Topical use of human breast milk for diaper rash in infants

Penjvini S, MSc in pediatric Nursing and Doctoral student in Nursing Education in Faculty of Nursing & Midwifery of Tabriz, East Azerbaijan, Iran. Co Author: Shahsavari S, MSc in epidemiology. Co Author: Gazerani F, BSc in nursing, Head nurse of Neonatal ward in Besat hospital, Sanandaj. Co Author: Abdolkavand S, BSc in nursing, Nurse Staff of pediatric ward in Besat hospital, Sanandaj. Institute: Medical Sciences University of Kurdistan, Faculty of Nursing & Midwifery

Pasdaran Street, Sanandaj, Iran Tel: 98 871 6622266 Fax: 98 871 6660092 E- mail: susanpenjvini@yahoo.com

ABSTRACT Background: Diaper dermatitis is common in infants and is one of several acute inflammatory skin disorders caused either directly or indirectly by wearing of diapers. It can be treated by zinc oxide or petrolatum. In this study our aim was to determine the effect of human breast milk (HBM) on diaper rash in hospitalized infants in Sanandaj. Methodology: Subjects comprised infants under two years of age with prematurity, sepsis, gastroenteritis and pneumonia who had diaper rash but did not have allergic causes of the rash. These 50 infants under two years of age were randomly assigned to intervention and control groups (25 in each group). Prior to the commencement of the study none of the children received or were receiving steroid and immunosuppressive drugs or topical medications. Results: There were no significant differences between the two groups (HBM and zinc oxide ointment) with respect to lesion size, inflammation and intense erythema (wound). But there were significant differences between before and after (two stages) treatment by HBM and zinc oxide. Conclusion: Though not statistically significant, results favored use of topical breast milk to aid recovery of diaper rash. Therefore, it is recommended that topical breast milk is considered for treatment of diaper rash. Key words breast milk, zinc oxide, infants, diaper rash.

INTRODUCTION

Diaper rash can be defined as contact dermatitis. Diaper rash is the most common irritant contact dermatitis occurring in approximately one third of young children, usually in a mild form. The most common prevalent age in infants is from 4-12 months of age⁽¹⁾.The incidence is greater in bottle-fed infants than breast-fed ones⁽²⁾.

The skin of the diaper area may become erythematous and scaly, often with papulovesicular or bullous lesions, fissures, and erosions. The eruption can be patchy or confluent, but the genitocrural folds are often unaffected. Chronic hypertrophic flat-topped papules and infiltrative nodules may mimic syphilitic lesions. Secondary infection with bacteria and yeast is common; and discomfort may be severe because of intense
inflammation⁽³⁾.

There are three factors responsible for producing diaper dermatitis - wetness, pH, and fecal irritants. The underlying skin condition of the infant and the degree of wetness of the skin corresponds with the degree of diaper dermatitis. Skin that is moist becomes more heavily colonized with microorganisms than dry skin⁽⁴⁾.

Human breast milk (HBM) is considered as the ideal food for newborn infants. It is a live nutrient, comparable with blood, with no similar substitute. Advances have occurred in the scientific knowledge of the benefits of breast milk in recent years. Some studies have documented anti- inflammatory effects of human milk in animal subjects. Colostrum contains a variety of immunologic materials against the bacteria, viruses and fungi which are present in the environment of mothers and their newborn babies⁽⁵⁾. Immunologic and anti-infective factors include: lactoferine, lymphocytes, special prostaglandins, bifidous factor, bioactive components and growth factors⁽⁶⁾. Epidermal growth factor (EGF) is a major growth promoting agent in breast milk, and stimulates proliferation of intestinal mucosa and epithelium also strengthening the mucosal barrier against the antigens⁽⁷⁾. EGF is usually applied topically, although it can also be used intravenously. When EGF is applied to injured skin, such as burns, ulcers (skin or GI tract), and surgical corneal wounds, it does promote healing^(7,8).

Several topical agents have been used for treating the condition of diaper rash. In this study we have compared the effects of topical human breast milk (HBM) with zinc oxide ointment for treating diaper rash in infants.

METHODS

This interventional study was carried out to assess the effects of topical use of HBM on diaper rash. It was done in Besat hospital in Sannandaj, Iran between February and July 2004. The study sample consisted of 50 infants under two years of age. These infants were hospitalized due to prematurity, sepsis, gastroenteritis and pneumonia and developed diaper rash. They were randomly allocated by block randomization method to either intervention or control groups (25 in each group).

Block randomization is a method that assigns subjects to treatment (intervention) groups in blocks of four. Each of the assignment blocks is balanced (equal number of intervention and control assignments) and blocks are selected by a random method.

None of them received steroid and immunosuppressive drugs. Infants were treated with either zinc oxide or HBM. The mothers of the infants in the intervention group were instructed to apply HBM on the lesion for treatment of diaper rash. The infants in the control group were treated with topical zinc oxide ointment (Sobhan pharmaceutical company, Iran). After cleaning the affected areas with water, HBM or zinc oxide was applied at each diaper change. Infants were assessed at baseline and twice a day on days 1, 2 and 3 of treatment (6 times).

In each assessment the efficacy variables included the affected area surface that considered by the lesion diameters (measured by using a sterilized ruler put along the lesions), in a way that, ³ 3´2 centimeter (cm²) =large size, 2´2 cm² = moderate, and < 1´2 cm² = small. We specified two conditions for severity of erythema, namely, mild or moderate redness with maculopapular lesion = presence of inflammation and fissures and intense erythema = presence of wound.

Data were analyzed using windows version 9.0 of the Statistical Package for Social Sciences (SPSS). A P value of <0.05 was considered to be statistically significant and the Chi-square test was used for comparing the differences between the two groups.

RESULTS

We compared the effects of topical application of HBM with zinc oxide ointment in treatment of diaper rash. Table 1 shows that 48% of the HBM group infants and 44% of the zinc oxide group had large size lesions on the first day (in the morning, between 8 - 9 o'clock). By the third day (in the evening, between 6-7 o'clock), these changes had fallen to 4% and 16% respectively.

Analysis of the data from Table 2 shows that 64% of the intervention group infants and 68% of the control group on the first morning (between 8-9 o'clock) had inflammation. These percentages by the third day (evening, 6-7 o'clock) decreased to 24% and 32% respectively.

With regard to the perineal intense erythema (wound), Table 3 indicates that 48% of HBM group and 36% of zinc oxide group on the first day morning had intense erythema that declined to 12% and 20% respectively by the third day¢s evening. The size of affected area and severity of erythema were reduced in both groups. Chi square test showed no significant difference between the two groups in terms of area size, inflammation and erythema severity.

Nevertheless the Chi square test in Tables 4 and 5 indicated that there were significant differences between the two stages of treatment (before and after P=0.004) in the HBM group. More precisely, the large size of the rash in 12 cases did not disappear completely, reduced to one case after applying HBM on to the perineal area (p=0.0004). Also findings in relation to inflammation demonstrated that after treatment with HBM, 19 infants did not have inflammation and only 6 of them had a problem. With respect to erythema severity (wound) results indicated that 22 infants did not have a rash after treatment by HBM in their perineal area and there was a significant difference between before and after treatment by HBM (p=0.005).

In the zinc oxide (control) group we observed the same reduction in the lesion size, namely, the large size of the rash (as mentioned before lesion diameters measured by a ruler) was observed in 11 infants that decreased to 4 and Chi square test showed there was a significant difference between before and after treatment by zinc oxide in the lesion size (p=0.032), and inflammation was noticed in 17 infants that declined to 8 (p=0.011). Although there was no difference after treatment by zinc oxide about intense erythema between two stages, only 5 infants had intense erythema.

CONCLUSION

All of the infants who participated in this study were breast-fed infants and they had diaper rash with a variety of degrees from rash to erythema. The findings showed that the width of lesions in the morning of the first day in the two groups were much the same, but after treatment and reassessment, the results indicated that the improvement in the HBM group was bigger than the zinc oxide group. Similar findings were reached by Kalliomaki et al (1999), who expressed the idea, that beta growth factor in human breast milk decreased atopic dermatitis in infants⁽⁹⁾. Kull et al (2002) followed 4,089 Swedish infants up to 2 years and also found protective effects of breast feeding on the incidence of asthma and atopic dermatitis⁽¹⁰⁾.

Ahmadpour et al (2006) found that human breast milk could be substituted for other topical agents for umbilical cord care. Because the umbilical cord dries and becomes mummified and polymorphonuclear leukocytes infiltrate the area between the drying cord stump and the vital tissues of the abdominal wall, forming demarcation zone. Breast milk may enhance the umbilical cord separation through polymorphonuclear leukocytes, proteolytic enzymes, or other immunologic agents⁽¹¹⁾.

This study found that the absence of inflammation in the evening of the third day of treatment in the two groups not significantly different. This finding was approved by studies of Giancarlo Pizza et al (1999), who found that the use of beta growth factor in HBM can reduce the inflammation in Dermatitis, Hepatitis, Herpes Zoster and conjunctivitis⁽¹²⁾. Brzozowski et al (2001) reached a similar conclusion regarding the local protective effect against gastric ulcer⁽¹³⁾ and Pishva et al (1998), indicated that topical application of HBM can be protective in the prevention of neonatal conjunctivitis⁽¹⁴⁾.

This study showed that the improvement of perineal nappy rash in the intervention group was greater than in the control group. Larijani et al (2003) and Grazul et al (2003) concluded that application of local EGF had a significant role on diabetic wound healing^(15,16) and numerous studies suggest that human epidermal growth factor has specific effects on corneal epithelial wound healing^(17-20). Therefore, it is recommended that topical breast milk is considered for treatment of diaper rash.

The results show that there were no significant differences between the two groups with respect to lesion size, inflammation and intense erythema. However the data revealed that there were significant differences between the two stages (before and after) of treatment of diaper rash by HBM and zinc oxide. This finding suggests that the HBM is a suitable, convenient and complication free choice for diaper rash treatment.

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