Diaper dermatitis prevalence and severity: Global perspective on the impact of caregiver behavior.

OBJECTIVES: To compare prevalence and severity of diaper dermatitis (DD) in infants and toddlers (babies) across three countries (China, USA, and Germany), including diapered skin measures and caregiver practices. METHODS: A cross-sectional study of 1791 babies (~600 from each country) was recruited at each clinical site. Based on regional toilet-training habits, exclusively diaper-wearing infants were recruited between ages 2-8 months in China and 2-18 months in the USA and Germany. DD was measured, as well as skin pH, transepidermal water loss (TEWL), and relative humidity (RH) in the diapered region. Caregiver habits were collected via a questionnaire and included information on hygienic practices. RESULTS: Diaper dermatitis was highest in the perianal area, followed by the intertriginous, genital, and buttock regions. In general, DD was significantly lower in babies in China, highest in Germany, and intermediate in the USA. This rank ordering of DD by geography was also observed in baby age 2-8 months. The lower DD observed in China was associated with lower skin pH and TEWL on diapered skin and decreased RH in the diaper. Chinese caregivers had the highest rate of prophylactic topical product usage, the most robust cleaning of the diapered area, lack of cleansing after urine-only diaper changes, and Chinese infants spent the least time in an overnight diaper. CONCLUSIONS: These data suggest caregiver behaviors including prophylactic use of topical products, thorough cleaning after stooling and reduced time in an overnight diaper are associated with less DD, lower superficial skin pH, and enhanced skin barrier.

Quantitative characterization of mechanically indented in vivo human skin in adults and infants using optical coherence tomography.

Influenced by both the intrinsic viscoelasticity of the tissue constituents and the time-evolved redistribution of fluid within the tissue, the biomechanical response of skin can reflect not only localized pathology but also systemic physiology of an individual. While clinical diagnosis of skin pathologies typically relies on visual inspection and manual palpation, a more objective and quantitative approach for tissue characterization is highly desirable. Optical coherence tomography (OCT) is an interferometry-based imaging modality that enables in vivo assessment of cross-sectional tissue morphology with micron-scale resolution, which surpasses those of most standard clinical imaging tools, such as ultrasound imaging and magnetic resonance imaging. This pilot study investigates the feasibility of characterizing the biomechanical response of in vivo human skin using OCT. OCT-based quantitative metrics were developed and demonstrated on the human subject data, where a significant difference between deformed and nondeformed skin was revealed. Additionally, the quantified postindentation recovery results revealed differences between aged (adult) and young (infant) skin. These suggest that OCT has the potential to quantitatively assess the mechanically perturbed skin as well as distinguish different physiological conditions of the skin, such as changes with age or disease.

Modern diaper performance: construction, materials, and safety review.

A review of the literature on diapers and diaper rash reveals that many clinicians are unfamiliar with modern diaper construction and materials as well as diaper safety testing methods. Typical modern diapers do not contain ingredients of concern such as latex and disperse dyes, but use ingredients such as spandex and pigments with a favorable safety profile. Today's disposable diaper is a high performance product whose carefully designed layers and liners provide optimal urine and feces absorption and an ever more clothing-like and comfortable fit. This is possible due to a variety of specialized polymer materials that provide optimal absorption of urine and feces, thereby minimizing skin exposure.

Induction of epidermal damage by tape stripping to evaluate skin mildness of cleansing regimens for the premature epidermal barrier.

BACKGROUND: Previous works indicate a compromised skin model may be a possible surrogate for premature, undeveloped skin. OBJECTIVES: This study was performed to investigate the use of a current model as a surrogate test design. METHODS: Serial tape stripping on the volar forearms of adult female volunteers (n = 36) was used to "thin" the stratum corneum. The forearm sites received intensive applications of different wiping options that exaggerated the exposures to cleansers that might be experienced by an infant in a neonatal intensive care unit. The recovery of skin barrier function during the wiping regimen, measured by transepidermal water loss (TEWL), was used as the primary indicator of the mildness of the cleansing options. Measurements of TEWL were made prior to the first wash on days 1-4, on day 5 and on day 8. Erythema was graded as a secondary endpoint. RESULTS: There was an early and sustained distinction in rates of skin barrier recovery between the washcloth and water treatment, and the two wipes treatments (P < 0.05). Areas submitted to the wipes treatments showed recovery rates similar to that of the tape-stripped untreated site, indicating that the use of disposable wipes led to minimal perturbation of the recovery process. By contrast, cleansing with a cotton washcloth and water markedly perturbed the repair process compared with all other conditions (P < 0.05). CONCLUSIONS: This model shows promise as a possible surrogate model for assessing the mildness of skin cleansing products for the care of premature infants.

Disposable diaper use promotes consolidated nighttime sleep and positive mother-infant interactions in Chinese 6-month-olds.

The emergence of consolidated nighttime sleep and the formation and maintenance of parent-infant relationships are 2 primary developmental achievements of the infancy period. Despite the development of a transactional model that links parenting behaviors to infant sleep, limited attention has been devoted to examining experimental manipulations of infant sleep that may impact the discrete parent-infant interactions that may form the foundation for emerging attachment relationships. In the present study, infants were randomly assigned to wear high-absorbency disposable diapers or to continue using traditional low-absorbency cloth diapers that necessitate frequent changes and associated disruptions of nighttime sleep. Parents reported on infant sleep before and during the 6-week experimental manipulation; a subset of infants also wore actigraphs. Parents and infants also participated in a parent-infant interaction task both before and near the end of the experimental manipulation. Infants who wore cloth diapers experienced more frequent sleep disruptions overall as well as a greater number of disruptions that did and did not wake the infant from sleep. Infants who wore disposable diapers were rated as experiencing more engagement and positive affect near the end of the intervention relative to infants who wore cloth diapers; mothers of infants who wore disposable diapers were rated as more engaged and sensitive near the end of the intervention relative to mothers of infants who wore cloth diapers. These findings suggest that the disposable diaper manipulation was causally related to characteristics of mother-infant interactions that may form the foundation for emerging attachment relationships.

Newborn infant skin: physiology, development, and care.

Infant skin is critical to the newborn child's transition from the womb environment to the journey to self-sufficiency. This review provides an integrative perspective on the skin development in full term and premature infants. There is a particular focus on the role of vernix caseosa and on the implications of skin development for epidermal penetration of exogenous compounds. Healthy full-term newborn skin is well-developed and functional at birth, with a thick epidermis and well-formed stratum corneum (SC) layers. Transepidermal water loss is very low at birth, equal to, or lower than adults, indicating a highly effective skin barrier. Vernix facilitates SC development in full-term infants through a variety of mechanisms including physical protection from amniotic fluid and enzymes, antimicrobial effects, skin surface pH lowering, provision of lipids, and hydration. Premature infants, particularly those of very low birth weight, have a poor skin barrier with few cornified layers and deficient dermal proteins. They are at increased risk for skin damage, increased permeability to exogenous agents and infection. The SC barrier develops rapidly after birth but complete maturation requires weeks to months. The best methods for caring for infant skin, particularly in the diaper region, are described and related to these developmental changes.

Diapering, diaper technology, and diaper area skin health.

Disposable diapers are the most common diaper care practice in Western societies today, and their use continues to increase globally. Improvements in disposable diaper technology have helped to reduce the prevalence and severity of diaper dermatitis (DD) over the course of the last few decades. This article reviews how changes in disposable diaper technology interact with the various etiological factors in DD, thus helping to improve overall diaper area skin health for children around the world.

Setting the Record Straight on Diaper Rash and Disposable Diapers.

Skin in the diapered area is continuously threatened by exposure to changes in pH levels, overhydration, mechanical friction, and fecal enzymes, making diaper rash a common occurrence among babies. Up to one third of infants may exhibit clinical symptoms of diaper rash at any time, and more than half of babies between the ages of 4 and 15 months develop diaper rash at least once in a 2-month period. Despite misperceptions that disposable diapers are related to an increase in diaper rash, the incidence of diaper dermatitis is on the decline, largely due to significant improvements in disposable diaper construction and materials. Modern-day disposable diapers are specifically designed to limit exposure to irritants in the diaper area, reduce overhydration, inhibit skin barrier compromise, and help maintain normal skin pH levels and have been thoroughly evaluated for safety and skin compatibility.

Frequency and severity of diaper dermatitis with use of traditional Chinese cloth diapers: observations in 3- to 9-month-old children.

Chinese cloth diapers differ from disposable diapers in several respects that are central to our understanding of the etiology of diaper dermatitis (DD), yet there are no published reports on the dermatological correlates of this manner of infant care, which is prevalent among the world's second-largest pediatric population. The objective was to determine the prevalence and severity of DD in exclusive users of Chinese cloth diapers. This observational study was conducted during a single home visit to 694 Chinese children who were exclusive users of cloth diapers in five inland cities of China. During each home visit, study nurses documented the presence and severity of DD using a visual dermatological scale and conducted transepidermal water loss (TEWL) and pH measurements. Diaper dermatitis was rare in the buttocks and genital area of the children (<20%) but was common in the perianal and intertriginous regions (50-70%). TEWL and pH were mildly higher in babies with DD than in those without DD in the genital and buttocks area. Diaper dermatitis is common in children who use traditional Chinese cloth diapers, especially in the perianal and intertriginous regions.

Efficacy of different strategies to treat anemia in children: a randomized clinical trial.

BACKGROUND: Anemia continues to be a major public health problem among children in many regions of the world, and it is still not clear which strategy to treat it is most effective. OBJECTIVE: To evaluate the efficacy and children's acceptance of several recognized strategies to treat anemia. METHODS: Non-breastfed children (n = 577), 6 to 43 mo of age, were screened for the trial; 267 were anemic (hemoglobin < 11.7 g/dL), and 266 of those were randomized into 1 of 5 treatments to received daily either: an iron supplement (IS), an iron+folic acid supplement (IFS), a multiple micronutrient supplement (MMS), a micronutrient-fortified complementary food as porridge powder (FCF), or zinc+iron+ascorbic acid fortified water (FW). The iron content of each daily dose was 20, 12.5, 10, 10 and 6.7 mg respectively. Hemoglobin (Hb), ferritin, total iron, weight and height were measured at baseline and after 4 months of treatment. Morbidity, treatment acceptability and adherence were recorded during the intervention. RESULTS: All treatments significantly increased Hb and total iron concentration; ferritin did not change significantly. Groups MMS, IS and IFS increased Hb (g/dL) [1.50 (95%CI: 1.17, 1.83), 1.48 [(1.18, 1.78) and 1.57 (1.26, 1.88), respectively] and total iron ((µg/dL) [0.15 (0.01, 0.29), 0.19 (0.06, 0.31) and 0.12(-0.01, 0.25), respectively] significantly more than FCF [0.92 (0.64, 1.20)] but not to FW group [0.14 (0.04, 0.24)]. The prevalence of anemia was reduced to a greater extent in the MMS and IFS groups (72% and 69%, respectively) than in the FCF group (45%) (p < 0.05). There were no significant differences in anthropometry or in the number of episodes of diarrhea and respiratory infections among treatment groups. The supplements MMS and IS were less acceptable to children, than IFS, FCF and FW. CONCLUSION: The three supplements IS, ISF and MMS increased Hb more than the FCF; the supplements that contained micronutrients (IFS and MMS) were more effective for reducing the prevalence of anemia. In general, fortified foods were better accepted by the study participants than supplements. CLINICALTRIAL.GOV IDENTIFIER: NCT00822380.

Skin care in the NICU patient: effects of wipes versus cloth and water on stratum corneum integrity.

BACKGROUND: NICU patients are at risk of skin breakdown due to prematurity, irritant exposure, medical status and stress. There is a need to minimize damage, facilitate skin development and reduce infection risk, but the literature on the effects of skin care practices in NICU patients is limited. OBJECTIVES: To test the hypothesis that baby diaper wipes with emollient cleansers and a soft cloth would minimize skin compromise relative to cloth and water. METHODS: In 130 NICU infants (gestational age 23-41 weeks, at enrollment 30-51 weeks), measurements of skin condition, i.e., skin erythema, skin rash, transepidermal water loss (TEWL) and surface acidity (pH), within the diaper and at diaper and chest control sites were determined daily for 5-14 days using standardized methods. Treatments were randomly assigned based on gestational age and starting skin irritation score: wipe A, wipe B, and the current cloth and water NICU standard of care. RESULTS: Perineal erythema and TEWL were significantly lower for wipes A and B than cloth and water beginning at day 5 for erythema (scores of 1.11 +/- 0.05, 1.2 +/- 0.05, and 1.4 +/- 0.06, respectively) and day 7 for TEWL (28.2 +/- 1.6, 28.8 +/- 1.6, and 35.2 +/- 1.6 g/m(2)/h, respectively). Wipe B produced a significantly lower skin pH (day 5, 5.47 +/- 0.03) than wipe A (5.71 +/- 0.03) and cloth and water (5.67 +/- 0.04). The starting skin condition, stool total, age and time on current standard impacted the outcomes. CONCLUSIONS: Both wipes are appropriate for use on medically stable NICU patients, including both full and preterm infants, and provide more normalized skin condition and barrier function versus the cloth and water standard. Wipe B may facilitate acid mantle development and assist in colonization, infection control and barrier repair. Neonatal skin continues to change for up to 8 weeks postnatally, presumably as it adapts to the dry extra-uterine environment.