Topical emollient for preventing infection in preterm infants

Background

Preterm infants (born before 37 weeks' gestation) are susceptible to bloodstream and other serious infections partly because their immature skin is not a fully effective barrier to micro-organisms. Applying emollient (ointment, cream, or oil) may protect against skin breakdown and thereby prevent micro-organisms from spreading into the bloodstream and causing serious infection.

Study characteristics

Our search (updated January 2021) identified 22 eligible trials. In total, 5578 infants participated. Eight trials (2086 infants) examined the effect of topical ointments or creams in very preterm infants (born more than eight weeks early) cared for in hospitals, mostly in high-income countries. Fourteen trials (3492 infants) assessed the effect of sunflower and other vegetable oils, mostly in low- or middle-income countries in south Asia. All but one of these trials was conducted in hospitals. One large trial in India (2249 infants) was based in the community.

Key results

Regular application of ointments or creams to the skin of very preterm infants may have little or no effect on serious infection or death. Application of sunflower and other vegetable oils may reduce invasive infection but have little or no effect on mortality.

Certainty of evidence

These analyses provide low certainty evidence about the effects of emollient therapy on serious infection or death in preterm infants. Since these interventions are mostly inexpensive, readily accessible, and generally acceptable, further good-quality randomised controlled trials in healthcare facilities, and in community-settings in low- or middle-income countries, may be justified.

Authors' conclusions: 

The level of certainty about the effects of emollient therapy on invasive infection or death in preterm infants is low. Since these interventions are mostly inexpensive, readily accessible, and generally acceptable, further good-quality randomised controlled trials in healthcare facilities, and in community settings in low- or middle-income countries, may be justified. 

Read the full abstract...
Background: 

Breakdown of the developmentally immature epidermal barrier may permit entry for micro-organisms leading to invasive infection in preterm infants. Topical emollients may improve skin integrity and barrier function and thereby prevent invasive infection, a major cause of mortality and morbidity in preterm infants.

Objectives: 

To assess the effect of topical application of emollients (ointments, creams, or oils) on the risk of invasive infection and mortality in preterm infants.

Search strategy: 

We searched CENTRAL via Cochrane Register of Studies (CRS) Web and MEDLINE via Ovid (updated 08 January 2021) and the reference lists of retrieved articles.

Selection criteria: 

Randomised or quasi-randomised controlled trials that assessed the effect of prophylactic application of topical emollient on the risk of invasive infection, mortality, other morbidity, and growth and development in preterm infants.

Data collection and analysis: 

We used the standard methods of Cochrane Neonatal. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on mortality and invasive infection.

Main results: 

We included 22 trials with a total of 5578 infant participants. The main potential sources of bias were lack of clarity on the methods used to generate random sequences and conceal allocation in half of the trials, and lack of masking of parents, caregivers, clinicians, and investigators in all of the trials.

Eight trials (2086 infants) examined the effect of topical ointments or creams. Most participants were very preterm infants cared for in healthcare facilities in high-income countries. Meta-analyses suggested that topical ointments or creams may have little or no effect on invasive infection (RR 1.13, 95% confidence interval (CI) 0.97 to 1.31; low certainty evidence) or mortality (RR 0.94, 95% CI 0.82 to 1.08; low certainty evidence).

Fifteen trials (3492 infants) assessed the effect of topical plant or vegetable oils. Most of these trials were undertaken in low- or middle-income countries and were based in healthcare facilities. One large (2249 infants) community-based trial occurred in a rural field practice in India. Meta-analyses suggested that topical oils may reduce invasive infection (RR 0.71, 95% CI 0.52 to 0.96; I² = 52%; low certainty evidence) but have little or no effect on mortality (RR 0.94, 95% CI 0.82 to 1.08, I² = 3%; low certainty evidence).

One trial (316 infants) that compared petroleum-based ointment versus sunflower seed oil in very preterm infants in Bangladesh showed little or no effect on invasive infection (RR 0.91, 95% CI 0.57 to 1.46; low certainty evidence), but suggested that ointment may lower mortality slightly (RR 0.82, 95% CI 0.68 to 0.98; RD -0.12, 95% CI -0.23 to -0.01; number needed to treat for an additional beneficial outcome 8, 95% CI 4 to 100; low certainty evidence). One trial (64 infants) that assessed the effect of coconut oil versus mineral oil in preterm infants with birth weight 1500 g to 2000 g in India reported no episodes of invasive infection or death in either group (very low certainty evidence).

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