Variation in Newborn Skincare Policies Across United States Maternity Hospitals

The study was conducted in partnership with the Academic Pediatric Association’s Better Outcomes through Research for Newborns (BORN) network, a practice-based network of researchers and clinicians who provide care for term and late-preterm newborns at academic and community medical centers during the birth hospitalization.³⁹  At the time of the survey (July 1, 2018, through November 26, 2018), the network included 109 newborn maternity sites located in 35 states. Cumulatively, these sites had an annual birth rate of 369 498 infants.

Sites participating in the BORN network were surveyed by using a voluntary electronic survey tool (Qualtrics, Provo, UT) e-mailed to the nursery medical director at each institution. To prevent overrepresentation of data from single BORN sites, the director for each site was instructed to complete the survey according to practices followed by the majority of clinicians at their institution for well infants born >36 weeks’ gestation. The electronic survey consisted of 16 questions (Supplemental Information 1) focused on 4 main topics: (1) timing of first bath, (2) skincare practices, (3) skincare products, and (4) skincare education for parents. Questions required either yes or no or multiple-choice responses. The option of responding “other” was provided for most questions, which opened a text field to allow narrative comments. Survey respondents were also asked to upload a copy of their institutional guidelines with completion of the survey. A total of 7 attempts were made to contact each institution over a period of 4 months before closing the survey to total responses. All data were collected by a BORN study coordinator and deidentified before analysis. The current study was determined to be exempt from human subjects research review by our institutional review board (no. 20445).

Data were coded by the BORN study coordinators (E.K. and D.W.), according to geographic location defined by US Census data,^40,41  to identify regional differences in responses to survey topics. Data were also coded according to the timing of the first bath to identify other possible similarities among hospitals practicing delayed bathing. “Delayed bathing” was defined as deferring the newborn’s first bath by 6 hours or more after birth. Survey responses were analyzed by using descriptive statistics cumulatively and regionally focused on the survey categories. Evidence reported in guidelines uploaded by survey respondents is separated into each of these topics of interest and reported within the Results section. Information in free text narratives and submitted copies of institutional guidelines is also described in the Results section when related to the study objectives, including separate newborn skincare policies for infants born to HIV-, Hepatitis B/C-, or HSV-infected mothers, and specific references supporting individual institutional policies on newborn skincare.

Nursery medical directors at 73 (67%) of 109 maternal hospitals across 4 geographic regions^40,41  of the Unites States (Table 1) completed the survey. The cumulative annual delivery rate was 279 819 infants for sites participating in the survey. Participating institutions comprised more academic than nonacademic hospitals and were characterized by variable rates of inpatient breastfeeding and public insurance carriage (Table 1). Written newborn bathing policies were reported by 69 (94%) of 73 hospitals, and 62 (90%) of these 69 institutions shared specific details and/or evidence supporting their skincare protocols. Four (5% of respondents) hospitals that were academic centers had no written policy, guideline, or standard work for newborn skincare but still completed the survey according to practices commonly followed by the majority of health care providers.

Excluding drying off the newborn at birth, as recommended in the Neonatal Resuscitation Program guidelines,³²  the majority (63%) of US maternal hospitals reported delaying the newborn bath 6 to 24 hours after delivery. A smaller percentage of hospitals (15%) reported delaying the first bath >24 hours, and only 8% reported bathing newborns before 6 hours. Discharging newborns without a bath was practiced in 10% of US hospitals, including 6% of academic and 20% of nonacademic centers. The majority (6 of 7) of hospitals discharging newborns without a bath were West Coast hospitals⁴⁰  (Fig 1). Two institutions that typically bathe newborns 6 to 24 hours after delivery noted that newborns could be discharged without a bath at the parents’ request. One of 2 medical directors with a response of “other” indicated that bathing time was the “parents’ choice.”

Among those 7 hospitals with policies to discharge newborns without a bath, the majority (71%) reported their policy was “evidence-based.” Among the remaining 66 hospitals, 32% (21 of 66) reported that sufficient evidence was available to inform their bathing policies. The evidence cited by the institutions that submitted their references for evidence-based practices included a compilation of small studies and differing guidelines (Supplemental Information 2).

Exceptions to delayed bathing were common for term newborns at risk for transmission of perinatally-acquired infection. One hundred percent (5 of 5) of institutions that delayed baths >24 hours and at least 20 institutions that delayed baths >6 hours made exceptions for newborns of mothers positive for HIV, hepatitis B/C, and/or HSV. At least 1 institution also promoted earlier bathing times for infants born to mothers colonized with Group B Streptococcus. The timing of bathing in these at-risk groups ranged from immediately after birth to 4 or more hours after birth. The mandate to use standard precautions and gloves by health care workers handling newborns before their first bath was also variable in written guidelines. The continued use of gloves to protect health care workers from potential pathogens on newborns’ skin was not mandated in written guidelines for health care workers handling newborns after the newborn’s first bath.

The most commonly reported bathing procedure for newborns was sponge bathing, practiced by 85% (62 of 73) of institutions. Immersion baths were reported by 11% (8 of 73) and swaddle baths by 3% (2 of 73) of hospitals. Liquid soap was used by 96% (70 of 73) of hospitals and was commonly a single brand name (Table 2). Skin cleanser wipes alone were used by 1 institution (1 of 73). Skin cleanser wipes at 2 hours after delivery followed by a bath with liquid detergent was reported by one institution (1 of 73). The use of water alone to cleanse newborn skin was reported by only 3% (2 of 73) of respondents. During diaper changes, the diaper area was cleansed with unscented wipes by 70% of institutions and cloth and water alone by 23% of institutions. Excluding circumcision care, a policy for skin moisturizer was reported by only 8% (6 of 73) of institutions. An additional 4 institutions (5%) reported supplying moisturizer to parents to apply themselves. A complete list of cleanser and emollient products used by respondent hospitals is included in Table 2. Twenty-six (36%) of 73 institutions reported providing parents with free manufacturer-supplied samples of the products used in the hospital to take home at discharge.

Education to delay tub immersion until “after the umbilical cord falls off” was provided to parents by 87% of hospitals, whereas 6% of hospitals taught parents to immerse their newborn “right away.” Instruction on soap usage on the newborn’s skin ranged from “right away” (37%) to waiting until the cord was off and circumcision healed (2%). Among 15% of hospitals that recommended immediate soap bathing to parents, a qualification was included to limit application to the hair and scalp for the first few weeks. Frequency of newborn bathing was discussed during skincare education in 68% of hospitals. Respondents from 70% of hospitals provided written information to parents of newborns about skincare, but copies of the hand-outs were provided from only 4 sites and consisted of 1 to 2 paragraphs about using a mild skin cleanser and about tub safety.

Education about moisturizing newborn skin occurred at 40% of sites, but recommendations on frequency of moisturizing skin ranged from daily (3% of 29 responses) to as needed (83% of 29 responses). Specific moisturizers (Coloplast, Eucerin, Lubriderm, or Aquaphor) were recommended by 12% of 28 responders.

Education about laundering newborn clothing and bedding occurred in 26% of 73 centers. Only 1 of 19 respondents recommended using a product that was fragrance-free. Twelve respondents reported giving additional advice about laundering newborn clothing, including separating newborn items from other laundry, avoiding fabric softener, and double rinsing the newborn’s clothes. Twenty respondents reported providing parents with education about specific products to avoid using on newborn skin, including scented products or fragrance (17 of 20), baby powder (4 of 20), sunscreen (1 of 20), dye (1 of 20), insect spray (1 of 20), and bleach (1 of 20).

We report the results of the first nationwide survey of current hospital-based newborn skin care practices. We discovered that the newborn skincare practices followed by US institutions vary widely among 4 specific topics. Current literature in each of these areas reveals conflicting evidence for and against institutional practices reported by maternal hospitals in this survey.

Several authorities advocate delaying the newborn bath to enhance the benefits of vernix contact on the skin,^1,2,37,38  but other authorities advise that bathing can be performed safely after body temperature is stable, usually within 3 hours following delivery.^36,42  Improved thermoregulation,^3,4  reduced hypoglycemia,⁵  and increased breastfeeding rates⁶  have each been observed when baths are delayed >12 hours. Scant data exist on benefits of delaying newborn bathing beyond 12 hours of age,^6,32,43  although this practice was followed by more than one-quarter of maternal newborn hospitals in this study. Interestingly, when bathing time was delayed from 7 hours to 14 hours in a southern California community hospital, exclusive breastfeeding rates did not change, but the number of newborns who were discharged from the hospital unbathed increased sevenfold (from 0.16% to 1.1%).²⁶  Respondents from West Coast maternity academic and nonacademic hospitals in our survey also reported higher rates of discharging newborns without in-hospital baths. Although this survey cannot explain the rationale for longer delays in bathing newborns in certain centers, it is possible that evolving trends in newborn skincare may echo those of hospital-based breastfeeding practices.⁴⁴  Enhanced parent participation and satisfaction has also been associated with delayed newborn bathing practices.⁴⁵  Taken together, several health benefits and no increase in infection rates have been associated with delayed or less frequent bathing. ^7,46,47  Although the majority of US hospitals in this study have adopted some version of delayed bathing guidelines, the optimal time to initiate newborn bathing remains unclear.

Researchers in only a handful of studies have examined the effects of skin procedures on other newborn health outcomes.^48,49  Reduced hypothermia rates and enhanced newborn comfort were associated with emersion versus sponge baths^30,50 ; however, the majority of hospitals in this survey still routinely practiced sponge bathing. Swaddle bathing was reported by only 2 US maternity hospitals in this survey. A swaddle bath involves swaddling the newborn in a soft towel during full immersion in a tub of warm water. This procedure was initially designed for bathing preterm newborns³¹  but may further improve temperature stability and reduce stress associated with bathing in other newborns.⁵¹ 

The use of detergent on newborn skin may favorably modify skin pH³⁶ ; however, newborn skin naturally acidifies days to weeks after delivery.²  Only a handful of hospitals in this study promoted not exposing newborn skin to liquid detergent in the early hours and days after delivery. The products applied to newborn skin impact skin integrity, allergy, and other childhood health outcomes.^10,52,53  One study revealed no difference in transepidermal water loss between water alone and soap bathing²⁷  and a few studies have highlighted potential benefits from promoting nonsterile newborn skin. ^7,18  Nonetheless, soap use remains a common hospital practice in bathing newborns soon after delivery. No researchers have supported the use of any specific product-brand on newborn skin, yet the majority of hospitals in this study used a single brand of infant soap.

Early application of skin emollients has been shown to improve skin appearance⁴⁶  and has been associated with decreased rates of atopic dermatitis in early childhood in 2 randomized controlled trials in Japan and the United States. ^10,29  However, the majority of current newborn skincare practices in this survey excluded routine emollient use.

The teaching provided to parents of newborns, including the products and procedures used (whether intentionally or unintentionally), can also have long-standing implications for infant skin health, as has been shown by the impact of education on breastfeeding.⁵⁴  Conflicting views among professional health care providers about newborn skincare, as in this survey, leave new parents confused and dependent on other resources to design their newborn’s skincare regimen at home. To this end, our report invites many questions, particularly those regarding the strength of evidence to support the use of any one brand of cleanser or other newborn skin products. Researchers in a recent article highlighted a series of evidenced-based, best care practices for neonatal skin based on a review of the literature and data from newborn nurseries and mother-newborn units in a single state.³⁵ 

Our findings point to a need to review more closely the available data on newborn skincare and a call for more research to develop new guidelines reflective of the best available evidence. Such guidelines may also need to account for current recommendations related to the current coronavirus disease 2019 pandemic. On the basis of 1 large case series of maternal hospitals in New York City revealing no increased morbidity to newborns, authors recommend that early skin-to-skin contact and delayed bathing can be practiced even in newborns born to mothers infected with coronavirus disease 2019.⁵⁵  BORN is systematically evaluating current care practices, including the timing of bathing for newborns with perinatal severe acute respiratory syndrome coronavirus 2 exposure. The first bath in otherwise healthy mother-newborn dyads is not currently a universally recommended standard-of-care prophylactic measure and the timing of the first bath, except when given too early in life, does not impact neonatal morbidity or mortality like other newborn procedures.⁵⁶  In this regard, the few hospitals in this survey who advocate parent participation in decisions about bathing may have adopted the ideal approach to certain aspects of newborn skincare.

In a national network of US maternity hospitals, we demonstrated regional variation in timing of the newborn’s first bath, bathing and other skincare, soaps and emollient products used, and parental advice on newborn skincare. Given the potential widespread clinical impact of newborn skincare and the paucity of data to support or refute widespread adoption of specific practices, further research is needed to improve and standardize care in US nurseries and mother-baby units.

The authors thank the members of the Better BORN Network for their participation in this study.