Nappy Rash Advice

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Nappy rash is a general definition used to describe a range of inflammatory reactions of the skin in the nappy area.

It is a common problem and is estimated to affect up to a third of nappy wearing infants at any one time]. It equally affects boys and girls. Some babies only have it once in a while, whereas others experience it time and again. A number of factors have been identified in clinical literature and anecdotally by parents which appear to be linked to an increased likelihood of nappy rash occurring. This article examines the evidence, both medical and word-of-mouth to support these ‘trigger times’ which include antibiotic use, an episode of diarrhoea, teething, weaning, switching from breast to formula milk and during mild infections like colds. A recent NOP survey was undertaken to examine parents’ perceptions of these’ trigger times.’

Incidence of nappy rash

There are variations in the estimated incidence of nappy rash, for instance in the US, a study revealed that 75% of parents reported nappy rash in the preceding two months. In Japan, 87% had experienced nappy rash whereas in Italy only 15% reported nappy rash, with infants aged 3 to 6 months identified as most at risk . In the UK, one study found that 25% of babies experienced nappy rash within the first four weeks after birth and it is generally recognised that a-children develop at least one episode of nappy rash at some time during infancy. However, in the UK, it is generally accepted that around a third of nappy wearing babies experience nappy rash at any one time, with the peak incidence in infants aged between 9 and 12 months.

Symptoms of Nappy Rash

The symptoms of nappy rash vary according to how severe the rash is. Most cases only present mild symptoms. A small part of
crying baby
the nappy area will be covered in a pink or red rash, usually made up of sma-spots or blotches. The baby should otherwise appear we-with no systemic symptoms. In moderate to severe cases, the infant may have more advanced and painful symptoms which make the child distressed and uncomfortable. Symptoms may include bright red spots, dry, cracked and broken skin and possibly ulcers or blisters on the skin. The rash wi-cover a larger part of the nappy area and may spread down the legs or up towards the abdomen. The infant is likely to cry more often than usual and be very irritable.

Diagnosis

Diagnosis is usually on the basis of the characteristic appearance of the rash. Typically, there is redness over the buttocks, genitals, pubic area and upper thighs. Usually there are no systemic symptoms except in severe cases. A skin swab is not generally required to make a diagnosis, as the results can be difficult to interpret. Both Candida and bacteria such as Staphylococcus aureus colonise healthy skin and a skin swab may be positive when infection is not present.

Causes

Nappy rash appears to arise from a combination of factors which include irritation or chafing by the nappy, friction, prolonged contact with urine and faeces and Candida infection . Anatomically, the nappy area features numerous folds and creases, which can present a challenge to efficient, but gentle, cleansing.

Nappy Rash Triggers

There appear to be a number of trigger factors which
sleeping baby
link with bouts of nappy rash. A comprehensive search of UK online parenting forums showed that parents believe nappy rash is particularly linked to teething, episodes of diarrhoea, antibiotic use, weaning, switching from breast to formula milk, mild infections like a cold and when a baby first starts to sleep through the night. These were the seven most frequently cited ‘trigger factors’. Other factors mentioned but only infrequently, included switching detergents for nappy washing, the use of cloth nappies and the use of disposable nappies.

The seven most frequently identified ‘trigger’ factors were included in a survey conducted by GFK NOP in March 2012 to learn more about parents’ views of nappy rash.

Nappy rash incidence

64% of younger parents (16 – 34) recalled that their children had suffered from nappy rash, a figure which is in line with other countries. This recall declines over the years, as children grow up, but it worth noting that even amongst those aged over 55, 40% still remember their children suffering from nappy rash – which does tend to confirm that the condition can be serious enough to remain lodged in the mind.

Trigger times

Parents do associate nappy rash with a number of ‘trigger times’ which predispose to the condition. These are listed below, in the order of priority for the younger parents, whose children had had nappy rash:
teething baby

-A cold 51%
-Teething 49%
-Diarrhoea 42%
-Weaning onto solids 35%
-First sleeping through the night 35%
-Antibiotic use 24%
-Changing from breast to formula milk 11%
-Can’t remember 13%
-None of the above 5%
Colds and teething were the most commonly mentioned causative factors, although dietary changes are also important, together with bouts of diarrhoea. It was also clear that parents said that several of these factors can play a part – with respondents giving an average of three causes each.

Parents aged 55 or over gave a different priority to these factors, when recalling the causes of nappy reach when their children were very young:
-Teething 58%
-Diarrhoea 40%
-A cold 27%
-First sleeping through the night 27%
-Weaning onto solids 24%
-Antibiotic use 23%
-Changing from breast to formula milk 10%
-Can’t remember 20%
-None of the above 3%
Although some of these causes received very similar ratings, it is notable that the older group did not consider colds or weaning nearly as significant as their younger counterparts did, whilst teething was given greater prominence. Summarising the survey’s results by combining both groups of parents that took part in the survey, the evidence and possible explanation for each of these trigger times for nappy rash is examined below.

Teething

Over 56% of parents who had encountered nappy rash in the survey reported a link between nappy rash and
breastfed baby
teething. Comments from popular parenting discussion sites consistently claim a link with posts like the two below, cited frequently. ‘Daughter used to get a shocking bum when teething. Only time we’ve ever had nappy rash really.’ [Mumsnet, 2012] ‘Son is 9 months and has got 7 teeth which have come one at a time since he was 7 months constantly, so he’s had a red, sore bottom for ages - and dirty nappies 5 times a day. Health Visitor said it was due to his teeth.’ [Mumsnet, 2012]

A literature search showed that irritability, increased salivation, runny nose, loss of appetite, diarrhoea, rash, and sleep disturbance are associated with primary tooth eruption. An Australian study reported that healthcare professionals believe that teething causes a range of symptoms, including loose stools, cold symptoms and nappy rash. Although there is no strong documented evidence of a firm link

Diarrhoea

The second most common cited trigger factor for nappy rash is an episode of diarrhoea, with 42% of parents who took part in the survey reporting a link. There is evidence to support this link and a high incidence of irritant nappy rash has been observed in babies who have had diarrhoea in the previous 48 hours.

Nappy rash usually begins with prolonged exposure to moisture and the contents of the nappy i.e. urine and faeces. Nappies cause the skin to become fragile by increasing its hydration and pH. Prolonged contact with urine and faeces and faecal enzymes damages the delicate skin, resulting in contact dermatitis. The dermatitis may predispose the skin to colonisation with Candida albicans and bacteria.

A cold

35% of parents linked having a common cold with nappy rash. This link may be due to the child experiencing diarrhoea or looser and more frequent stools while suffering a cold; the link between diarrhoea and irritant nappy rash is we-established. In a Japanese study mothers also reported a link between nappy rash and the common cold. The study also suggested that a baby may be bathed less frequently because of a cold and this hygiene lapse could be a contributory factor to the increased likelihood of nappy rash occurring.

First sleeping through the night

‘I feel that changing his nappy wakes him quite a bit,
sleeping baby
so I let him sleep through the night. The downside was he developed nappy rash.’ [Mumsnet, 2012] 29% of parents linked nappy rash with their baby first sleeping through the night. However, it is unlikely to be the actual sleeping through the night that caused the nappy rash. The underlying cause is more likely to be the delayed nappy changes. In a paper by R. Philipp the delayed changing of nappies had the greatest effect on provoking nappy rash. This is due to the association between nappy rash and the prolonged contact with faeces or urine].

Antibiotic use

There is evidence that nappy rash is linked to antibiotic use. A study of 57 children showed that after 10 days of amoxicillin treatment, 16% of children developed nappy rash and there was a twofold increase in skin colonisation with Candida. A recent study of children under two with otitis media who were treated with amoxicillin-clavulanate showed an increased incidence of diarrhoea and diaper-area dermatitis.

The reason for the link is likely to be due to antibiotics disrupting the normally protective barrier of intestinal microflora leading to diarrhoea.

Dietary changes

Weaning onto solid foods was given as a link to nappy rash by 25% of
baby eating
parents and changing from breast to formula milk by 12%. These two factors wi-be considered together under the general heading of dietary changes as the underlying cause is likely to be the production of more frequent, looser or watery stools due to the changes in diet. There are ongoing discussions about the link between weaning and nappy rash. A Scottish study [Philipp, 1997] reported that the incidence of nappy rash was not related to the early introduction of solids. Yet another study reported that ‘during the first twelve months of life, the change from breast milk to formula or other foods may tend to increase the likelihood of nappy rash.’.

Skincare Advice

Whatever the trigger or cause of nappy rash, parents wi-need information about treatment and prevention. Skincare advice is key to both the treatment and
baby and father
prevention of nappy rash. Parents/carers should be advised to try and reduce the baby’s exposure to skin irritants including urine, faeces and friction. Nappies should be left off for as long as is practical, as the longer the skin is occluded, the greater the risk of persistent dermatitis due to ongoing increases in skin hydration, pH and friction. The child should be cleaned and changed as soon as possible after the nappy has become wet or soiled. A US survey of 1089 infants showed that the incidence and severity of nappy rash was significantly lower when parents reported more frequent nappy changes.

Water or fragrance-free /alcohol-free baby wipes should be used for cleansing the skin, which should be patted dry gently after cleansing. Vigorous rubbing should be avoided because of the friction on the delicate skin. The child should be bathed daily but excessive bathing should be avoided as this may dry the skin and lead to worsening of nappy rash. Soap, bubble baths and lotions should be avoided as they can remove lipids from the skin, making it more vulnerable to irritants and microorganisms.

Nappy Rash Treatment

For mild nappy rash that is not causing discomfort, give advice about appropriate skincare (see above). A barrier cream should be prescribed or recommended for use at each nappy change to protect the skin. Zinc ointment BP, Zinc and Castor Oil or Metanium ointment are recommended. Ointments are generally more effective than creams and lotions, as they provide a better moisture barrier [Atherton, 2004]. If nappy rash is not causing distress it is unlikely that a secondary candidal infection is present and management with skincare advice and an appropriate ointment is a-that is needed.

Prevention

The best way to prevent nappy rash occurring is to follow good skin care routines.
-Leave the nappy off for a long as possible
-Change the nappy regularly
-Use only water or alcohol-free /fragrance-free
baby wipes
-Avoid soap, bubble baths and lotions
-Avoid using tight-fitting plastic pants over
nappies
-Avoid the use of talcum powder
-Pat rather than rub the baby’s bottom dry
-Use a suitable barrier ointment at each nappy
change

Always seek medical advice from your Health Visitor, Practice Nurse or GP if:
Bullet The rash doesn't go away within
a couple of days
Bullet Your baby develops a persistent bright red, moist rash with white or red pimples, which
spreads to the folds of the skin
Bullet Your baby has a fever and
a raised temperature


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