Transcutaneous application of oil and prevention of essential fatty acid deficiency in preterm infants

Essential fatty acid deficiency in parenteral nutrition: Historical perspective and modern solutions, a narrative review

Essential fatty acid deficiency (EFAD) may occur in the setting of inadequate fat intake, malabsorption, malnutrition, and altered fat metabolism. Humans lack the enzymes to synthesize the essential acids linoleic acid and alpha-linolenic acid, so they must be obtained from the diet. Patients dependent on parenteral nutrition need adequate amounts of these essential fatty acids supplied in lipid injectable emulsions (ILEs). With the increasing use of multicomponent ILEs that are lower in linoleic and alpha-linolenic acid, it is imperative that clinicians understand appropriate dosing to prevent EFAD. An understanding of fatty acid composition and metabolic pathways is important, as the use of the Holman Index (triene:tetraene ratio) alone may lead to an inaccurate diagnosis of EFAD.

Effect of Massage with Oil Balanced in Essential Fatty Acids on Development and Lipid Parameters in Very Premature Neonates: A Randomized, Controlled Study

Background: Oil massage versus only massage can increase preterm newborn development, especially weight gain, via a supposed percutaneous absorption of oil lipids, but data are contradictory. Aims: Investigating whether massage with a vegetable oil balanced in essential fatty acids improves neonatal weight gain, and digestive autonomy as proxy for neuro-development outcomes. Methods: A prospective monocentric randomized study was conducted in very premature newborns who received massage with oil (isio4 10 mL/kg/day, n = 18) versus with no oil (n = 18) for five consecutive days (10-min session twice daily) at a corrected gestational age of 34−35 weeks. Anthropometrics and clinical characteristics were recorded. Plasma triglyceride and total cholesterol concentrations were analyzed with an enzymatic kit. The fatty acid composition (weight%, mg/mL) of total plasma lipids and of red blood cell (RBC) membrane was analyzed by gas chromatography. Results: Weight gain velocity at the end of massage period was 12.3 ± 1.4 g/kg/day with oil vs. 9.8 ± 1.4 g/kg/day with no oil (p = 0.1). Digestive autonomy, plasma lipid parameters, polyunsaturated fatty acids in plasma total lipids or in RBC were comparable. The no oil group displayed a higher RBC level in nervonic acid at discharge (4.3 ± 0.2 vs. 3.4 ± 0.2%; p = 0.025) and in C18:1n-9 plasmalogen species at the end of the massage period and at discharge (0.73 ± 0.06 vs. 0.48 ± 0.06; 0.92 ± 0.06 vs. 0.69 ± 0.06%; p < 0.01), two molecules that are involved in neurodevelopment. Conclusions: The use of isio4 oil did not provide additional benefits for the development of very premature newborns, neither changed lipid metabolism nor polyunsaturated fatty acid biological status, which did not corroborate the existence of a percutaneous route for oil lipid absorption. The reason for different levels of nervonic acid and plasmalogen in RBC remains to be explored.

Risk factors and assessment considerations for essential fatty acid deficiency in nonparenterally fed patients using a case example

Essential fatty acid deficiency (EFAD) has most commonly been reported in parenterally fed individuals but may also present in patients receiving fat-restricted diets and in patients with fat-malabsorption disorders. This article reviews the physical and biochemical assessment for EFAD in clinical practice and disorders of fat malabsorption as potential risk factors for EFAD. A case report is included to describe the fatty acid profile of a patient with exocrine pancreatic insufficiency receiving low-dose pancreatic enzyme replacement therapy after a self-imposed fat-restricted diet. The current challenges with laboratory interpretation of essential fatty acid status are also discussed.

Topical emollient for preventing infection in preterm infants

BACKGROUND

Breakdown of the developmentally immature epidermal barrier may permit entry for micro-organisms leading to invasive infection in preterm infants. Topical emollients may improve skin integrity and barrier function and thereby prevent invasive infection, a major cause of mortality and morbidity in preterm infants.

OBJECTIVES

To assess the effect of topical application of emollients (ointments, creams, or oils) on the risk of invasive infection and mortality in preterm infants.

SEARCH METHODS

We searched CENTRAL via Cochrane Register of Studies (CRS) Web and MEDLINE via Ovid (updated 08 January 2021) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of prophylactic application of topical emollient on the risk of invasive infection, mortality, other morbidity, and growth and development in preterm infants.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on mortality and invasive infection.

MAIN RESULTS

We included 22 trials with a total of 5578 infant participants. The main potential sources of bias were lack of clarity on the methods used to generate random sequences and conceal allocation in half of the trials, and lack of masking of parents, caregivers, clinicians, and investigators in all of the trials. Eight trials (2086 infants) examined the effect of topical ointments or creams. Most participants were very preterm infants cared for in healthcare facilities in high-income countries. Meta-analyses suggested that topical ointments or creams may have little or no effect on invasive infection (RR 1.13, 95% confidence interval (CI) 0.97 to 1.31; low certainty evidence) or mortality (RR 0.94, 95% CI 0.82 to 1.08; low certainty evidence). Fifteen trials (3492 infants) assessed the effect of topical plant or vegetable oils. Most of these trials were undertaken in low- or middle-income countries and were based in healthcare facilities. One large (2249 infants) community-based trial occurred in a rural field practice in India. Meta-analyses suggested that topical oils may reduce invasive infection (RR 0.71, 95% CI 0.52 to 0.96; I² = 52%; low certainty evidence) but have little or no effect on mortality (RR 0.94, 95% CI 0.82 to 1.08, I² = 3%; low certainty evidence). One trial (316 infants) that compared petroleum-based ointment versus sunflower seed oil in very preterm infants in Bangladesh showed little or no effect on invasive infection (RR 0.91, 95% CI 0.57 to 1.46; low certainty evidence), but suggested that ointment may lower mortality slightly (RR 0.82, 95% CI 0.68 to 0.98; RD -0.12, 95% CI -0.23 to -0.01; number needed to treat for an additional beneficial outcome 8, 95% CI 4 to 100; low certainty evidence). One trial (64 infants) that assessed the effect of coconut oil versus mineral oil in preterm infants with birth weight 1500 g to 2000 g in India reported no episodes of invasive infection or death in either group (very low certainty evidence).

AUTHORS' CONCLUSIONS

The level of certainty about the effects of emollient therapy on invasive infection or death in preterm infants is low. Since these interventions are mostly inexpensive, readily accessible, and generally acceptable, further good-quality randomised controlled trials in healthcare facilities, and in community settings in low- or middle-income countries, may be justified.

Prevalence and perceptions of infant massage in India: study from Maharashtra and Madhya Pradesh states

Background

Knowledge of the prevailing infant care practices and their effects is important to inform practice and public programs. Infant massage is a traditional practice in India but remains less studied. This study was conducted to study the prevalence and perceptions of infant massage practices in two states of India.

Methods

A total of 1497 caretakers of children under 18 months of age were interviewed in a cross-sectional study at immunisation units of medical schools in Maharashtra (MH) and Madhya Pradesh (MP) states and through home visits in villages in MH during March through August 2018.

Results

Infant massage was a prevalent practice (93.8% [95%CI: 92.4,94.9]) in both study states – 97.9%[95%CI:96.9,98.8] in MH and 85.3%[95%CI: 81.9,88.3] in MP – and the prevalence did not vary between male (94.5%) and female (93.5%) infants (p = 0.44). Massage was mostly initiated in the first week of life (82%); it is widely viewed as a traditional practice. It was common to massage the baby once daily (77%), before bathing (77%), and after feeding (57%). Massage was mostly conducted using oils (97%). In MH, preferred oils were a sesame oil-based proprietary traditional medicine oil (36%) and coconut oil (18%) while olive (29%) and mustard (20%) oils were most popular in MP. Commonly reported application techniques included gentle massage with minimal pressure, pressing (30%) and manually stretching certain joints (60%). Commonly reported perceived benefits of infant massage included increased bone strength, better sleep and growth, while no harm was perceived (95%).

Conclusion

Infant oil massage is a highly prevalent traditional practice in MH and MP. Clear guidance on the use of massage, choice of oil, and techniques for application is required to optimize benefits and minimize risks of this popular traditional practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02416-y.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

A Meta-Analysis of the Efficacy and Safety of Using Oil Massage to Promote Infant Growth

The synthesizing evidence on the effectiveness of using oil massage to promote the growth of infants is still lacking. This paper aims to determine whether oil massage can promote the physical and neurobehavioral growth of infants according to variables and to evaluate whether oil massage is safe for infant skin.

ELIGIBILITY CRITERIA

The randomized controlled trials, clinical controlled trials and quasi-experimentally designed trials published prior to or in 2014 were searched according to predetermined inclusion criteria and exclusion criteria in Medline, PubMed, Ovid, the Cochran Library, and Chinese databases, including the China National Knowledge Infrastructure, Wan Fang database and VIP journal integration platform. Besides, the grey lectures were searched as well through Open Grey, GrayLIT Network and Clinical Trials.gov.

SAMPLE

Eight studies out of 625 retrieved articles were eligible for inclusion.

RESULTS

Oil massage increased the infant weights, lengths and head circumferences. However, it did not promote a significant advantage in neurobehavioral scores or cause a significant risk of adverse skin reactions.

IMPLICATIONS

The core mechanisms and standard procedures of oil massage as well as the preferred oil type should be the focus of future nursing practice and research.

CONCLUSIONS

Oil massage may effectively improve the physical growth of infants, and it presents a limited risk of adverse skin reactions. However, the relationship between neurodevelopment and oil massage requires further study.

Topical emollient for preventing infection in preterm infants

BACKGROUND

Breakdown of the developmentally immature epidermal barrier may permit entry for micro-organisms leading to invasive infection in preterm infants. Topical emollients may improve skin integrity and barrier function and thereby prevent invasive infection, a major cause of mortality and morbidity in preterm infants.

OBJECTIVES

To assess the effect of topical application of emollients (ointments, creams, or oils) on the incidence of invasive infection, other morbidity, and mortality in preterm infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), MEDLINE via PubMed (1966 to August 2015), EMBASE (1980 to August 2015), and CINAHL (1982 to August 2015). We also searched clinical trials databases, conference proceedings, previous reviews and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of prophylactic application of topical emollient (ointments, creams, or oils) on the incidence of invasive infection, mortality, other morbidity, and growth and development in preterm infants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference for continuous data, with respective 95% confidence intervals. We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in subgroup analyses.

MAIN RESULTS

We identified 18 eligible primary publications (21 trial reports). A total of 3089 infants participated in the trials. The risk of bias varied with lack of clarity on methods to conceal allocation in half of the trials and lack of blinding of caregivers or investigators in all of the trials being the main potential sources of bias.Eight trials (2086 infants) examined the effect of topical ointments or creams. Most participants were very preterm infants cared for in health-care facilities in high-income countries. Meta-analyses did not show evidence of a difference in the incidence of invasive infection (typical risk ratio (RR) 1.13, 95% confidence interval (CI) 0.97 to 1.31; low quality evidence) or mortality (typical RR 0.87, 95% CI 0.75 to 1.03; low quality evidence).Eleven trials (1184 infants) assessed the effect of plant or vegetable oils. Nine of these trials were undertaken in low- or middle-income countries and all were based in health-care facilities rather than home or community settings. Meta-analyses did not show evidence of a difference in the incidence of invasive infection (typical RR 0.71, 95% CI 0.51 to 1.01; low quality evidence) or mortality (typical RR 0.94, 95% CI 0.81 to 1.08; moderate quality evidence). Infants massaged with vegetable oil had a higher rate of weight gain (about 2.55 g/kg/day; 95% CI 1.76 to 3.34), linear growth (about 1.22 mm/week; 95% CI 1.01 to 1.44), and head growth (about 0.45 mm/week; 95% CI 0.19 to 0.70). These meta-analyses contained substantial heterogeneity.

AUTHORS' CONCLUSIONS

The available data do not provide evidence that the use of emollient therapy prevents invasive infection or death in preterm infants in high-, middle- or low-income settings. Some evidence of an effect of topical vegetable oils on neonatal growth exists but this should be interpreted with caution because lack of blinding may have introduced caregiver or assessment biases. Since these interventions are low cost, readily accessible, and generally acceptable, further randomised controlled trials, particularly in both community- and health care facility-based settings in low-income countries, may be justified.

The empiric use of palm kernel oil in neonatal skin care: justifiable or not?

Palm kernel oil is a vegetable oil derived from Elaeis guineensis and widely used in neonatal settings for skin care. It is a good emollient with a beneficial effect in moisturizing the skin and preventing transdermal heat and water loss. However, it's putative roles in the prevention or treatment of fatty acid defificiency is still controversial. So is its function in the improvement of neurological development from its longchain polyunsaturated fatty acids? We set out in this review to verify whether its empiric use in this context has any scientific justification and is recommendable. Although there is evidence that it has emollient and moisturizing properties necessary for softening the skin and restoring elasticity, controversy subsists on its other nutritional and neurodevelopmental properties.

The effect of multimodal stimulation and cutaneous application of vegetable oils on neonatal development in preterm infants: a randomized controlled trial

BACKGROUND

Preterm newborns admitted to the Neonatal Intensive Care Unit are deprived of sensory stimulation. Tactile/kinaesthetic stimulation results in weight gain. Studies involving the cutaneous application of vegetable oils have shown improvement in somatic growth and on skin barrier function.

OBJECTIVE

To assess the neurodevelopmental and biological benefits of the simultaneous use of multimodal stimulation (SMS) and the cutaneous application of vegetable oils. Setting Tertiary referral centre serving the Poitou-Charentes region of France.

METHODS

Randomized controlled trial of 49 low-risk preterm infants, born at 31- to 34-week gestation. Each infant was randomly assigned to one of three treatment groups, Sensori-Tonico-Motor (STM) touch for 10 days with either: sweet almond oil, ISIO4 blended oil, or placebo - normal saline, or to a control group who did not receive any intervention. The primary outcome was weight gain. Secondary outcomes were linear growth, neurological maturation, psychomotor development and number of days of admission. Analysis was by intention-to-treat.

RESULTS

The group who received STM with ISIO4 oil demonstrated enhanced weight gain (+57%, 95% CI 37-76) compared with controls (P = 0.030). All STM groups showed shorter admission times (mean reduction 15 days, 95% CI 23-50 days hospitalised, P = 0.005), and an increase in body length (P = 0.030). Both groups of oil massaged babies (almond and ISIO4) showed an increased neurological score (P = 0.001) compared to controls. The infants receiving ISIO4 oil had an associated increase in psychomotor scores (P = 0.028), time spent in quiet wakefulness (P = 0.036), improved orientation (P = 0.036), and enhanced development of the oculomotor (P = 0.012) and sensorimotor (P = 0.003) systems. An additional benefit seen was improved moisturization (P = 0.001), and quicker recovery of dermatological conditions. No adverse dermatological events were observed.

CONCLUSIONS

The combination of STM and cutaneous application of oils to healthy preterm babies resulted in enhanced weight gain and neurological development, and a shorter stay in hospital.

Topical ointment for preventing infection in preterm infants

BACKGROUND

Nosocomial sepsis is a frequent and serious complication of premature infants. The increased susceptibility of ELBW infants to infection has been attributed to less effective immune function compared to mature newborns and the invasive nature of necessary supportive care. Breakdown of the barrier function of the skin may be an additional risk factor for nosocomial sepsis.

OBJECTIVES

To assess the effect of prophylactic application of topical ointment on nosocomial sepsis rates and other complications of prematurity in preterm infants.

SEARCH STRATEGY

Searches were made of the Cochrane Central Registry of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003), Ovid DC MEDLINE through June 2003, previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, and journal hand searching in the English language.

SELECTION CRITERIA

Randomized controlled trials which compared the effect of prophylactic application of topical ointment to routine (standard) skin care or as needed topical therapy in preterm infants are included in this review.

DATA COLLECTION AND ANALYSIS

Data regarding clinical outcomes including infection [including any bacterial infection, bacterial infection with a known pathogen, coagulase negative staphylococcal infection, fungal infection, and any nosocomial infection (bacterial or fungal)], patent ductus arteriosus, oxygen requirement at 28 days, chronic lung disease and mortality were excerpted from the reports of the clinical trials by the reviewers. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group.

MAIN RESULTS

Four randomized controlled trials were identified. All four studies reported improved skin condition in infants treated with prophylactic topical ointment (results not reported here). All four studies reported on the incidence of any nosocomial infection, fungal infection and coagulase negative staphylococcal infection. Infants treated with prophylactic topical ointment are at increased risk of coagulase negative staphylococcal infection (typical relative risk 1.31, 95% CI 1.02, 1.70; typical risk difference 0.04, 95% CI 0.00, 0.08); and any nosocomial infection (typical relative risk 1.20, 95% CI 1.00, 1.43; typical risk difference 0.05, 95% CI 0.00, 0.09). A trend toward increased risk of any bacterial infection was found in infants treated with prophylactic topical ointment (typical relative risk 1.19, 95% CI 0.97, 1.46; typical risk difference 0.04, 95% CI -0.01, 0.08). There was no significant difference found in the risk of bacterial infection with a known pathogen, fungal infection, or other complications related to prematurity.

REVIEWER'S CONCLUSIONS

Prophylactic application of topical ointment increases the risk of coagulase negative staphylococcal infection and any nosocomial infection. A trend toward increased risk of any bacterial infection was noted in infants prophylactically treated. Topical ointment should not be used routinely in preterm infants.

Transdermal Xenobiotics in Newborn Skin

Newborn infants are regularly exposed to a wide variety of topical agents, including treatments for rashes, antimicrobial agents, solvents, and skin barriers or moisturizers. Premature and hospitalized infants are also exposed to topical iodine for antisepsis and to topical analgesic agents. The fact that most of these agents have not been specifically evaluated for use in infants has recently been recognized as a major public health concern. The epidermis of preterm infants is not fully developed, constituting an incomplete barrier to systemic absorption of topical agents. Thus, substances applied to the skin can have adverse systemic effects. Povidone-iodine and steroid creams have been associated with thyroid and hypothalamic-pituitary axis suppression, respectively, in premature infants. Application of topical EMLA (Eutectic Mixture of Local Anesthetics) for analgesia has been implicated in methemoglobinemia in premature infants. Exposure to natural latex in gloves and medical equipment may sensitize infants, leading to the development of airway hyperreactivity and other allergic manifestations. Therefore, it is advisable to limit skin exposure of premature infants to xenobiotics. Further work is required to define safe doses of common agents. In addition, transdermal administration of systemic medications, including methylxanthines, may be practical in premature infants.

Cutaneous application of vegetable oil as a coadjutant in the nutritional management of preterm infants

BACKGROUND

The cutaneous application of vegetable oil as a therapeutic practice and dietary coadjuvant has been described mainly in adult patients at risk for essential fatty acid deficiency. In the current study, the effects of cutaneous soybean oil application on somatic growth and plasma linoleic and arachidonic acid levels were examined in enterally fed preterm newborns.

METHODS

Sixty consecutive preterm infants were chosen from patients admitted to the nursery. Infants were randomly assigned to one of two groups: the oil group, which was treated cutaneously with soybean oil, or the control group, which received no cutaneous treatment.

RESULTS

After 30 days, a significant increase in anthropometric parameters was observed in infants who received cutaneous oil, mainly in infants small for gestational age. An increase in linoleic acid level and a decrease in arachidonic acid level were seen in both groups but do not justify the difference found in growth rates in the control and oil groups.

CONCLUSIONS

Preterm infants treated cutaneously with soy oil showed better somatic growth than the control group. The factors leading to the present results, especially the response of the infants who were small for gestational age merit further evaluation.

Neonatal skin and skin care

Infant skin differs from adult skin in several ways. These important differences place infants at increased risk for fluid electrolyte imbalance, thermal instability, skin damage, percutaneous infection, and percutaneous toxicity from topically applied agents. This article includes a review of skin development, as well as the details of current skin care practices in the neonatal nursery. A better understanding of the principles of infant skin care and a more uniform approach to skin care in the neonatal nursery can minimize risks and costs to this special population of patients.