Preventing Neonatal Infections Through Skin Barrier Therapy
This talk was presented by Gary L. Darmstadt, Associate Professor and Director, International Center for Advancing Neonatal Health, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, U.S.A.
Neonatal infectious diseases are responsible for 36 per cent of neonatal deaths or more than 1.4 million deaths a year worldwide (Figure 6.1). As noted in the presentation by Dr. Hoath, the skin is an important barrier to bacterial infections, however in some newborns that barrier is compromised (Figure 6.2).
The management of the skin of the newly born infant varies from community to community, however, throughout many places in the world, the common practice is to massage the newborn with oil. In Bangladesh, a questionnaire survey found that this technique was practiced in 97 per cent of deliveries, usually with mustard oil (Figure 6.3). The effect of this practice was studied by using transepidermal water loss (TEWL) as an index of skin recovery after application of a variety of emollients (Figure 6.4). Skin treated with mustard oil had the poorest recovery and ultrastructural studies of the skin revealed significant damage to keratin filaments and to mitochondrial and nuclear membranes.
In the same study it was found that sunflower oil maintained the skin’s integrity. Subsequently, two studies of newborn infants receiving topically applied sunflower oil in Bangladesh and Egypt found that it significantly reduced the incidence of nosocomial infection (Figure 6.5).
The studies of Drs.Hoath and Darmstadt strongly suggest that the skin is an important barrier to infection and when it is compromised (for example by premature birth or by inappropriate management) the barrier is weakened. This, in turn, contributes to the potential for nosocomial infections. The conclusions of Dr. Darmstadt’s studies are shown in Figures 6.6 and 6.7.
Omphalitis is an important cause of neonatal morbidity and mortality in developing countries. Dr. Darmstadt reported on a community-based, cluster-randomized trial in Nepal. In the trial the umbilical cord was treated either with chlorhexidine, soap and water, or nothing. As shown in Figure 6.8 there was a significant reduction in all forms of omphalitis and a borderline reduction in neonatal mortality (Figure 6.9). However, when intervention occurred in the first 24 hours there was significant reduction in mortality (Figure 6.10). The conclusions of the study are shown in Figure 6.11.