths until your baby’s umbilical cord stump falls off and heals • You will need a bowl of lukewarm water, a washcloth and a mild, fragrance-free baby soap • Soap only really needs to be applied to dirty areas; the neck and diaper area are usually sufficient. Add the baby soap into the bowl of water and use the washcloth to gently wash your baby. Make sure to rinse off any soap after cleaning US AAD: How to Parents • Use water and a soft washcloth or baby wipes that are alcohol- and – No— appear to treat diaper fragrance-free. If the rash is severe, use a squirt bottle of water to clean be based on rash13 the area, as doing so is gentler to the skin. Next, allow the area to air dry. expert opinion Let your child go diaper-free as long as possible to let the skin dry and heal
3 “Is it important to involve multiple Cork University specialities in infant care guidelines. Maternity Hospital, Ireland Midwives will be the ones advising on normal skin care but if the barrier becomes “Cotton wool can result in the need to rub the skin more disrupted and a dermatitis develops that compared with use of a wipe. Bigger size wipes are also more does not respond to simple measures, care practical compared with the small balls of cotton wool,” usually moves to the dermatologist,” Margaret Merrigan-Feenan, Clinical Midwife Manager, Dr Susan Mayou, Skin Health Alliance Dublin, Ireland Dermatologist, UK Is now the time to finally move on from cotton wool/ Purity is the foundation to build cloth and water? recommendations on Even when water is from a reliable source or boiled, there In the absence of up-to-date evidence- may be further purity considerations around the use of cotton based guidelines, the expert HCPs wool and water. Both tap and boiled water continue to contain considered what they should be impurities and particulates. When considering the cotton wool recommending as best practice for itself, although clean within its packaging, it is not entirely free cleansing infant skin. Overwhelmingly, from contamination and will have been processed using chemical the message that can be taken away from detergents. Furthermore, if the same piece of cotton wool is guidance and expert opinion is the need to dipped in water more than once or hands touch the surface, there use cleansing techniques that are as mild is a risk of contaminating the water. and gentle as possible to avoid potential irritants to delicate baby skin.1–3,9,11–13 “There’s a lot of ignorance out there about water and water purity,” While historically, this may have equated Cheryll Adams, Executive Director, Institute of Health Visiting, UK to the recommendation of cotton wool and water, to this group of HCPs, this was The fact that water impurities can affect the skin, particularly not necessarily the case. For the attendees of babies, is supported by evidence that hard water (i.e. water from the US, in particular, cotton wool with increased levels of dissolved calcium and magnesium and water were seen as an archaic and carbonate) has been associated with an increased incidence of impractical recommendation for modern atopic dermatitis (AD).16,17 In a UK-based study of 1,204 babies, parents, especially when spending time those exposed to harder water had more visible AD at 3 months away from the home. Qualitative study of age than those exposed to softer water (P=0.005).18 In the data from 280 parents also supported the subgroup of babies with a genetic predisposition to eczema in the notion that wipes may be more convenient, form of a filaggrin loss of function mutation (n = 141), the effect as preparing cotton wool and water can of hard water on atopic dermatitis development was even more be time-consuming, as well as it being pronounced with the prevalence of AD increasing with cumulative potentially difficult to access clean sources exposure to hard water up until 36 months of age.18 of water when out and about.15 Other practical difficulties involving cotton wool and water included that cotton fibres can “Up to 20% of children get eczema in the first year of life. In stick to the skin and that cotton balls or Germany, it is the number one disease that young parents are pads can be small, requiring repeated concerned about,” wiping and use of many balls/pads.15 This Professor Peter Hoeger, Paediatric Dermatologist, Children’s group of HCPs particularly felt this was the Hospital Wilhelmstift, Hamburg, Germany case with cleansing meconium.
“No one really uses cotton wool and water in the US—wipes are far more convenient,” Misty Williams, NICU Advanced Practice Partner, University of Arkansas for Medical Sciences, Arkansas, US
“Cotton wool and warm water can cause blockages of sinks and pipes,” Lucille Bradfield, Clinical Nurse Manager,
4 Following a review of the scientific literature by a team of A prospective, assessor-blinded, independent experts, the Skin Health Alliance validated randomised controlled equivalence WaterWipes baby wipes as being purer than cotton wool and trial examining napkin area cleansing of water. WaterWipes are manufactured under clean room conditions newborn term babies with alcohol-free using a unique purifying technology. The water passes through baby wipes vs cotton wool and water was a seven-step purification process that removes physical and published by Lavender, et al. in 2012.20 chemical impurities, softens and purifies the water. This purifying This landmark study demonstrated baby process makes the water in WaterWipes significantly purer than wipes to be equivalent to cotton wool cooled boiled water. Additionally, the wipe material undergoes a and water in terms of skin hydration, decontamination process, when combined with the formulation skin surface pH, trans-epidermal water results in a fresh, pure product that is stable for 20 months loss (TEWL) and erythema (see Figure unopened or 4 weeks after opening. 1).20 In a smaller study (N = 44), also published in 2012, a comparison of baby “The water used for WaterWipes is safer wipes to a water-moistened washcloth [than tap water],” demonstrated that babies cleansed with Emilia Jaśniewska, Midwife, Baby Sleep Consultant, the wipes vs water had a significantly owner of Emilymed.pl, Poland lower TEWL. However, neither of the cleansing procedures were shown to harm skin barrier maturation (P=0.007).21
Figure 1. Randomised controlled equivalence trial of alcohol-free baby wipes vs cotton wool and water by Lavender, et al. 201220
4 weeks post birth n = 140 alcohol-free baby wipes for napkin area cleansing N = 280 healthy term R babies <48 hours old n = 140 cotton wool and water for napkin area cleansing
Should baby wipes be a modern standard of care for Primary outcome: infant napkin area cleansing? Skin hydration score If baby wipes have the potential to be purer than cotton wool and water, as well as more convenient, the question for HCPs becomes Analysis Alcohol-free Cotton wool P whether baby wipes should be recommended as best practice baby wipes and water for napkin area cleansing. NICE recommends non-medicated ITT 65.4 (SD 12.4) 63.5 (SD 14.2) 0.47 baby wipes in the postnatal period, as well as ‘mild’ cleansers, however, many parents do not understand what is meant by ‘non- PP 64.6 (SD 12.4) 63.6 (SD 14.3) 0.53 medicated’ or ‘mild’, with ‘mild’ also appearing to be a relative term that lacks a concrete definition.3,19 Over the past decade or so, a number of studies have investigated the comparative tolerability ITT=intention-to-treat; PP=per protocol; of baby wipes compared with cotton wool/cloth and water for R=randomisation; SD=standard deviation. baby skin cleansing.
5 Baby wipes have also been compared Mothers using WaterWipes also reported fewer days of moderate- with cloth and water in premature to-severe nappy rash than those using the other two brands babies. Perineal erythema and TEWL (P=0.002 and P<0.001) (see Figure 2).24 were significantly lower for wipes than cloth and water, beginning at Day 5 “The number of participants is a huge strength of the study. for erythema (P≤0.04) and Day 7 for Close to 700, compared with approximately 200 in the landmark 22 TEWL (P≤0.03). Moreover, a US-based study that compared wipes with cotton wool and water,” neonatal intensive care unit found that implementing perineal skin care Marie Louise, Midwife, UK guidelines, while introducing WaterWipes specifically, led to a reduction in the incidence of nappy rash by 16.7%, a Figure 2. Midwifery-led real-world study 34.9% reduction in severe cases and a comparing the effects of different brands of baby reduced duration of nappy rash by 57% 24 (3.5 days) per 100 patient-days.23 While wipes on nappy rash by Price, et al. 2020 some advisers would feel comfortable using baby wipes, such as WaterWipes on premature babies as young as 23 weeks, 8 weeks post birth others called for more studies on skin care in these micro-premature babies Brand 1 to generate a stronger evidence base n = 233 supporting their tolerability. N = 698 Brand 2 R n = 227 “Premature babies at the lower edge of newborn babies* viability (23–24 weeks’ gestation) have WaterWipes an epidermis that is only a few cells n = 238 thick. These babies need separate, more cautious guidelines on skin care,” Fauzia Paize, Consultant Neonatologist, Bliss, UK Analysis of moderate-to-severe nappy rash across brands Considering choice of baby wipes For one day of clinical significant nappy rash withWaterWipes , in a densely populated market the rash would have lasted 1.48 days (95% Cl–1.15-1.90) with without clear clinical guidance Brand 1 (P=0.002) and 1.69 days (95% Cl–1.32-2.17) with Brand 2 (P<0.001). Studies comparing baby wipes with cotton wool/cloth and water often group all baby wipe products together, while in reality, Skin integrity was graded from one (no rash) to five (severe rash) and the choice available can be overwhelming moderate-to-severe nappy rash was identified as three or above. and ingredients within these wipes can *N number includes those participants that completed the full 8 weeks of the vary considerably. The Baby Skin Integrity study. CI=confidence interval; R=randomisation. Comparison Survey (BaSICS) is the first study to directly compare different wipe formulations to identify any differences in the incidence of nappy rash (N = 698).24 “This real-world study utilised a prospective experimental WaterWipes were compared with two design model of mothers as co-researchers. The mothers’ other brands marketed specifically as observations were recorded daily, in real time via a user-friendly being mild enough for newborn skin.24 In app on their smartphone. This resulted in a set of nappy rash the BaSICS study, 19% of mothers using data that, to our knowledge, is the most comprehensive to date WaterWipes reported moderate-to-severe for younger infants,” nappy rash on their babies compared with 25% and 30% with the other two brands.24 Dr Fiona MacVane Phipps, Senior Research Fellow - Midwifery (now retired), University of Salford, UK
6 What makes WaterWipes different to other Conclusions and a call to action baby wipes? AnConclusions expert group of and 17 professionals a call to action from Even in wipes considered ‘pure’ or ‘natural’ the average number eightAn expertdifferent group countries of 17 professionalswas brought of ingredients can start at seven. Made from 99.9% purified water togetherfrom eight by WaterWipes different countries to consider was and a drop of grapefruit seed extract, WaterWipes do not contain currentbrought guidance together on bybaby WaterWipes skin cleansing to any artificial fragrances or added surfactants. andconsider whether current these guidancereflect emerging on baby evidenceskin cleansing and their and own whether perceptions these of best practice,reflect with emerging the ambition evidence to andbe better their Fragrances can cause and worsen itching, in both those with and equippedown perceptions to educate of parents best practice, on how with to without AD—in some cases, the mechanisms behind this can be correctlythe ambition care for to their be better baby’s equipped skin. Despite to unclear.25 They can also provoke irritation or allergic skin responses thereeducate being parents numerous on how existing to correctly guidelines, on contact.26 Surfactants are added to many baby wipes to decrease manycare were for their found baby’s to be skin. out-of-date, Despite surface tension, allowing fat-soluble impurities to be removed vaguethere and being inconsistent. numerous The existing overarching from the skin surface.26 The interaction of cleanser surfactants with messageguidelines, that manycould werebe taken found from to bethese stratum corneum proteins and lipids can be harmful to skin. This documentsout-of-date, and vague the HCPs and inconsistent.own experiences damage can cause increased TEWL and provoke scaling, dryness, wasThe that overarching techniques message to cleanse that babies could tightness, roughness, erythema and swelling.26–28 shouldbe taken be as from mild these and gentle documents as possible and to theavoid HCPs potential own experiences irritants. Cotton was that wool/ WaterWipes technology means that there is no need for added clothtechniques and water to maycleanse no longer babies be should the surfactants. The unique water purifying technology lowers surface bestbe methodas mild andto achieve gentle asthis, possible nor the to most tension, resulting in increased wettability and access to more dirt practicalavoid potential and that irritants.current standard-of-care Cotton wool/ and impurities, therefore providing a deeper and more effective is movingcloth and towards water maythe useno longerof baby be wipes clean with just two ingredients. withthe minimal best method ingredients to achieve and maximal this, nor purity.the most Furthermore, practical dataand thatare emergingcurrent thatstandard-of-care suggest that brands is moving of wipes towards can be Typical skin Skin cleaned Skin cleaned furtherthe use delineated of baby wipesbased withon the minimal incidence surface with tap water with WaterWipes andingredients duration of and nappy maximal rash inpurity. babies Dirt, urine, stool, Tap water/ WaterWipes impurities etc boiled water water cleansedFurthermore, with them. data are emerging that Givensuggest this clearthat brandsdisconnect of wipes between can the guidelinesbe further and delineated expert recommendations based on the in incidence2020, this andgroup duration of experts of nappy are calling rash forin updated babies cleansedguidelines with on them.infant skin cleansing.Given this They clear should disconnect be informed by experiencesbetween the across guidelines the multidisciplinary and expert Typical skin surface of an The surface tension of tap Our unique 7 stage purifying infant contains dirt, urine, water/boiled water is too technology lowers the team,recommendations reflect the latest in 2020,scientific this evidence stool and impurities high to reach the dirt in surface rension of water, as groupwell as of practical experts considerationsare calling for of deeper pores and crevices resulting in an increased wetting and deeper clean modernupdated life, guidelines are regularly on infantupdated and skin cleansing. They should be informed by experiences across the provide specific guidance that can be multidisciplinary team, reflect the WaterWipes are highly recommended by midwives and other conveyed to parents and other caregivers. HCPs and have become the preferred wipe for many neonatal latest scientific evidence as well as intensive care units throughout Ireland, UK, Portugal, US, practical considerations of modern Australia and New Zealand.29 life, are regularly updated and provide specific guidance that can be conveyed to parents and other caregivers. Additionally, WaterWipes are the only baby wipes to hold numerous accreditations, acceptances and registrations from global skin and allergy associations including: Financial support • The Skin Health Alliance • The French Association for Financial support for the global meeting • Allergy UK the Prevention of Allergies was provided by WaterWipes UC. A report (Association Française pour was generated, which formed the basis of • The National Eczema la Prévention des Allergies) this document. Association of America’s Seal of Acceptance • The Eczema Association of Australasia – gold sponsor • Vegan Society
7 References
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3. National Institute for Health and Care Excellence. Postnatal 19. DermatologyTimes. What constitutes “mild” soap?,
4. Association of Women’s Health, O. a. N. N. New neonatal skin 20. Lavender, T. et al. Effect on skin hydration of using baby wipes care evidence–based practice guideline. Nurs Womens Health to clean the napkin area of newborn babies: assessor-blinded 17, 2, doi:https://doi.org/10.1111/1751-486X.12085 (2013). randomised controlled equivalence trial. BMC Pediatr 12, 59, doi:10.1186/1471-2431-12-59 (2012). 5. Polish Neonatal Society. Standards of medical care for a newborn in Poland,
14. World Health Organization (WHO). About us,
16. Danby, S. G. et al. The Effect of Water Hardness on Surfactant Deposition after Washing and Subsequent Skin Irritation in Atopic Dermatitis Patients and Healthy Control Subjects. J Invest Dermatol 138, 68-77, doi:10.1016/j.jid.2017.08.037 (2018).
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