Emollient Therapy for Newborn Infants—A Global Perspective Marty Visscher, PhD a, c, ⁎, Susan Geiss, RN, LMT, CHTP b a Skin Sciences Program, Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA b Integrative Care, Cincinnati Children's Hospital Medical Center, OH, USA c Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA abstract article info Keywords: Emollients Neonatal skin Infant Transepidermal water loss Premature Research on emollient therapy as a strategy to reduce mortality in newborn infants is a global priority. This paper discusses the use of emollients on newborn infants. Since the question is “Should emollients be applied to newborn infants, particularly premature infants?” the focus is on reports that discussed some measure of skin condition such as skin grades, skin effects, transepidermal water loss (TEWL), or impact on infection/mortality. The investigations on the use of emollients for premature infants are reviewed. Consideration is also given to the infant caregiver interactions during the applicaton as the process itself may be important for achieving benefits on skin barrier development and integrity. The remaining questions and subjects of future research are presented. © 2014 Elsevier Inc. All rights reserved. Research on emollient therapy as a strategy to reduce mortality in newborn infants is a global priority. 1 The term “emollient” is broadly defined as a topical material composed of fat or oil that hydrates and softens the skin. It may refer to a specific materials and/or combinations. Daily application of emollients with whole body massage is a cultural norm in some countries. In rural Nepal, massage with mustard seed oil was conducted in 99.8% of households. 2 The primary reasons were to (a) make the baby's body strong (69.6%), (b) keep the infant healthy (41.4%), (c) keep the infant warm (36.8%), and (d) make the skin look good (23.7%). Infants are massages 2–3 times daily and nearly 50% have the first massage within an hour of birth (Table 1). This paper discusses the use of emollients on newborn infants. Since the question is “Should emollients be applied to newborn infants, particularly premature infants?” the focus is on reports that discussed some measure of skin condition such as skin grades, skin effects, transepidermal water loss (TEWL), or impact on infection/mortality. Transepidermal water loss occurs when water from respiration passes through the skin layers and into the environment at rates of 4–8 g/m 2 /h in healthy full term infants (Fig. 1). 3,4 Measures of TEWL are used to determine the integrity of the stratum corneum (SC) with low values indicating an effective barrier. High TEWL means that water is passing through at a greater rate, indicating a SC barrier is damaged, not well formed, or has fewer layers than normal. Any topical treatment, including oils, creams, petrolatum-based treatments, films and humidity was considered to be an emollient. More than 350 citations used these terms: infant skin and emollient, premature infant skin and emollient, premature infant skin and development, newborn skin and oil, newborn skin and topical treatment, and newborn skin and animal models. There were 29 studies on infants encompassing 2882 subjects. Seventeen studies included one or more of these outcomes and the specific emol- lients were: (1) sunflower oil or safflower oil (n = 8), (2) petrolatum, paraffin, or Aquaphor® (n = 11), olive oil (n = 2), soybean oil (n = 1), coconut oil (n = 2), meadowfoam oil (n = 1) and almond oil of varying compositions (n = 2). “Premature infant” broadly refers to infants of 23–37 weeks gesta- tional age (GA). The extent of stratum corneum maturation depends upon GA and, therefore, varies considerably over the 23–37 week prema- turity period. Extremely premature infants have a significantly underde- veloped SC and may have only a few layers, depending upon GA. The question of skin response to emollients is discussed in the context of premature age. Emollient Properties and Technical Rationale for Use Emollients are usually mixtures of a few or many ingredients. They are composed largely of fatty acids of varying chemical chain lengths. Oils, like those used in India, often come from natural plant sources. Table 2 lists the types and amounts of fatty acids in oils such as sunflower, mustard seed, coconut, and safflower. The fatty acids are mixtures of saturated and unsaturated (containing at least one double bond) com- pounds. Another emollient type is derived from the distillation of petro- leum, including petrolatum and brands such as Aquaphor®. They range for liquid (mineral oil) to more solid forms. The use of fatty acid containing emollients is based, in part, on their effects on skin. For example, linoleic acid activates protein transcription factors that increase the rate of stratum corneum barrier formation. 5 Linoleic acid has anti-inflammatory properties. 6 The SC contains three classes of lipids, namely fatty acids, cholesterol and ceramides. Treatment of tape-stripped skin with SC type lipids increased the rate of barrier repair. 7 The ceramide component influenced the SC barrier properties in model systems. 8 A mixture of physiological lipids cholesterol, Newborn & Infant Nursing Reviews 14 (2014) 153–159 ⁎ Corresponding author at: Skin Sciences Program, Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA. Tel.: +513 803 0934; fax: +513 636 7182. E-mail address: Marty.Visscher@cchmc.org (M. Visscher). http://dx.doi.org/10.1053/j.nainr.2014.10.003 1527-3369/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Newborn & Infant Nursing Reviews journal homepage: www.nainr.com