Clinical Guidelines (Nursing)

Neonatal & infant skin care

  • Introduction

    Preserving the skin integrity of the neonate is important to maintain the function of the skin, protect against potential wounds and avoid skin disorders in the future.


    • Provide evidence based skincare to neonates
    • Identify those who may be at risk for alterations in skin integrity
    • Protect against potential skin breakdown caused by epidermal stripping, extravasation, wound breakdown and excoriation
    • Implement interventions to promote and protect optimal skin function
    • Care for premature neonates in an environment that minimises Trans Epidermal Water Loss and promotes Stratum Corneum barrier maturation
    • Minimize the potential for future skin sensitization

    Definition of terms

    Preterm baby Less than 37 weeks gestational age

    Term baby 37- 40 weeks gestational age

    Neonate Less than 4 weeks age (post term)

    Infant Young children, 1 month to 12 months age

    TEWL Trans Epidermal Water Loss

    Atopy Predisposition toward developing certain allergic hypersensitivity reactions

    Emollient A substance that softens & moisturizes the skin

    Erythema Redness of the skin

    Stratum Corneum (SC) The outermost layer of the epidermis acting as a mechanical barrier

    Xerosis Skin dryness

    Vernix Waxy white substance on newborn skin

    Rediwipes Absorbent disposable towels (available from Equipment Distribution Centre)


    Assess skin condition on admission and commencement of each shift (and at each nappy change as needed). Be proactive. Observe and clean areas such as the neck, behind the ears, axillae and groin. Dry, red or itchy skin is an indication that skin integrity may be impaired. If a pustular, vesicular or purulent skin lesion is noted, communicate with the appropriate medical team for management.

    Consider the following factors that may increase the risk of skin trauma and breakdown;

    • Prematurity
    • Vacuum or forcep extraction
    • Skin oedema, infection, thermal injury
    • Sedation or inability to mobilise
    • Use of endotracheal tubes, continuous positive airway pressure, nasogastric/orogastric tubes Extracorporeal membrane oxygenation (ECMO)  
    • Monitors, electrodes, probes
    • Surgical wounds, ostomies
    • Adhesive removal
    • Environmental humidification
    • Nappy rash
    • Nutritional status
    • Family history of atopy


      To maintain skin integrity and minimise heat loss consider the following -


      • Ensure vital signs and temperature are stable before first bath
      • Consider universal precautions, wear gloves
      • Immersion bathing should be considered based on assessment of individual condition
      • Newborns may be bathed after 1 hour of age when appropriate care is taken to support thermal stability. To minimise heat loss after first bath, immediately put a nappy and hat on and wrap in warm blankets. When infant temperature is within normal limits (after approximately 10 minutes) dress and re wrap in dry warm blankets
      • Bath or sponge daily or more often as needed
      • Use warm water
      • Use a water depth deep enough to allow the infants' shoulders to be well covered
      • Maintain an adequately heated environment
      • pH neutral cleanser may be used if needed or plain water
      • Carefully dry the skin folds including armpits, groin, neck and behind the ears
      • Allow vernix to wear off with normal care and handling
      • Disinfect bath equipment before and after use

      Examples of appropriate pH neutral cleansers: QV Wash, QV Gentle Cleanser, Hamilton Wash, Cetaphil Gentle Skin Cleanser, Avene Trixera Cleansing Gel, Kenkay Body Wash, Dermaveen Baby Soap Free Wash

      Cord care

      • Wash hands before handling umbilical cord
      • Keep cord area clean with water. No need for alcohol wipes
      • Cleanse with water and pH neutral cleanser if soiled with urine or stool
      • Keep nappy folded under the cord to facilitate drying
      • Identify signs of infection such as inflammation or an offensive odour
      • The cord usually separates from the baby 7 to 10 days after birth
      • Cord clamp may remain insitu until separation
      • Educate staff and families about normal mechanism of cord healing


      • At the first sign of dryness, fissures or flaking, apply an emollient twice a day or as needed
      • Emollients should be applied as a preventative therapy at least daily to newborns and infants with a family history of atopy
      • Emollients should not be shared and always dispensed from a hospital pharmacy in patient-specific containers
      • Spoon emollient on to paper towel prior to use (to maintain sterility of the container)
      • Emollient use has not been associated with negative thermal effects or burns when used in conjunction with phototherapy or radiant heat
      • Emollients may interfere with the adherence of adhesives
      • Choose emollients without fragrances, dyes or preservatives

      Examples of appropriate emollients:  QV Cream, QV Kids balm, QV Intensive, Hydraderm Cream, Cetaphil Cream, Aqueous cream, Avene Trixera Cream, Dermeze Ointment, Kenkay Extra Relief Cream, Dermaveen Baby Moisturising Cream, Mustela Stelatopia Moisturising Cream

      Nappy area care

      • Assess neonate for risk factors for skin breakdown. ie. loose stools, frequent stooling, drug withdrawal, medications that alter stool frequency or composition. Monitor skin condition closely
      • Change nappies frequently, usually every 3- 4 hours or when soiled
      • Use disposable nappies
      • Nappy wipes may cause irritation and should be reserved for healthy looking skin
      • Gently clean nappy area with water and Rediwipes or cotton wool
      • A pH neutral cleanser, sorbolene cream, aqueous Cream or olive oil may be used to help cleanse the nappy area
      • To maintain skin integrity, apply a thick barrier cream that contains zinc oxide at every nappy change
      • Complete removal of barrier ointments with nappy changes is not necessary, rather apply another layer
      • Assess for presence of infection ie candida albicans, and need for topical antifungal
      • Do not use talcum powder
      • Do not use creams with fragrances or unnecessary additives such as tea tree oil
      • Allow as much "nappy off" time as possible
      • If the area is red, a mild hydrocortisone 1% ointment may need to be applied bd, prn e.g. Sigmacort 1% ointment. A prescription is not needed for this
      • For further information see Nappy Rash Clinical Practice Guideline

      Examples of appropriate barrier creams: 10% Olive Oil in Zinc Paste, Covitol, Desitin, Sudocream, Bepanthan Nappy Ointment


      • Minimal use of adhesives on all neonates
      • Delay the removal of adhesive for at least 24hrs after application
      • Tape should be backed with cotton wool where possible
      • A semipermeable dressing should be used between the skin and adhesive to secure nasogastric tubes, intravascular devices, nasal cannulas or central venous catheters
      • Barrier films should not be used on premature neonates or infants < 4 weeks of age (ie. Smith & Nephew Skin Prep Protective Barrier Wipes, Convacare Protective Barrier Wipe, 3M Cavilon No Sting Barrier Film )
      • Gently and slowly remove adhesives with warm water soaked cotton balls, peeling back parallel to the skin surface. Avoid solvents
      • Solvents (ie. Convacare wipes) must not be used on premature neonates. If required to aid adhesive removal on term neonates, the area should be rinsed with warm water immediately after use
      • For transparent adhesives, stretch to release adherence
      • Use wraps such as stretchy gauze or Koban to anchor probes, electrodes or limbs to arm boards
      • Use only gel electrodes

      Examples of appropriate adhesives: Mepitac, Comfeel, Duoderm, Siltape, Transparent adhesive dressings (Tegaderm), Hydrocolloids, Gel Electrodes, Silicone adhesives


      Special considerations for premature neonates

      Ensure vital signs and temperature are stable before the first bath. Neonates <1000g or < 32 weeks sponged in plain water only every 3-4 days. Use soft materials such as cotton balls. Avoid rubbing. Consider immersion bathing for stable infants >1800g

      Emollients should not be part of routine care for infants 23-30 weeks' gestation. TEWL may be reduced by other means ie. Humidity

      No nappy wipes. Cotton wool and olive oil /water only to cleanse the nappy area

      No solvents for adhesive removal, toxicity may result from absorption through the skin  ie. Convacare wipes

      For further neonatal and Infant skin care management see:

      Environmental humidty

      Extravasation care

      Wound care

      • Clinical management as per Wound Care Clinical Guideline

      Pressure area care

      Common newborn rashes

      Erythema Toxicum Neonatorum

      A common condition affecting as many as half of all full term newborn infants. Most prominent on day 2, although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs. Palms and soles are not usually affected.

      Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual for an individual lesion to persist for more than a day.

      Treatment: The infant is otherwise well and requires no treatment.

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      Neonatal Milia

      Affects 40-50% of newborn babies. Few to numerous lesions.

      Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk.

      Treatment: Lesions will heal spontaneously within a few weeks of birth.

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      Miliaria (heat rash)

      Arises from occlusion of the sweat ducts. In infants lesions commonly appear on the neck, groins and armpits, but also on the face.

      Clinical features: 1-3mm papules (vesicular or papular).

      Treatment: Remove from heated humid environment or adjust incubator temperature. Cool bathing or apply cool compresses. Topical steroids may be used to facilitate relief while the condition resolves.

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      Pityrosoprum folliculitis

      Infantile acne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the newborns' sebaceous glands cause inflammation and folliculitis.

      Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops, commonly affecting the cheeks, nose and forehead. This rash is not itchy.

      Treatment: Will resolve within weeks without treatment or may be treated with ketoconozole shampoo (eg. Sebizole shampoo) diluted 1:5 with water, applied with a cotton bud twice a day. Rinse off with water after 10 minutes. Or apply Hydrozole cream bd to the affected areas until the rash has resolved.


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      Companion documents


      For further assistance the Epidermolysis Bullosa nurse can be paged via switchboard

      Evidence table


      1. Allwood M. Skincare guidelines for infants aged 23-30 weeks' gestation:a review of literature. Neonatal, paed & Child health Nurs., 2011, 14(1)
      2. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal skin care. Evidence-based clinical practice guideline. Washington (DC): association of Women's Health, Obstetric and Neonatal Nurses9AWHONN); 2001 Jan. 54p
      3. Blackburn S. Maternal, Fetal & Neonatal Physiology: A clinical perspective. Missouri, USA: Saunders Elsevier, 2007
      4. Connor J, Soll R, Edwards W. Topical ointment for preventing infection in preterm infants (review). Cochrane Database of Syst Rev. (internet). 2009 (cited 22 Feb 2010) Art No:CD001150
      5. Darmstadt G, Dinulos J. Neonatal Skin Care. Pediatric Clinics of North America. Vol 47(4) Aug 2000
      6. Franck L, Quinn D, Zahr L. Effect of less frequent bathing of preterm infants on skin flora and pathogen colonization. J Obstet Gynecol Neonatal Nurs.(Internet). 2000; 29(6)584-89
      7. Gregory J, Anschau N, McCutchan D, Patterson J, Martin S, Allwood M. Skincare Guidelines for babies in NICU. Kaleidoscope, The Children's health network. Jan 2011
      8. Kuller J. Skin care management of the low birth weight infant. In Gunderson L, Kenner C, editor(s). Care of the 24/25 week gestational age infant: A small baby protocol. 2nd ed. Petaluma (CA): NICU Ink 1995. P 107-144
      9. Lund C, Kuller J, Lane A, Lott J, Raines D, Thomas K. Neonatal skin care: Evaluation of the AWHOON/NANN research-based practice projection knowledge and skin care practices. J Obstet Gynecol Neonatal Nurs. (Internet). 2001 (cited 1 Feb 2010); 30(1)30-40.
      10. Lund C, Kuller J, Lane A, Lott J, Raines D. Neonatal skin care: The scientific basis for practice. J Obstet Gynecol Neonatal Nurs. [Internet]. 1999 May/June [cited 1 Feb 2010];28(3)241-254.
      11. Lund C. Nonato L, Kuller J, Frank L, Cullander C, Durand. Disruption of barrier function in neonatal skin associated with adhesive removal. J Pediat. [Internet]. 1997 [cited 25 Jan 2010];131 (3)367-372
      12. Lund C, Osborne J, Kuller J, Lane A, Wright J, Raines D. Neonatal skin care: Clinical outcomes of the AWHNN/NANN evidence-based clinical practice guidelines. J Obstet Gynecol Neonatal Nurs. [Internet]. 2001 [cited 1 Feb 2010]; 30(1)41-51.
      13. New Zealand Dermatological Society (NZDS),, May 2013
      14. Nopper A. Horii K, Sookdoe-Drost S, Wang T, Mancini A, Lane A. Topical ointment therapy benefits premature infants. J Pediatr. (Internet). 1996 (cited 3 Feb 2010); 128 (5)660-669.
      15. Royal Prince Alfred Hospital. RPA Newborn Care Guidelines: Small Baby Protocol. (Internet) 2009. Available from:
      16. Trotter S. Neonatal Skincare: why change is vital. RCM Midwives J. (internet). 2006 (cited 3 Feb 2010); 9 (4)134-138.
      17. Varda, K & Behnke R. The effect of timing of initial bath on newborn's temperature. JOGNN. Jan/Feb 2000 27-32
      18. Visscher M. Update on the use of topical agents in neonates. Newborn Infant Nurs Rev.2009 March 31-47
      19. Zaccaria E, Baker C. Systemic candidiasis in extremely low birth weight infants receiving topical petrolatum ointment for skin care: a case control study. Paediatrics. [Internet]. 2000 [cited 2010 Feb 1; 105 (5) 1195-1203.
      20. Zupan J, Garner P, Omari AAA. Topical umbilical cord care at birth. The Cochrane Database of systematic Reviews 2004, Issue 3. Art. No.: CD001057. DOI: 10.1002/14651858.CD001057.pub2.
      Please remember to read the disclaimer

      The development of this clinical guideline was coordinated by Robyn Kennedy, Registered Nurse, Dermatology. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published August 2009, reviewed July 2013.