Neonatal emollient therapy and massage practices in Africa: a scoping review

Abstract There have been few reports from Africa on the use and health effects of emollient therapy for newborn infants. We aimed to describe neonatal skin care practices in Africa, and to illuminate opportunities to introduce evidence-based interventions to improve these practices. We conducted a scoping review of the quantitative and qualitative published peer-reviewed and grey literature in English on emollient use in Africa. Outcomes of interest included neonatal skin care practices, with a focus on the application of oils and other products to infant skin, including in association with bathing and massage. We screened 5257 articles and summarised findings from 23 studies—13 qualitative, nine quantitative and one mixed methods—that met our study criteria. Seven studies reported the use of emollients for perceived benefits, including thermal care, treatment for illness, promotion of growth and development, infection reduction, skin condition improvement, spirituality and lubrication to aid massage. Four studies reported the quantitative health impact of skin care product applications, including improvements in skin condition, neurodevelopment and bone growth, as well as a reduction in nosocomial infections. This review highlights opportunities for skin care intervention and future research on neonatal skin care practices in Africa.


Introduction
Most neonatal deaths (98%) occur in low-and middle-income countries and are largely ascribed to complications from preterm birth (birth before 37 completed weeks of pregnancy), intrapartum-related events, serious infections and congenital anomalies. 1At the regional level, sub-Saharan Africa (SSA) had the highest neonatal mortality rate in the world in 2019 at 27 deaths per 1000 live births. 2 Compromised skin barrier function is an important factor associated with preterm birth. 3The skin barrier of preterm infants is developmentally immature, has a minimal protective layer of vernix and heightened susceptibility to injury, and is functionally compromised, leading to increased losses of water, heat and en-International Health resource requirements, feasibility and equity.This resulted in a conditional recommendation to consider the use of emollient therapy in preterm or low birthweight (LBW) infants globally, and a call for additional research, particularly in Africa. 16 -18While the application of oils and other products to the skin of newborn infants is a widespread cultural practice in South Asia, 19 -21 less is known about this behaviour in Africa, 22 as there have been few reports from Africa on the effects of emollient therapy on newborn health. 12he main objective of this scoping review was to describe neonatal skin care practices in Africa, and to illuminate opportunities to introduce evidence-based interventions to improve these practices.We aimed to address two primary research questions: 'What are the common neonatal skin care practices throughout Africa, with a focus on bathing, the application of oils and other products, and massage?' and 'What is the reported impact of neonatal skin care practices throughout Africa, for example, the impact of emollient therapy on neonatal survival, growth, infection and neurodevelopment?' 23

Review framework
The review followed a methodological framework proposed by Arksey and O'Malley, 24 consisting of the following five steps: (i) identifying the research question(s); (ii) identifying relevant studies; (iii) selection of eligible studies; (iv) charting the data; and (v) collating and summarising the results.A scoping review methodology was selected for its aims to delineate and identify gaps in available evidence on the area of focus.Quality appraisal was not performed.The review protocol was published previously. 23

Search strategy
We searched for literature pertaining to the research questions in electronic databases-PubMed, Scopus (Elsevier), Embase (Elsevier), Web of Science (Clarivate Analytics) and PsycINFO (Ovid)published between 1 January 2000 and 15 July 2021.We initially designed a search strategy for PubMed using relevant keywords and subject headings related to skin care practices for newborn infants in Africa, as described in the review protocol. 23The search strategy was piloted to check the appropriateness of keywords and databases.Once finalised, the strategy was adapted for replication in the other databases, and all searches were updated on 2 September 2021, as shown in the Online Supplementary Material.The bibliographic search was supplemented with examination of the grey literature in OpenGrey, GreyNet and trial registries including ClinicalTrials.govand the Pan African Clinical Trials Registry.Grey literature was also identified through direct queries to authors of the included literature to explore whether they were aware of unpublished literature on the topic.Finally, a 'snowballing' method was used to identify potentially relevant literature that was cited in the included studies.

Selection of studies
Title and abstract and full text screening was conducted by two researchers, who each reviewed one-half of the articles.Data ex-traction was performed by both researchers and any discrepancies were resolved by discussion together with a third researcher.The proportion of data where there was a discrepancy was < 5%.Title and abstract screening was guided by a series of eligibility criteria to ensure that the content of the included studies was relevant to the research questions.The inclusion criteria were: (1) qualitative and quantitative studies published after 1 January 2000 and prior to 1 July 2021 (updated to 2 September 2021); (2) participants were newborn infants in Africa; (3) interventions were massage, use of body oil or emollient, and bathing; and (4) outcomes were skin care practices and measures of health.Studies were excluded if they had any of the following characteristics: (1) they did not include participants from Africa; (2) were multicentre or multi-country studies reporting data from Africa that could not be isolated from mixed summary data that included non-African countries; (3) they were studies with an exclusive focus on umbilical cord care and/or bathing practices, and an absence of information on emollient applications to the skin; (4) they were not available in English or French; and (5) the full text of the article could not be obtained.Screening processes were aided by COVIDENCE software (Melbourne, Australia).

Data extraction and management
We used a series of guiding queries to extract relevant data.Because most of the studies that were relevant to this review were qualitative or observational in design (interviews, focus group discussions and surveys), this approach was selected in lieu of the Population, Exposure, Comparator and Outcomes framework.This same approach was applied to randomised controlled trials (RCTs) and quasi experimental clinical trials.
We present findings for oil/emollient use and massage as the primary outcomes.Data were recorded on bathing, primarily in relation to emollient and massage practices.Because the review was not designed to comprehensively identify newborn bathing practices in Africa, we did not summarise these data separately.
For emollient use, data on the following outcomes were extracted and summarised: sample size; location of the study (city/district/province/country and hospital/home setting); gestational age and chronological age of infants; type of substance(s) applied to the skin; whether the substance(s) was/were applied to the umbilical cord; how often substance(s) was/were applied; by whom was/were the substance(s) applied; how was/were the substance(s) applied; how was/were the substance(s) distributed on the body (i.e. the scalp, nappy area, etc.); health impacts of product application; acceptability of the product(s) to those involved in the study; product preferences of those involved in the study; why the substance(s) was/were applied; with what were the newborns bathed; temperature of the bath water; whether anything was applied to the skin after bathing, and if so, what substance(s) were applied; by whom were the newborns bathed; how often were the newborns bathed; why were the newborns bathed in a particular way; the mode of childbirth if recorded (i.e.spontaneous vaginal delivery/caesarean section); health outcome measures, if any; observations about newborns' responses to care; and descriptive or injunctive norms and/or perceived sanctions of norm(s), if any, that influenced the scenario.Regarding massage, the following data were extracted and summarised: type of massage performed; how massage was performed; how often massage was performed; when massage was performed; who performed the massage; the rationale behind the selected massage technique; perceived benefits of the technique; any harms or concerns about the technique; and health impacts of the massage technique.

Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans for this research.

Results
We imported 8357 studies and 31 records from other sources for screening, from which 3131 duplicates were removed (Figure 1 ).The remaining 5257 studies underwent title and abstract screening, of which 5189 studies were deemed irrelevant.We assessed the remaining 68 full-text studies for eligibility; 45 studies were excluded and 23 studies were included.Data were extracted from 23 qualitative and quantitative studies conducted in communities and health facilities across Africa (Table 1 ). 12 , 25 -46Data came from nine countries: South Africa, Zambia, Tanzania, Kenya, Uganda, Ethiopia, Ghana, Nigeria and Egypt.Thirteen studies were qualitative in nature with mothers, relatives and herbal sellers as key subjects of interviews, focus group discussions and/or surveys about newborn infants.Nine studies were quantitative with neonatal subjects; and one study with newborn-maternal pairing was both qualitative and quantitative, including newborn subjects for the quantitative component and mothers for the qualitative inquiry.Of the seven studies that reported the gestational age of infant participants, five studies focused on preterm infants ( < 34 wk [n = 1], 28-34 wk [n = 1], < 37 wk [n = 1], 28-37 wk [n = 1], 30 wk [n = 1]) and two studies included preterm and term infants (mean age of 39.7 wk [n = 1], 28-41 wk [n = 1]).Nine studies were community-based, nine were hospital-based, four were a combination of the two and one was home-and work-based.Of the hospital-based studies, facilities were primary care clinics (n = 2), district-level hospitals (n = 5) and referral hospitals (n = 2).
Unadulterated emollients were utilised in seven studies, with sunflower seed oil (SSO; n = 2) and coconut oil (n = 3) as key emollients (Table 2 ).Emollients were adulterated through mixture with herbal treatment or heating in eight studies.For newborns in rural Zambia who were perceived to be small, leaves from the mabono plant were mashed and mixed into petroleum jelly and placed directly on the skin, all over the newborn infant's body. 32arious oils were reported in eight of nine countries, in addition to traditional herbs in Uganda and Tanzania.Use of butter, vaseline and hair lotion was reported in Ethiopia.The skin care practices were administered by mothers, relatives, traditional birth assistants or nurses in all countries.Application involved massage in sites in Ethiopia, Egypt, Zambia, South Africa and Tanzania.Across sites, the frequency of emollient application varied; emollient was applied at frequencies ranging from once exclusively after birth to three times daily.
Four studies reported quantitative findings on the health impact of skin care product applications.These findings included: a significant improvement in skin condition (p = 0.037) and a highly significant reduction in the incidence of nosocomial infections (adjusted incidence rate ratio, 0.46; 95% CI 0.26 to 0.81; p = 0.007); 12 an improvement in overall neurodevelopment and a significant effect on the hearing and speech and general quotient percentile (19.3 vs. 7.7) (p = 0.03) based on the Griffiths Mental Development Scales; 29 an improvement in bone growth and physical activity; 31 and a significant improvement in skin condition and association with higher rates of Staphylococcus aureus colonisation. 46ualitative studies in rural Nigeria, rural Tanzania, urban Tanzania, rural Zambia and rural Ethiopia examined perceptions, beliefs and norms motivating skin care practices (Table 3 ).Seven studies reported the use of emollients for perceived benefits, including thermal care, treatment for illness, promotion of growth and development, infection reduction, skin condition improvement, spirituality and lubrication to aid massage.Within the seven studies, thermal care was reported as the rationale for skin care practices in five sites, growth and development and improving skin condition were recorded in four sites and treating illnesses and spiritual beliefs were recorded in three sites.

Discussion
We conducted a scoping review of literature reporting common neonatal skin care practices in Africa, with a focus on the application of oils and other products, and associated bathing and massage.While our search identified > 5000 potential sources, only 23 were found to provide information on newborn skin care practices in Africa, pointing to the need for further research on skin care in this region.
We found oil to be a common form of emollient therapy, used in eight of nine countries included in the study.Traditional herbal mixtures in oils such as cooking oil, SSO and coconut oil were also reported as a form of emollient in Uganda and Tanzania.The use of butter, vaseline and hair lotion was reported only in Ethiopia, yet the experience of the authors suggests that the use of vaseline is common in other locations, including Kenya, Uganda and Zimbabwe.Quantitative studies that reported health outcomes found a variety of effects, including an improvement in skin condition associated with a reduction in nosocomial infections 11 or an increase in the rates of S. aureus colonisation; 46 an improvement in measures of the neurodevelopment of HIV-exposed infants; 29 and increased growth and physical activity. 31A variety of beliefs and norms were reported to motivate neonatal skin care practices, including improved thermal care, treatment for illness, promotion of growth and development, infection reduction, improved skin condition, spiritual beliefs and massage to aid movement and improve strength.
Our present review adds 14 additional publications to the literature pool compared with those analysed in a previous review of the literature on neonatal skin care in Africa by Duffy et al. 22 We Unspecified local herbs for bathing and applying to infants' skin 25 Smeared baby with cooking oil using a clean cloth 40 Not stated 25 Mother 33 , 40 Not stated 25 , 33 , 40 Not stated 25 Twice a day 33 Not stated 25   Ground nut oil for removing vernix 28 Borno: ground nut oil to clean the baby after delivery Other oil to clean the baby after delivery, Shea butter, baby oil, 'olive oil, mahogony or neem oil to the fontanelle Engine oil on circumcision wound Ekiti: Goya 'olive' oil to clean baby after delivery, other oil to clean baby after delivery, baby lotions, herbal/medicated creams, Shea butter, mentholatum, engine oil, baby oil to the fontanelle 39 Not stated 43 Mother 26 , 39 Not stated 43 Apply to affected area 26 Not stated 43 Not stated 26 After every birth 39 Not stated 43 After bathing 26 After bathing 35 , 39   Not stated 43 Treat various skin ailments, traditional management practice 26 Not stated 28 , 35 EMs were applied to make the skin 'soft', 'smooth', 'attractive', 'healthy', 'strong' and 'rash free', to keep the baby warm, to soften/strengthen the joints/bones, shape the baby, ensure flexibility, encourage growth and weight gain, and to help the baby sleep 39 Not stated 43

Zambia
Water 32 , 34 Umbilical cord: powders made of roots, burnt gourds or ash 32 Petroleum jelly, glycerin, cooking oil 34 Whole body but taking care not to involve the mouth, ears and eyes Petroleum jelly, commercial baby lotion, cooking oil (mixture, similar to vegetable oil, often made with SSO), leaves from the mabono plant mashed into petroleum jelly 32 Not stated 34 Not stated 32 Not stated 34 Whole body but taking care not to involve the mouth, ears and eyes 32 Not stated 34 Several times 32 Not stated 34 Mothers and TBAs 32 Not stated 34 To ward off malevolent spirits, improve babies skin, keep baby warm with mabono leaves 32 Not stated 34 Kenya Not stated 44 Not stated 44 Massage 44 Nurse 44 Not stated 44 Three times a day 44   Not stated 44 Effect on body temperature 44 Egypt Not stated 12 , 30 , 31 Soap and water 41 Not stated 12 36 To obtain cure for illness 38 Ethiopia Not stated 39 Not stated 39 Butter, vaseline, hair lotion 39 Mothers/care takers 39 Done during the application Technique sometimes rough and included rubbing, pulling, pressing, manipulating joints and shaping features 39 Once daily 39 Only after the morning bath 39 To make the skin 'soft', 'smooth', 'attractive', 'healthy', 'strong' and 'rash free',to keep the baby warm, to soften/strengthen the joints/bones, shape the baby, ensure flexibility, encourage growth and weight gain, and to help the baby sleep 39 Abbreviations: CHG, chlorhexidine gluconate; EM, emollient; NICU, neonatal ICU; SOC, standard of care; SSO, sunflower seed oil; TBA, traditional birth attendant.have not yet developed, each time the baby is massaged, his limbs become stronger.' 38 soften the skin 27 Applying oil mixed with traditional medicine to the newborn's skin was perceived as a form of prevention against 'evil': 'We say that the young baby is appealing to evil spirits (mash-etani) and to the supernatural (majini) […]   when oil mixed with traditional medicine is applied on the baby's skin, those [evil spirits] encounter the bad smell of the oil, then it is not easy for them to harm the baby.' 38 International Health EMs were applied to make the skin 'soft', 'smooth', 'attractive', 'healthy', 'strong' and 'rash free' 40 Rural Zambia, community and hospital 'The oil makes the baby warm, so I put the oil many times per day.I rub all over the body so all the skin is covered and his skin is shiny, but I always cover him again with mabono so he will stay warm and get bigger.'(Interview, recently delivered woman) 32 To ward off malevolent spirits 32 Urban South Africa, hospital To aid massage movement 29

Rural Ethiopia, community
To keep the baby warm 40 To soften/strengthen the joints/bones, shape the baby, ensure flexibility, encourage growth and weight gain, and to help the baby sleep.Some effects were jointly attributed to the emollient and to massage during application: 'We have seen that massaging with butter has allowed my baby to gain weight since she sleeps well' (30-y-old mother Ethiopian mother) 40 EMs were applied to make the skin 'soft', 'smooth', 'attractive', 'healthy', 'strong' and 'rash free' 40 Abbreviation: EM, emollient.
found similar practices and motivations for skin care as reported by Duffy et al. 22 For example, massage was associated with perceived benefits of increasing limb strength and suppleness in Nigeria and Tanzania and to protect and strengthen the skin, cleanse impurities and warm the baby in Uganda, Tanzania, Nigeria and Egypt.Our present review also indicates that spiritual beliefs and the belief that massage will aid movement are motivators of skin care practices in Africa.Shared themes from the two reviews for the motives behind topical emollient therapy include thermal care, treatment for illness, growth and development, infection reduction and skin condition improvement.Our review found that oil massage does not appear to be a universal practice in Africa, as it is in much of South Asia.There is a need for more formative research to understand avenues for sensitisation and introduction of emollient therapy in Africa.Many emollients that are reportedly applied to newborn skin in South Asia and SSA have been demonstrated in laboratory studies with a mouse model of human infant skin to perturb important epidermal functions, including permeability barrier homeostasis, and thus are potentially harmful, 47 , 48 highlighting the need for improved emollient practices.Given the relevance of the mouse model for human infant skin, it can be anticipated that these products perturb the epidermal permeability barrier of infants to whom they are applied, which may contribute to the high rates of neonatal morbidity and mortality seen in SSA. 49Intervention with appropriate products that have a compositional profile consistent with the promotion of skin barrier function (e.g.high levels of linoleic acid) plus demonstrated enhancement of skin barrier function in the mouse model is crucial for the improvement of neonatal health outcomes, especially in preterm infants whose skin barrier is highly permeable and fragile.
The use of oil as emollient therapy is highly prevalent in Asia, providing some observations that may be helpful for Africa.A study conducted in Maharashtra and Madhya Pradesh states in India found that massage was mostly conducted using oils. 50ike our findings from Africa, reported perceived benefits of infant massage included increased bone strength and better growth, while no harm was perceived.Improved sleep was an additional perceived benefit.In Bangladesh, a study found that topical therapy with SSO or Aquaphor was perceived by many families to be superior to traditional use of mustard oil after their infants received emollient therapy with SSO or Aquaphor in the hospital. 51 study conducted in Uttar Pradesh pointed to the necessity of further research on potential approaches to improving adherence to recommended therapy, particularly in community settings. 52 , 53Acceptance of SSO in the intervention arm was high at 89.3%, but adherence to exclusive applications of SSO was 30.4%. 53The community's inherent belief in the goodness of traditional use of mustard oil appeared to be strong, suggesting that more intensive behaviour change management was required to shift deeply entrenched community norms toward adoption of recommended practices.
The application of mustard oil is particularly universal in Asia due to its perceived benefits including prevention of infections and hypothermia, promotion of strength, maintenance of health and provision of warmth. 19 -21There is evidence from mouse models, however, that mustard oil may be harmful to the skin. 47A community-based trial in Nepal comparing the effects of SSO and mustard oil on skin integrity in premature and full-term newborns suggests that SSO may be protective for newborns in lower resource settings due to the more rapid acid mantle development observed for SSO. 54The potential health impact for intervention with SSO applications at population level was shown in the Uttar Pradesh study where growth increased by 0.94 g/kg/d, rates of hospitalisation and of any illness were reduced by 36% and 44%, respectively, and the mortality of the subgroup of very low birthweight ( ≤1500 g) infants was reduced by 52%. 52 , 53 strength of the present review is its synthesis of data from quantitative and qualitative research on emollient use in SSA, thus expanding on the 'how' and 'why' of previous reports.22 A limitation, however, is that we did not conduct a formal quality appraisal or assessment of the risk of bias for the studies that were included, given the relatively small number of studies on our topic of interest.
Our study also highlights key areas for additional research (Table 4 ).While the WHO recently recommended that emollient therapy-particularly with SSO or coconut oil-should be considered for the care of preterm or LBW infants globally, it was also noted that there is a need for additional evidence in a number of areas, including impacts on growth, thermoregulation, the microbiome, invasive infection/sepsis, mortality and longer-term neurodevelopment.In addition, more data are needed on emollient composition and dosing for maximal effectiveness.Data are particularly lacking from Africa.Similar to research undertaken in South Asia, we recommend prioritisation of systematic, prospective RCTs in the most vulnerable group with the greatest skin barrier compromise-hospitalised very low birthweight infantsin several countries, using common study designs that would enable data to be included in existing meta-analyses, ideally enrolling infants with untreated skin for comparison with infants treated identically in all ways, except for application of emollient.

Table 1 .
Characteristics of included studies on neonatal emollient therapy and massage practices in Africa

Table 2 .
Newborn skin care practices in Africa

Table 3 .
Beliefs and norms motivating newborn skin care practices in Africa

Table 4 .
Key research questions on emollient therapy in newborn infants in Africa What motivates the use and choice of skin-care products for newborn infants in sub-Saharan African contexts?What are the survival, growth, morbidity, microbiome, thermoregulatory and neurodevelopmental impacts of emollient therapy on newborn infants in SSA?What forms of emollient therapy are effective for newborns in sub-Saharan African contexts?Do skin-care practices for preterm infants differ from practices for full-term infants in SSA?What traditional neonatal skin care practices in SSA could we learn from?Which could be potentially harmful?What values do sub-Saharan African families and healthcare providers place on skin and skin care?How do social norms and cultural practices influence skin care practices in SSA? Who do we need to educate for emollient interventions to be successful in SSA?How can adherence to recommended skin care practices be increased, and use of harmful practices be diminished in SSA?