Clinical Review DATE OF PUBLICATION: OCTOBER 2017

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1 Clinical Review DATE OF PUBLICATION: OCTOBER 2017 NAPPY RASH: FROM TREATMENT TO PROTECTION Nappy rash is the most common dermatological condition during infancy. 1 Indeed, at any given time, up to a third of nappy-wearing infants has nappy rash. 2 In recent years, nappy rash management has shifted from treatment to prevention. 3 This CPD module examines the causes of nappy rash and explains why prevention is better than treatment. SCIENCE PHOTO LIBRARY Written by Mark Greener, BSc (hons), MRSB Reviewed by Amanda Burleigh RGN, RM, BSc (hons) In association with: LEARNING OBJECTIVES After studying this Clinical Review, you should: Appreciate the importance of immature skin in the pathogenesis of nappy rash Understand the importance of protecting neonatal skin against factors that might trigger nappy rash Appreciate the importance of the formulation of topical preparations used to protect against and manage nappy rash Feel empowered to help parents prevent and manage nappy rash QUESTIONS Visit our website to test your knowledge. Our questions cover: The structure of immature skin The pathogenesis of nappy rash Protecting immature skin against the causes of nappy rash The importance of the formulation of topical preparations used for nappy rash COMPLETE YOUR CPD USING ONE OF THE FOLLOWING STEPS ONLINE RESPONSE Remind yourself of the main points, take our reflective and multiple choice on-line assessment, download your CPD certificate and check out our additional resources at POSTAL RESPONSE Complete the multiple choice questions and return your answers using the card inside, no stamp is required. On receipt, we will you a learning certificate for your records. FOR HEALTHCARE PROFESSIONALS ONLY

2 This material is prepared for training purposes only and is not intended to sell or promote any particular product. The material is intended for healthcare professionals only. The material should not be supplied to non-healthcare professionals. The Mum & Baby Academy is committed to improving antenatal, postnatal and paediatric care by offering free, easy-to-use CPD and other resources that help professionals in their daily practice. HOW TO COMPLETE THIS CPD MODULE After reading this clinical review, please visit where you can assess your learning with reflective and multiple-choice questions. You can save work in progress and access a CPD learning log. MUM & BABY ACADEMY TEAM Healthcare director: Sunil Singh Written by: Mark Greener, BSc (hons), MRSB Reviewed by: Amanda Burleigh RGN, RM, BSc (hons) Design: Paul Stratford Website management: Melanie Reynolds Printed by: Qwerty Ltd, The Markham Centre, Theale, Berkshire RG7 4PE Contact the team through our website: ADVERSE EVENTS To report an adverse event, please contact us at with Adverse event in the subject line. We will then pass your communication onto the organisation funding the CPD module. ACKNOWLEDGMENT Bayer Plc funded and reviewed this CPD module and the associated materials. The Mum & Baby Academy does not endorse any particular products and is not responsible for claims made by advertisers and sponsors in advertorials and advertisements. ABOUT THE MUM & BABY ACADEMY The Mum & Baby Academy is an educational initiative by Lifecycle Marketing, who also publish Emma s Diary. Published in association with the Royal College of General Practitioners (RCGP), Emma s Diary is the UK s most trusted and influential communication platform for mums-to be and new parents. Mum & Baby Academy 2017 Lifecycle Marketing (M&B) Ltd, Remenham House, 3 Regatta Place, Marlow Rd, Bourne End, Buckinghamshire SL8 5TD. Date of publication: October Abstract Nappy rash is the most common dermatological condition among infants. 1 Indeed, at any given time, up to a third of nappy-wearing infants has nappy rash. 2 Several factors contribute to nappy rash, including moisture, friction, urine and faeces, and, occasionally, micro-organisms. 1 Nappy rash is, however, primarily an irritant contact dermatitis. Prolonged contact with urine and faeces seems to be the single most important cause of nappy rash. 4 The relative structural and functional immaturity of an infant s skin means that young children often lack adequate defences against dermatological damage from, for example, urea in faeces and urine. 3 For example, the stratum corneum accounts for most of the skin s physical barrier. 5, 6 Full-term infant skin is only between 40% and 60% of the thickness of an adult s skin. 7 Regularly changing the nappy helps avoid dermatological damage and, in turn, the rash. Breast feeding with the child s nappy area exposed avoids occlusion and allows skin to dry and so protects against nappy rash. 1,7 Cleansing helps remove irritants that could break down skin and increase the risk of nappy rash. If nappy rash occurs, a thin layer of barrier ointment helps protect the stratum corneum from over-hydration, friction and irritation from urine and faeces. 7,8,9 Brief courses of Introduction Nappy rash is the most common dermatological condition during infancy. 1 Indeed, at any given time, up to a third of nappy-wearing infants has nappy rash, 2 which can develop at any time from 3 weeks to two years after birth. 8 The relative structural and functional immaturity of an infant s skin means that young children often lack adequate defences against dermatological damage caused by factors linked to nappy rash, such as moisture, friction, urine and faeces, and, 1, 3, 7 occasionally, micro-organisms. As this CPD module describes, good hygiene can reduce the likelihood that nappy rash will develop. In particular, protecting the delicate infant skin with a thin layer of barrier ointment helps prevent damage from over-hydration, irritation from urine and faeces, and friction. 7, 8 Nappy rash management now emphasises prevention rather than treatment. 3 The formulations used to protect against and manage nappy rash should avoid potential sensitizers and irritants. 3 Immature skin The skin consists, broadly, of three layers (figure 1): The outer epidermis, which consists of four low potency topical steroids are appropriate only when very inflamed dermatitis does not respond to other treatments. 1, 8 NICE suggest considering antifungals if painful nappy rash persists. 10 If nappy rash does not respond to topical steroids and, if appropriate, antifungals, the child should be referred. Nappy rash management now emphasises protection rather than symptomatic treatment. 3 So, skin protection should, for example, be part of each nappy change and the bedtime routine. In response to the increased emphasis on protection, an international expert panel of dermatologists and paediatricians agreed nine standards for nappy rash preparations. 3 The standards stress, for example, that any nappy rash preparation should offer proven clinical efficacy and safety in babies. 3 The panel notes that water-in-oil formulations with a lipid content of at least 50% offer durable and long-lasting skin protection, reduce friction and prevent excessive water loss. 3 The expert panel added that nappy rash preparations should contain only agents shown to be clinically efficacious and safe in infants and should not include components with enhanced allergenicity, antiseptics and preservatives. 3 The panel considered that the ideal nappy rash preparation should be pleasant to use, easily applied, and not require removal at each nappy change to encourage compliance. 3 major layers: basal, spinous, granular and stratum corneum The dermis, which contains, among other structures, blood capillaries, nerve endings, sweat and sebaceous glands and hair follicles, as well as providing mechanical structure The underlying hypodermis (also called subcutis), which is comprised mainly of fat and connective tissue. The skin forms a physical barrier between the infant and the environment, which protects the child against ultraviolet radiation, pathogens, mechanical trauma and irritants. 5, 6 The stratum corneum accounts for most of the skin s physical barrier. 5 In addition, the skin helps regulate body temperature, mediates sensory perception, contributes to the immune system s ability to detect and tackle pathogens and produces most of the body s stores of 5, 6, 11 vitamin D. Infant skin is, however, structurally and functionally immature (figure 2). For example, mature stratum corneum consists of 10 to 20 layers of cells and is approximately 2 mm thick. 7 Full-term infant skin is only between 40% and 60% of the thickness of an adult s skin. 7 One study, compared the skin of the 2 FOR HEALTHCARE PROFESSIONALS ONLY

3 In association with: Figure 1: Skin structure nappy rash during the first month of life. The inner arm phs were 6.83 and 6.47 in those with and without nappy rash respectively. 15 Midwives and health visitors could remind parents and carers that using harsh soap and detergents can increase the ph of the skin s outer layers, which could compromise barrier function. 16 Causes of nappy rash Nappy rash is primarily an irritant contact dermatitis and can arise from numerous factors (figure 3). Prolonged contact with urine and faeces, however, seems to be the single most important cause. 4 As a result, nappy rash typically affects concave areas, 1 reflecting the areas exposed to the most urine and faeces. So nappy rash predominately affects the buttocks, the perianal area, the genitals, the inner thighs and the waistline. 17 lower thigh of 20 healthy mothers and their biological children (3-24 months). On average, the stratum corneum was 30% thinner in infants than in adults. On the lower thigh, for instance, the average thickness of the infant and adult stratum corneum was 7.3μm and 10.5μm respectively. 12 Studies have identified numerous other differences between adult and infant skin. Newborn infants, for example, seem to have 10 times more hair structures in a given area of skin surface than adults. 12 Moreover, corneocytes (cells that make up most of the epidermis) and granular cells (which help bind the skin together and produce lipids) are smaller in infants than those in adults. 12 The differences in corneocyte and granular cell size suggest that the turnover of skin cells is more rapid in infant than adult skin. 12 The rate of epidermal cell proliferation seems to decline progressively during the first year of life. 12 Barrier function Transepidermal water loss (TEWL) offers a marker of the skin s barrier function: the greater the TEWL, the poorer the barrier function. The skin s barrier function develops during the first year of life. Before then, TEWL appears to be higher in infants than adults, although results from studies are mixed. 6, 13 Skin affected by nappy rash shows greater TEWL than unaffected areas, 9 reflecting the compromised barrier function. Skin ph Maintaining an acid ph (between 5 and 5.5 in adults) 14 is essential for healthy skin function and for the formation of the normal microflora. 8 Skin is alkaline at birth (ph >6). The acid mantle (skin ph <5.0) forms within approximately four days. 7 Skin affected by nappy rash shows higher skin ph than unaffected areas. 9 Protecting and preserving the acid mantle might help protect against nappy rash. In one study, high skin ph on the inner arm in 4-dayold infants seemed to be associated with Stratum corneum Granular cell layer Spinous layer In addition to the dermatological symptoms, behavioural changes - such as increased crying and agitation, as well as changes in eating and sleeping patterns - may indicate that the nappy rash is causing the child emotional distress. 17 Parents often report an increase in the frequency of crying and agitation when nappy rash causes an infant discomfort. 17 Other behavioural indicators of distress, such as eyes squeezed shut and deepening of the nasolabial furrow, also seem to be more common in children affected by nappy rash. In addition, parents may report disrupted eating habits and sleeping patterns as well as less frequent urination and defecation in children affected by nappy rash. Some infants also show increases in levels of salivary cortisol, a steroid hormone released by the adrenal cortex in response to stress, while they have nappy rash. 17 Figure 2: Structural and functional differences between infant and adult skin 1,6,7,15,17,20,21,22 Vernx caseosa covers fetal and newborn skin Increased transepidermal water loss Microbiome differs Increased microrelief lines Lower ph Corneocytes smaller Stratum corneum and epidermis thinner Granular cells smaller Keratinocytes smaller Increased proliferation rate Partly because of the reduced barrier function, infant skin absorbs water more rapidly than in adults. Indeed, in infants aged 3 to 12 months the stratum corneum is significantly more hydrated than that in adults. 13 Basal layer Dermis More hair structures Fewer collagen bundles; collagen organisation differs FOR HEALTHCARE PROFESSIONALS ONLY 3

4 Figure 3: Factors involved in nappy rash FAECES URINE WARMTH INCREASED ph HYDRATION PROTEASES LIPASES UREASES EXCESSIVE HYDRATION MICROBIAL PROLIFERATION INCREASED ph AMMONIA UREA STRATUM CORNEUM MACERATION LIPID AND PROTEIN DIGESTION STRATUM CORNEUM BARRIER COMPROMISED SKIN IRRITATION PENETRATION OF IRRITANTS AND MICROBES Adapted from Stamatas and Tierney 17 Prolonged skin wetting such as from urine softens and weakens the stratum corneum (maceration). 4 In turn, maceration undermines barrier function, facilitates skin penetration by irritants - such as chemicals and enzymes - and increases the child s susceptibility to damage from friction from a nappy. 4, 8, 18 This vulnerability to friction may explain why nappy rash appears to be most common among infants aged between 9 and 12 months of age. The friction increases as children become increasingly mobile. 1, 8 Urea in faeces and urine can irritate the child s delicate skin and damage the stratum corneum. 7 Faeces contains proteases, lipases and urease - enzymes that break down protein, fat and urea respectively. Proteases and lipases can directly undermine skin integrity. 1, 18 Urase increases skin ph, which enhances the action of proteases and lipases. 1, 8 Clearly, a cycle of maceration leading to skin damage, leading to a further undermining of the barrier function and increased susceptibility to the trigger, can soon become established. Against this background, it s not surprising that antibiotics and diarrhoea in the previous 24 hours markedly increase the risk of nappy rash. 4 Enhanced gastrointestinal transit increases the activity of, and exposure to, proteases and lipases in faeces. 8 Antibiotics also commonly cause diarrhoea and can increase the risk of secondary Candida infections (see figure 4). 4 Infections with the yeast Candida tend to present as beefy red plaques with surrounding papules and pustules. 1 Feeding patterns may also influence the risk of developing nappy rash. Exclusive breast-feeding, for example, seems to reduce nappy rash risk compared to formula feed, perhaps by modulating faecal ph. 1 Good hygiene Regularly changing the nappy helps avoid nappy rash. Parents should change nappies immediately after defecation and at intervals throughout the day, depending on the frequency of urination. 8 Changing the nappy at least once during the night also seems to reduce the risk of nappy rash. 7 Breast feeding with the child s nappy area exposed avoids occlusion and allows skin to dry. 1, 7 Cleansing helps remove irritants such as urine, faeces and micro-organisms that could break down skin and increase the risk of nappy rash. In the 8 weeks after birth, NICE recommends that parents should not add cleansing agents to a baby s bath water. When needed, parents can use a mild non-perfumed soap, which is only cleansing agent suggested by NICE. 10 Nevertheless, water does not remove all the oil-soluble contaminants from the skin and is a poor ph-buffer - so daily bathing can compromise maturation of the acid mantle - as well as, in some cases, irritating and drying skin. 19 Midwives and health visitors can, in general, advise that babies may be bathed 2-3 times a week and the child can be topped and tailed in-between. 7 Table 1. The nine standards of an ideal nappy care preparation The ideal topical preparation for nappy care products should : 1 Offer proven clinical efficacy and safety in babies 2 Enhance natural skin protection 3 Maintain optimum moisture levels 4 Contain ingredients with documented safety and benefit 5 Contain no unnecessary ingredients 6 Contain no potentially toxic ingredients 7 Contain no potential sensitizers, such as fragrances 8 Contain no antiseptics or preservatives 9 Be pleasant to use Adapted from table 1 in Atherton D et al 3 4 FOR HEALTHCARE PROFESSIONALS ONLY

5 In association with: Treating nappy rash If nappy rash occurs, a thin layer of barrier ointment helps protect the stratum corneum from over-hydration, irritation from urine and faeces, and friction as well as improving skin hydration, TEWL and ph. 7-9 Parents can apply a barrier ointment until the macerated or damaged skin heals. Figure 4: Rash on an infant s buttocks caused by Candidiasis Topical steroids should be used only for more severe nappy rash. Immature skin and occlusion, such as from a nappy, can increase systemic absorption of steroids. As a result, brief courses of low potency topical steroids are appropriate only when very inflamed dermatitis does not respond to other treatments. 1, 8 Candida is the most common factor contributing to moderate to severe nappy rash (figure 4). 1 So, NICE suggest considering antifungals if painful nappy rash persists. 10 If nappy rash does not respond to topical steroids and, if appropriate, antifungals, the child should be referred to a GP with a special interest in dermatology or a paediatric dermatologist. Protection and prevention Nappy rash management increasingly emphasises prevention and protection rather than symptomatic treatment. 3 Indeed, skin protection could be part of each nappy changes and the normal bedtime routine. In response, an international expert panel of dermatologists and paediatricians agreed nine standards for nappy rash preparations (table 1). 3 The standards stress, for example, that any nappy rash preparation should offer proven clinical efficacy and safety in babies (table 2). 3 For example: Used alone, petrolatum jelly is highly occlusive, which can prevent repair of damaged stratum corneum. 3, 8 As a result, petrolatum jelly alone is not recommended for regular continued use. 3 Some formulations containing zinc or titanium oxides, which can be difficult to remove and, in turn, cause friction. 4 SCIENCE PHOTO LIBRARY Table 2. Comparison of formulations for a topical IDD preparation Talcum powder does not form a continuous layer and is abrasive. 3, 4 The panel advised against using talcum powder. 3 In contrast, the consensus panel noted that water-in-oil formulations with a lipid content of at least 50% offer durable and long-lasting skin protection, reduce friction and prevent excessive water loss. 3 The expert panel added that nappy rash preparations should not include components with enhanced allergenicity, antiseptics and preservatives (table 3). 3 For instance: Benzyl alcohol, benzyl benzoate and benzyl cinnamate may show enhanced allergenicity. Antiseptics may disrupt the normal skin microflora, potentially increasing the risk of secondary infections. Some studies suggest that parabens, a preservative, may potentially disrupt the endocrine system. 3 Water-in-oil ointment Preferred formulations, especially with a lipid content 50% Provide superior breathable moisture barrier Pleasant to use Oil-in-water paste Water-in-oil paste Oil-in-water cream/lotion White soft paraffin BP Talcum powder Adapted from table 2 in Atherton D et al 3 Hydrophilic; absorbs some water Does not form an effective barrier Extremely lipophilic Highly occlusive Hydrophilic; absorbs some water Does not provide a very effective barrier Unsuitable for daily use Highly occlusive; can prevent repair stratum corneum damage Not recommended for regular continued use Does not provide continuous skin barrier Abrasive Not recommended Finally, the panel considered that the ideal nappy rash preparation should be pleasant to use, easily applied, and not require removal at each nappy change. These features are likely to encourage compliance with nappy rash prevention. 3 Conclusions Nappy rash, the most common dermatological condition during infancy, 1 is often distressing for children and parents. 1, 17 Children with nappy rash frequently exhibit behavioural changes, 17 which can disrupt the family s life, cause considerable stress and leave patients feeling worried and guilty. Any nappy rash preparation should offer proven clinical efficacy and safety in babies and should not include components with enhanced allergenicity, antiseptics and preservatives. 3 Good hygiene and protecting infant skin with thin layer of barrier ointment can reduce the likelihood that this potentially distressing condition will emerge. Table 3. Ingredients considered to be unfavorable for a topical IDD preparation Ingredients Rationale for exclusion Antimicrobials/antifungals e.g., boric acid Vitamin A Titanium dioxide Parabens Fragrances Adapted from table 3 in Atherton D et al 3 IDD pathology usually has no microbial component No studies support a role in infants No studies support a role in amelioration of IDD Used in UV protective creams No studies support a role in the improvement of IDD progression Can potentially disrupt the endocrine system Fragrances are generally hyperallergenic Not recommended. FOR HEALTHCARE PROFESSIONALS ONLY 5

6 COMPLETE YOUR CPD USING ONE OF THE FOLLOWING STEPS ONLINE RESPONSE Remind yourself of the main points, take our reflective and multiple choice on-line assessment, download your CPD certificate and check out our additional resources at POSTAL RESPONSE Complete the multiple choice questions and return your answers using the card inside, no stamp is required. On receipt, we will you a learning certificate for your records. REFERENCES 1. Bikowski J Update on prevention and treatment of diaper dermatitis. Practical Dermatology for Pediatrics 2011; July/August NICE Nappy rash - Clinical Knowledge Summaries Available at: cks.nice.org.uk/nappy-rash#!topicsummary Accessed August Atherton D, Proksch E, Schauber J et al. Irritant diaper dermatitis: Best practice management. SelfCare 2015;6(S1): Atherton D and Mills K What can be done to keep babies skin healthy? RCM Midwives 2004;7: Visscher M and Narendran V The ontogeny of skin. Advances in Wound Care 2013;3: Oranges T, Dini V, and Romanelli M Skin physiology of the neonate and infant: clinical implications. Advances in Wound Care 2015;4: Jackson A Time to review newborn skincare Infant 2008;4: Atherton DJ A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current Medical Research and Opinion 2004;20: Garcia Bartels N, Lünnemann L, Stroux A et al. Effect of diaper cream and wet wipes on skin barrier properties in infants: a prospective randomized controlled trial. Pediatric Dermatology 2014;31: NICE Postnatal care up to 8 weeks after birth: Clinical guideline Published: 23 July 2006 Available at: nice.org. uk/guidance/cg37 Accessed August Holick MF Vitamin D deficiency. New England Journal of Medicine 2007;357: Stamatas GN, Nikolovski J, Luedtke MA et al. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatric Dermatology 2010;27: Nikolovski J, Stamatas GN, Kollias N et al. Barrier function and water-holding and transport properties of infant stratum corneum are different from adult and continue to develop through the first year of life. Journal of Investigative Dermatology 2008;128: Fluhr JW, Darlenski R, Lachmann N et al. Infant epidermal skin physiology: Adaptation after birth. British Journal of Dermatology 2012;166: Yonezawa K, Haruna M, Shiraishi M et al. Relationship between skin barrier function in early neonates and diaper dermatitis during the first month of life: a prospective observational study. Pediatric Dermatology 2014;31: Thomas K, Batchelor J, Bath-Hextall F et al. A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease. Programme Grants Appl Res 2016;4:DOI /pgfar Stamatas GN and Tierney NK Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatric Dermatology 2014;31: Scheinfeld N Diaper Dermatitis. American Journal of Clinical Dermatology 2005;6: Telofski LS, Morello AP, Mack Correa MC et al. The infant skin barrier: Can we preserve, protect, and enhance the barrier? Dermatology Research and Practice 2012;DOI: /2012/ Robinson M, Visscher M, Laruffa A, et al. Natural moisturizing factors (NMF) in the stratum corneum (SC). I. Effects of lipid extraction and soaking. J Cosmet Sci 2010;61: Dorit R. The Superorganism revolution. American Scientist 2014;102: Schrijver K, Schrijver I. Living With The Stars: How the Human Body is Connected to the Life Cycles of the Earth, the Planets and the Stars. Oxford: Oxford University Press; FOR HEALTHCARE PROFESSIONALS ONLY

7 ADVERTORIAL In association with: Bepanthen: the only leading nappy care product that meets the nine standards 1 of an ideal nappy care product* In recent years, the focus of nappy rash management shifted from treatment to protection. 1 So, an international expert panel of dermatologists and paediatricians agreed nine standards for the ideal nappy care preparation that is suitable for repeated application (see checklist). 1 Bepanthen is the only leading nappy care product that meets all nine standards. * Clinically proven efficacy The panel agreed that water-in-oil formulations are the most appropriate for nappy rash preparations. In particular, water-in-oil formulations with a lipid content of at least 50% offer durable and long lasting skin protection, reduce friction and prevent excessive water loss. 1 Bepanthen is a water-in-oil ointment containing more than 70% lipid. The expert panel added that nappy rash preparations should be supported by data for efficacy and safety in babies and contain no unnecessary ingredients, such as compents for example, components that have no proven benefit for nappy rash. 1 The panel noted that dexapanthenol helps skin naturally repair its skin barrier. In addition, studies show that provitamin B 5 moisturises the skin. 1 Bepanthen contains dexpanthentol (provitamin B 5 ). I have always recommended Bepanthen cream and use it for my own family. Bepanthen is clinically proven to protect against the causes of nappy rash. 2,3 These trials included premature and fullterm babies. Avoiding sensitizers, antiseptics or preservatives The expert panel noted that infant skin is susceptible to environmental and biological allergens and sensitizers. Therefore, nappy rash formulations should not include components with enhanced allergenicity, such as benzyl alcohol, benzyl benzoate and benzyl cinnamate. In addition, the panel suggested that nappy rash formulations should not include antiseptics and preservatives such as parabens. Antiseptics for example, may disrupt the normal skin microflora. 1 Bepanthen does not contain colours, fragrances, preservatives or antiseptics. The panel considered that the ideal nappy rash preparation should be pleasant to use, easily applied, and not require removal at each nappy change. These features are likely to encourage compliance. 1 Bepanthen nappy care ointment forms a non-sticky transparent, breatheable layer and does not need to be removed before applying a new layer. 3 I will ensure the nappy rash creams... do not contain preservatives, such as parabens, and antiseptics. Midwives, health visitors and other healthcare professionals could suggest applying a thin layer of Bepanthen to the baby s clean, dry bottom after each nappy change. Indeed, many of your colleagues value Bepanthen - as our selected quotes show. They recognise that Bepanthen helps parents and professionals protect baby s skin from the causes of nappy rash. A checklist of the nine standards of an ideal nappy care preparation The ideal topical preparation for nappy care products should : Clinically proven for babies delicate skin Enhances natural skin protection Maintains optimum moisture levels Contains ingredients with documented safety and benefit Contains no unnecessary ingredients Contains no potentially toxic ingredients Contains no potential sensitizers, such as fragrances Contains no antiseptics or preservatives It is pleasant to use Adapted from table 1 in Atherton D et al 1 Date of publication: October 2017 References 1. Atherton D, Proksch E, Schauber J, et al. Irritant diaper dermatitis: Best practice management. SelfCare.2015;6(S1): Putet G, Guy B, Andres P, et al. Effect of Bepanthen ointment in the prevention and treatment of diaper rash on premature and fuil-term babies. Realites Pediatriques.2001;63: Sznurkowska K, Liberek A, Brzozowska Cieloch K, et al. Evaluation of a new cosmetic topical formulation in the management of irritant diaper dermatitis in infants. SelfCare.2015;6(S1): * Comparison made between top 3 selling brands in this category. Nielsen EPOS Data 12 Months to The quotes have been slightly edited for English and clarity. The originals are available from the Mum & Baby Academy on request. FOR HEALTHCARE PROFESSIONALS ONLY 7

8 Recommend Bepanthen as part of babies bedtime routine Did you know? Night time can be the longest uninterrupted period that the skin is exposed to over-hydration and irritation caused by urine and faeces, and friction. How can Bepanthen help? By making Bepanthen part of the last nappy change of the day, caregivers help to provide protection against these nappy rash triggers at night. The water in oil emulsion contains 5% dexpanthenol (pro-vitamin B5) and gently aids natural skin recovery. It forms a breathable, transparent layer of protection. It is suitable for highly sensitive skin of babies, even for premature ones. Helps put nappy rash to bed.

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10 NAPPY RASH: FROM TREATMENT TO PROTECTION Complete the multiple choice questions and return your answers using this card, no stamp is required. On receipt, we will you a learning certificate for your records. 1. Please rate the overall quality of this CPD module: A) Excellent B) Good C) Fair D) Poor 2. Before completing this module, how likely would you be to suggest a barrier formulation for nappy rash? A) Very likely B) Likely C) Neither likely or unlikely D) Very unlikely 3. After completing this module, how likely would you be to suggest a barrier formulation for nappy rash? A) Very likely B) Likely C) Neither likely or unlikely D) Very unlikely 4. Before completing this module, how likely would it be that you would recommend Bepanthen? A) Very likely B) Likely C) Neither likely or unlikely D) Very unlikely 5. After completing this module, how likely would it be that you would recommend Bepanthen? A) Very likely B) Likely C) Neither likely or unlikely D) Very unlikely Title First Name Surname Role/Job title BEP Address IMPORTANT: PLEASE READ DATA PROTECTION: The Mum and Baby Academy is a wholly owned subsidiary of Lifecycle (Mother & Baby) Ltd. By completing this form you are signing up to the Mum and Baby Academy. If you do not wish to receive information from the Mum and Baby Academy, please tick the box For further information please refer to

11 Learning Log NAPPY RASH: FROM TREATMENT TO PROTECTION First Name Surname Date completed Your Mum & Baby Academy unique code In association with: Mark Greener BSc (hons), MRSB Clinical Editor Mum & Baby Academy Amanda Burleigh RGN, RM, BSc (hons) Consultant Editor Mum & Baby Academy Disclaimer: This CPD Learning Log reflects data and answers provided by the user. It does not imply approval, verification or endorsement by the Mum & Baby Academy or its associated companies.

12 The Mum & Baby Academy is a free learning channel dedicated to the needs of antenatal healthcare professionals, produced by Lifecycle Marketing. Lifecycle Marketing also publish Emma s Diary in association with The Royal College of General Practitioners. We are committed to improving the health and wellbeing of mothers and infants. Our approach is to provide clinically robust, independently reviewed, accessible CPD and other resources that support daily practice. Our content undergoes rigorous clinical review by leading academic midwives and health visitors, and our user friendly website mumandbabyacademy.co.uk allows professionals to assess learning, save work in progress and download CPD learning logs to support your revalidation.