1. Consultant Dermatologist
Why should Health Care Practitioner's prioritise infant skin health?
Dr. Carol Hlela
Consultant Dermatologist
Head of Unit, Department of Dermatology Paediatrics
Red Cross Children’s Hospital, UCT
Good morning everyone and thank you for being here.
Let me tell you a little bit about myself...
I grew up in KwaMashu near Durban, where I was the first recipient of Netcare’s Hamilton Naki Clinical Scholarship in This enabled me to complete my Masters in Science in Global Science and PhD in Clinical Medicine at Oxford University in England. During my community service year in a rural hospital in KwaZulu-Natal, I realised that the majority of patients they saw, had skin rashes. For these patients, getting to a specialist involved a journey of almost 300km. The general process those patients had to negotiate to access expert treatment was a nightmare. So, I was inspired to specialise in dermatology because I saw the need. Once in it, I fell in love with the skin.
When I was studying, my PHD was centered on children, and when I returned to South Africa in 2012 I was encouraged by my mentors to continue working with children. Having already found my love for skin, I shifted my focus to pediatric dermatology and it was then that I realised my passion.
Currently I am heading the Pediatric Dermatology Unit, at Red Cross Childrens Hospital, and am I also teaching medical students from third to sixth year and supervising PhD candidates at UCT.
My partnership with JnJ began in 2015 as a Consultant Dermatologist. They requested I become involved in a Health Care Professional Training Function, by specifically doing a road show through the country, covering the topic "Common Pediatric Skin Disorders". This training was for midwives and nursing sisters from well-established baby clinics. This training was a great success as I am passionate about educating patients, medical professionals and medical corporations about innovative and simple skin solutions. I look forward to further assisting Johnson and Johnson on this very exciting project. (Dr Hlela to please elaborate)

2. Africa Healthcare in Crisis
In million children under the age of 5 died1
50% of those deaths occurred in Africa1
Nearly half of all people using dirty water live in sub-Saharan Africa2
34% of Children u/5yrs - no clean drinking water access in SOUTH AFRICA3
Healthcare in Africa is in a dire situation, 50% of children deaths under the age of 5 occur in Africa. Nearly half of all people using dirty water live in sub-Saharan Africa and 34% of Children under the age of 5 years old have no access to clean drinking water in South Africa. Poor living conditions combined with poor healthcare contribute to the shattering statistics for mother and baby deaths.
References:
2.4 billion people in the world – one in three – do not have an adequate toilet. (WHO/UNICEF Joint Monitoring Programme (JMP) Report 2015 update)663 million people in the world – one in ten – do not have clean water. (WHO/UNICEF Joint Monitoring Programme (JMP) Report 2015)Around 315,000 children under-five die every year from diarrhoeal diseases caused by dirty water and poor sanitation. That's almost 900 children per day, or one child every two minutes. (WASHWatch.org) Every minute a newborn baby dies from infection caused by a lack of safe water and an unclean environment.  (WHO, 2015) 42% of healthcare facilities in Africa do not have access to safe water. (WHO/UNICEF, 2015)
Nearly half of all people using dirty water live in sub-Saharan Africa, and one fifth live in Southern Asia. (WHO/UNICEF Joint Monitoring Programme (JMP) Report 2015) Globally, 19% of the urban population and 49% of the rural population lack an adequate toilet.  (WHO/UNICEF Joint Monitoring Programme (JMP) Report 2015) At current rates of progress, everyone in low- and middle-income countries won’t have clean water until 2057 – 27 years behind schedule. (WHO/UNICEF Joint Monitoring Programme (JMP) Report 2015 and WASHwatch) At current rates of progress, everyone in low- and middle-income countries won’t have adequate toilets until 2135 – 105 years behind schedule.  (WHO/UNICEF Joint Monitoring Programme (JMP) Report 2015 and WASHwatch) $28.4 billion of investment is needed every year to reach everyone everywhere with clean water, adequate toilets and good hygiene by 2030.  (World Bank, The costs of meeting the 2030 Sustainable Development Goal targets on drinking water, sanitation and hygiene summary report, 2016)If everyone everywhere had clean water, the number of diarrhoeal deaths would be cut by 34%.  (Prüss-Ustün A, Bartram J, Clasen T et al. Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: a retrospective analysis of data from 145 countries. Tropical Medicine & International Health. 2014;19(8): doi: /tmi.12329) Almost a billion (946 million) people in the world defecate in the open. (WHO/UNICEF Joint Monitoring Programe (JMP) Report 2015) Across the countries where we work, people have to walk an average of 30 minutes to collect water and return home. In some cases it can be a lot longer. (WHO/UNICEF Joint Monitoring Programme (JMP) Progress on sanitation and drinking water, 2012 update)
Globally, 31% of schools do not have clean water and 34% lack adequate toilets. (UNICEF, Advancing WASH in Schools Monitoring, 2015).Stunting affects 156 million children under-five – down from 169 million in (UNICEF/WHO/WORLD BANK Joint Child Malnutrition Estimates 2016).Wasting affects 50 million children under-five. (UNICEF/WHO/WORLD BANK Joint Child Malnutrition Estimates 2016).
A Promise Renewed
gamapserver.who.int/gho/interactive_charts/health_workforce/PhysiciansDensity_Total/atlas.htm

3. Improved quality of care will
More than 80% of all new born deaths result from 3 preventable and treatable conditions4:
1. Prematurity
2. Intrapartum related deaths
3. Neonatal infections
In South Africa alone, more than 80% of all new born deaths result from 3 preventable and treatable conditions:
1. Prematurity
2. Intrapartum related deaths
3. Neonatal infections
Improving quality of care around the time of birth will save the most lives, but this requires educated and equipped health workers, including those with midwifery skills, and availability of essential commodities.” Extract from Every Newborn, an action plan to end preventable deaths, WHO, 2014.
These statistics are why I am standing here today. I am passionate about making a difference to the lives of these children.
Improved quality of care will
save the most lives4
EVERY NEWBORN ACTION PLAN, WHO, 2014

4. References 1. Lancet. 2013. Global child mortality.
24% of the global disease burden resides in sub Saharan Africa with only 2.3% of the health work force.
References 1. Lancet Global child mortality.
Lancet, 2013, Gglobal Child Mortality
SA Health Review 2013

5. South Africa needs simple, cost-effective interventions
to help save lives
In South Africa, on average there are 29 public sector medical practitioners to every people, and only 141 public sector professional nurses to every people on average.
24% of the global disease burden resides in sub Saharan Africa with only 2.3% of the health work force.
References 1. Lancet Global child mortality.
Lancet, 2013, Gglobal Child Mortality
SA Health Review 2013

6. Baby skin barrier protection should be a vital part of holistic healthcare intervention.
Studies conducted in emerging market settings (Bangladesh and Egypt), suggest that the application of emollients that strengthen the health of baby skin effectively reduce the risk of pathogens penetrating the skin, helping to prevent 1 in 3 preterm deaths.1
Emollient Therapy has been shown to prevent 1 in 3 infant deaths and has been demonstrated to improve clinical assessments of skin condition, improve skin barrier function and hydration and does not interfere with normal skin maturation.
Emollients are effective in strengthening the skin barrier - increasing neonatal survival in – developing countries.
References:
Darmstadt E ect of Skin Barrier Therapy on Neonatal Mortality Rates in Preterm Infants in Bangladesh: A Randomized, Controlled, Clinical Trial.
Darmstadt E ect of Skin Barrier Therapy on Neonatal Mortality Rates in Preterm Infants in Bangladesh: A Randomized, Controlled, Clinical Trial

7. The skin, baby’s first line of defence
The skin is the largest organ of the body, with a total area of about 20 square feet and weighs about 6 pounds. The skin protects us from elements and infection, helps regulate body temperature, and permits the sensations of touch, heat, and cold as well as stores water, fat, and vitamin D.
The skin has three layers:
1. The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone.
2. The dermis, beneath the epidermis, contains tough connective tissue, hair follicles, and sweat glands.
3. The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

8. The role of skin
The main function of the skin is protection - The normal skin barrier
The main function of skin is protection, skin cells are building blocks that act as the body’s 1st line of defense, in fact we can refer to it as our armor.
It is an amazing organ, but when it has been weakened by living conditions, it cannot protect us like it should and we become vulnerable to infections.
References:
Cork MJ et al. Community Practitioner. 2005

9. Importance of this armour: protects baby from the environment
Detergents
Sun Damage
Our skin acts as an armor against various factors within the environment like detergents, Sun Damage and Microbes.
It is vital for people to realise the important role that skin plays in the health of babies, especially as their immune systems are not yet fully developed. The skin is important in keeping out germs and diseases, which, if left untreated could become fatal.
Microbes

10. Baby Skin Care: An Evolving Science
Difference in baby vs adult skin and why it needs special care
Baby skin differs from that of adult skin in its structure, composition and function. Their skin is 30% thinner than adult skin and loses moisture 2x faster, so it needs very special care to keep it healthy.
We need to recognise that a baby’s skin barrier is vulnerable:
1. More permeable
2. Prone to dryness
3. Less mature
4. Continues to develop beyond the age of 2
5. Potentially more vulnerable to applied substances
Baby skin has low barrier reserve and needs special care.
References:
Cork MJ et al. J Invest Dermatol. 2009
Nikolovski J et al. J Invest Dermatol. 2008
Cork MJ et al. J Invest Dermatol. 2009
Nikolovski J et al. J Invest Dermatol. 2008 10

11. Baby Skin Care: An Evolving Science
Baby skin differs from that of adult skin in its structure, composition and function
Baby skin differs from that of adult skin in its structure, composition and function. Their skin is 30% thinner than adult skin and loses moisture 2x faster, so it needs very special care to keep it healthy.
We need to recognise that a baby’s skin barrier is vulnerable:
1. More permeable
2. Prone to dryness
3. Less mature
4. Continues to develop beyond the age of 2
5. Potentially more vulnerable to applied substances
Baby skin has low barrier reserve and needs special care.
References:
Cork MJ et al. J Invest Dermatol. 2009
Nikolovski J et al. J Invest Dermatol. 2008
Cork MJ et al. J Invest Dermatol. 2009
Nikolovski J et al. J Invest Dermatol. 2008 11

12. Adult skin Baby skin smaller cells thinner stratum corneum
A Baby skin is uniquely different and still developing for at least the first year of life.
In the first year the babies’ skin barrier is maturing… but is not yet the same as adult skin
A babies’ skin loses and gains water more rapidly than adult skin
A babies’ skin pH is higher at birth than adult skin, and then acidifies within the first few weeks
A babies’ skin is also more reactive
Skin provides a protective barrier.
Newborn skin is adapting to a new environment and is changing over time.
Some skin changes in neonates occur within days and some changes take longer.
Skin barrier function parameters have been studied in infants and children up to 4 years and have been found to differ from adult skin parameters.
The mature skin barrier is partly established by acidification of the skin.
Baby skin differs from adult skin in structure, composition and function.
Baby skin is thinner and cells are smaller than adult skin.
Baby skin handles water differently than adult skin; it loses and gains water more rapidly than adult skin.
Baby skin has less natural moisturizing factor compared with adult skin.
Infant skin is more vulnerable than adult skin. There is a thin line between healthy skin and skin problems needing medical care.
Infant skin continues to develop over time.
References:
Stamatas GN, Martin K. Cosmetics and Toiletries. 2009;124:50-53
Stamatas G et al. International J of Cosmetic Science. 2010;1-11
Instruction Box:
For more information on differences between infant and adult skin see Meeting the Needs of Baby Scientific Dossier section on Scientific Insights About Babies’ Unique Needs.
Adult skin
Baby skin
Stamatas GN, Martin K. Cosmetics and Toiletries. 2009;124:50-53
Stamatas G et al. International J of Cosmetic Science. 2010;1-11

14. That which may be tolerated by an adult can be catastrophic for a child
The impact of applied substances to the skin is that much greater in babies versus adults!
Principles of Paediatric Environmental Health. How Are Newborns, Infants and Toddlers Exposed To and Affected by Toxicants?

15. How do you protect skin?
Be careful what you wash with. Avoid harsh detergents, use baby skin friendly products
 Bad skin practices can break down skin armour.
Many people think they can protect their babies from the harsh environment and prevent infectious diseases by using strong antiseptic products during bath time. Traditional baby skincare routines include amongst others:
Using an adult bar of soap
Adding antiseptic liquid to the water, and
Scrubbing with a sponge using harsh cleansers too many times a day
References:
Cork MJ et al. Community Practitioner. 2005
The effect of harsh cleansers (detergents) on baby skin
Cork MJ et al. Community Practitioner. 2005

16. Allergens penetrate through defective skin barrier
Baby Skin Care: An Evolving Science
Allergens penetrate through defective skin barrier
Allergens
Allergens
Allergens penetrate defective skin barrier and interact with the immune system.
Immature and compromised skin barrier can be an entry point for invasive pathogens that cause infections, and the baby’s skin barrier becomes compromised and irritated by harsh cleansers. Scrubbing with the use of harsh cleansers can disrupt the epidermal barrier and weaken the baby’s natural ability to fight off infection.
Baby’s skin surface area to body weight ratio is approximately 3 times greater than that of an adult. This makes protection of the epidermal barrier even more critical for babies.
Infant skin barrier protection is a vital part of holistic healthcare intervention, as something simple as dry, itchy skin can get so out of control.
References:
Cork MJ et al. Community Practitioner. 2005
Skin barrier breakdown
Allergens interact with the immune system
Cork MJ et al. Community Practitioner. 2005

17. How to maintain a healthy skin barrier
Baby Skin Care: An Evolving Science
How to maintain a healthy skin barrier
CLEANSE
MOISTURISE i
It is imperative to maintain a healthy skin barrier, and this can be done through simple practises that give optimal care for baby skin.
3 simple steps are: Cleanse, moisturize and sun protection.
Maintaining hygiene through cleansing to eliminate dirt and bacteria is important as bacterial colonization present at second day of life. However one must avoid using harsh cleansers.
Moisturise the skin to keep skin barrier hydration level by using products specifically formulated to protect and enhance baby’s skin barrier.
Lastly, using high spf sun screen and apply regularly, even when in the shade. Also wearing a hat and covering the skin with clothing will protect the skin from the sun’s harmful UV rays.
SUN PROTECTION

18. The sensitivity of baby’s skin requires specialised care.
The importance of using the correct products
The sensitivity of baby’s skin requires specialised care.
The sensitivity of baby’s skin barrier requires specialized cleansing. That’s why it is important to use the correct product. Cleansing with water alone can be ineffective, as it only removes water-soluble substances. One needs a cleanser as it contains surfactants which enables the removal of fat soluble materials, such as faces and other unwanted material. In solution form, surfactants form sphere-like structures called micelles. Optimal baby cleansers contain surfactants which form large micelles that increase mildness, cannot easily penetrate the skin and are unlikely to irritate baby skin.
Walters, R et al, 2008, Cosmetics and Toiletries Magazine, Vol. 123, No. 12, P

19. Moisturising with an emollient
The vulnerability of baby’s skin barrier requires protection with specially formulated moisturising emollients.
Appropriate emollients can preserve and protect the infant skin barrier by penetrating the upper layers of skin without pore clogging. This will strengthen the skin barrier and will also create a lipid barrier between the skin and the outside environment, which is the mechanism that blocks the penetration of harmful pathogens, thereby reducing the risk of infection, and increases the ability of the skin to hold water.
Emollients create a partially occlusive barrier between skin and air, thereby reducing trans-epidermal water loss (TEWL), and allows skin to rehydrate by diffusion of water from deeper skin layers. They also have the potential to protect skin from the external environment. This helps to protect against skin conditions like Staphylococcal Skin Scalded Syndrome (SSSS), bacterial infections like Impetiginised Atopic eczema.
Only emollients that help to promote the skin barrier should be considered. Oleic Acid found in vegetable oils can damage the skin barrier, even at low levels.
Lotions, creams, ointments, and oils can act as emollients, and baby will also thrive with a protective massaging routine using emollients that helps baby’s physical development.
References:
Cork MJ et al. J Allergy Clin Immunol. 2006;118:3-21
Lynde C Skin Therapy Letter.com
Cork MJ et al. J Allergy Clin Immunol. 2006;118:3-21
Lynde C Skin Therapy Letter.com

20. Healthy skin means improved overall health, so that a baby can thrive
Healthy skin means improved overall health, so that a baby can thrive. It’s critical to the development of healthier babies – a healthy baby skin is a reflection and indicator of good care and healthy growth.
Mothers are concerned about the appearance of their babies’ skin and find healthy baby skin to be reassuring and a sign of good parenting
It is also important to note that unhealthy skin can be an indicator of other health problems and should never be overlooked.
Maintaining healthy skin is critical in the development of a healthy child.

21. Summary
Skin serves as a baby’s first line of defense against the external environment
Infant skin is uniquely different and still developing and therefore in need of protection
Protection of the infant skin barrier can be achieved with appropriate cleansing and moisturising.
Moisturised, intact skin is one of baby’s natural defenses against bacteria and viruses because healthy skin keeps moisture in and infections out. When the skin is dry it can crack which allows in germs which can result in an infection.
Lotions or other “leave-on” products (e.g., creams, ointments, oils, other emollients) can play a role in preserving and protecting the infant skin barrier
Baby skin health is an important aspect of overall baby health
Skin serves as a baby’s first line of defense against the external environment
Infant skin is uniquely different and still developing and therefore in need of protection
Protection of the infant skin barrier can be achieved with appropriate cleansing and moisturizing.
Moisturized, intact skin is one of baby’s natural defenses against bacteria and viruses because healthy skin keeps moisture in and infections out. When the skin is dry it can crack which allows in germs which can result in an infection.
Lotions or other “leave-on” products (e.g., creams, ointments, oils, other emollients) can play a role in preserving and protecting the infant skin barrier