Oil for the Neonatal Unit                                    Updated February 2007 By Cherry Bond. RSCN, RGN, Neonatal Nurse, Massage Therapist, Baby Massage Instructor (CIMI).

An edible or plant-based oil is an ideal working medium for the Positive Touch programme© Cherry Bond is promoting. The oil is a vehicle to help the parents to promote nurturing touch (and possibly adapted massage strokes) for their infant. The oil should act as a good medium for carrying out massage movements without causing drag or friction. Massaging without oil can be irritating, especially for a sensitive newborn [Field ‘96].

For vulnerable premature or sick babies, who have unique skin problems [Hoath 2000], and may have a poorly functioning immune system, it is safer to use a highly purified/refined oil. Refined oil, has a limited smell, is thin in texture, has a longer shelf-life (check the oil’s Material Safety Data Sheet - MSD), and is less likely to contain any unwanted impurities i.e. high lead levels, yeast moulds, fungal spores, or allergens, which can be present in un-refined or cold pressed oils. Refined oil is obtained from the pulp (which may be left after cold pressing) that still contains a reasonable amount of oil. It may then be subjected to a high temperature, high pressure process, or may be treated with steam and solvents. The refining process removes most of the allergens from the oil [Hefle 1999], however allergy of oils is a subject that is constantly subjected to controversy and the bibliography does not cease to give contradictory examples [Fremont 2002].

When choosing the oil for in-patient use, one would need to make sure the proposal has been checked with the hospital’s Paediatric Allergist, the ward Consultant and Manager, the Pharmacist and the latest Nursing & Midwifery Council recommendations.

GENERAL CAUTIONS FOR ‘BABY MASSAGE OILS’

• Mineral oil (paraffin oil), which is used for some commercially produced oil/gel, is not an ideal medium for Positive Touch or Baby Massage. This oil/gel does not absorb into the outer layers of the epidermis, leaving a greasy film on the baby’s skin. This pore-sealing effect may hamper the natural functions of the skin (excretion, heat regulation etc.). Mineral oil is a highly processed by-product of petroleum; it is not broken down by the body or used in our diet, so the safety of babies sucking their fingers after application is an unknown risk factor.
  
• Most mineral-based baby massage oils/gels have an added scent, which may not be appropriate for a sensitive premature/newborn infant who relies on the normal smell of their parent for bonding, feeding and instinctive sense skills.
• There is no research to validate the safety of using essential oils for infants: any staff advising or prescribing these oils are advised to check their insurance cover.

• Some commercial ‘baby massage oils’ have essential oils added; these are acknowledged as having therapeutic effects. These ’treatments’ may not be appropriate for the immature system of neonates. For safety reasons they should be avoided. Some manufacturers produce a whole baby-range that contain essential oils. There is a concern that parents may unwittingly use them all together (on the skin, nappy area, hair, in the bath and for inhalation), which could be intensely overwhelming for the infant’s sensitive physiological system.

• A scented oil, whether it is a natural or chemical scent, is best avoided as the fragrance can mask the odour of the parents hands (the natural parental odour is very important for the baby in hospital).

• A scented oil can mask the obvious odour of rancid oil, which is not good for use on the skin.

SAFETY ISSUES

• Bacteria are not generally supported by oil. There is no evidence that application of refined oil to neonatal infant skin, when used as a Positive Touch or Massage purpose causes any increased bacteria or fungal cultures [Darmstadt 2004, Kusmirek 2002]. 
• Sunflower oil application on premature infants has been shown to decrease the incidence of dermatitis by restoring the epidermal barrier. Thus application of oil may improve outcome in neonates who are at risk with compromised barrier function [Darmstadt 2002].
• Sunflower or coconut oil has not been found to be degraded by phototherapy.
• There is no substantiation of burning of preterm skin under lights or heaters after sunflower or fractionated coconut oil application [Lee’93/Nooper ‘96/Rutter ‘97].
• Edible oils are not generally absorbed into the systemic circulation, as the molecular structure of these oils is not conducive to trans-dermal transfer [Lee ‘93], however certain components, such as triglycerides, in the oil can be absorbed leaving the skin in better condition and increasing blood lipid levels (important in preterm infants) [Pourarian 2006].

ALLERGIC PROPERTIES OF EDIBLE OILS

As edible oil has the potential to cause sensitization – just as any food (like milk) could do [Breiteneder 2001 /Crevel 2000]. Care should be taken in the choice of the oil.

To have an allergic reaction one must first be sensitized.  A newborn infant may already be sensitized to allergens transferred in utero (during the last trimester) from the mother via the placenta. The breast-fed infant may be exposed to human milk-borne allergens derived from foods the mother has eaten during lactation [Lovegrove ’94].

If the infant’s skin is broken the risk of being exposed to food allergens is much greater [Lack 2003]. The molecular structure of plant-based oil ensures it mostly only absorbs into the uppermost surface layers of the skin [Zatz 1993]. However, recently more evidence of transcutaneous absorption of topically massaged oil in neonates is being shown (in preterm as well as term infants) [Solanki 2005]. When oils are highly purified (refined), allergen-bound proteins are mostly destroyed, so there is a greatly reduced risk (some say no risk) of the oil causing an allergy. [Hourihane‘97].  

SUNFLOWER OIL (Helianthus Annuus)

	The Sunflower originated in South America, where it was worshipped by the Aztecs as a representation of the sun [Kusmirek 2002]. Sunflower seeds contain an oil yield of 30% (although some modern varieties contain 50%).

Sunflower oil has many positive attributions to recommend its use for Positive Touch in the Neonatal Unit and baby massage.

• Sunflower oil is the most widely grown edible oil crop [Price 1999]. It is produced and sold in large quantities so it likely to be fresher than a more infrequently sold product, which may be sitting on the shelf waiting to be sold for a long period of time.
• It has a lovely light texture, which is very pleasant to use, leaving the skin with a satin-smooth, non-greasy feel.
• Given its high content in essential fatty acids, sunflower oil presents restructuring, regenerative and moisturizing properties.
• It resembles the human sebum in the skin [Kusmirek 2002].
• Studies by Sechi demonstrate evidence that the properties in sunflower oil have an anti-microbial effect [Sechi 2001].
• Research in Spain [Rojas-Molina 2005] showed sunflower oil not to be toxic.
• Studies in a Neonatal Unit in Cairo, showed that using sunflower oil resulted in a significant improvement in skin condition and a highly significant reduction in the incidence of nosocomial infections and mortality [Darmstadt 2004]
• It is not commonly associated with allergic reactions. However even refined sunflower oil, may contain minute trace elements of allergen, therefore sunflower seed-sensitive people should avoid all sunflower oil products [Zitouni 2000].
• Sunflower oil does not induce burning of the skin under phototherapy, and would not alter the effectiveness of phototherapy [Rutter ‘97]
• Sunflower oil should not be stored in extreme temperatures. Do not store in a fridge as it can cause clouding and separation of the oil, as the oil’s natural waxes have been removed.

The refined sunflower oil used at the Winnicott Baby Unit, St. Mary’s Hospital in London is food grade (can be ingested) and meets BP (British Pharmaceutical) and food federation standards. It is obtained from sunflower plants, which are grown in several European countries; supply depends on the yearly climate and yield. The sunflower oil is produced by an alkali refining process i.e. it is refined, deodorised and heat treated. This oil is clear pale yellow in colour and has no odour. The oil is bottled by Huddersfield Royal Infirmary Hospital Pharmacy and bought in already labeled in 50 ml bottles. 

 FRACTIONATED COCONUT OIL (Cocos Nucifera)

The coconut palm is grown in many tropical areas, with the Philippines and Indonesia being the most important regions in terms of international trade. Coconut oil is extracted from the white flesh of the coconut, which when pressed yields an odorous solid fat that has therapeutic properties.  The white flesh of the coconut has an oil yield of up to 65%, making it the highest yielding of traditional oil-bearing materials, and contains over 90% saturated fatty acids [NEODA].

NB: The whole oil (un-fractionated) is wonderful for baby massage with babies who are not in hospital or those who do not have immune or nut allergy problems.

Fractionated (refined) coconut oil is probably safer for use in hospital situations.
To extract the fractionated oil, this fat is subjected to heat and the top liquid fraction is removed [SCOPA]. 

• This fractionation process purifies the oil removing the fungal spores, pesticides and yeast moulds that may be present in some unrefined oils.
• Fractionation produces perfume-free oil that stays in liquid form.
• Fractionated coconut oil does not oxidise (‘go off’) as quickly as other oils. The stabilization quality of this oil is particularly advantageous when used in a warm environment such as the NICU.
• It is rare for coconut to cause an allergic reaction and should a reaction occur it is usually mild. The process of fractionation removes most of the proteins to which the allergens are attached.
• There have been studies demonstrating the presence of cross-reactive allergens between tree nuts such as hazelnut and coconut, which is a distantly related palm family member [Roux 2003].

A small, bottle of oil should be supplied to each baby; this avoids any risk of contamination from shared containers or the practice of decanting oil into unsuitable containers (which is an illegal practice).  

INFORMATION SUPPLIED BY:

Breiteneder H, Ebner C. (2001) Atopic allergens of plant foods. Current Opinion in Allergy and Clinical Immunology, 1(3):261-7
Crevel RW, Kerkhoff MA, Koning MM. (2000) Allergenicity of refined vegetable oils. Food Chemical Toxicology, 38 (4): 385-393.

Darmstadt GL, Badrawi N, Law PA, Ahmed S, et al. (2004). Topically applied sunflower seed oil prevents invasive bacterial infections in preterm infant in Egypt: a randomized, controlled clinical trial. The pediatric Infectious Disease Journal, 23(8):719-725.

Darmstadt GL, Mao-Qiang M, Chi E, et al. (2002) Impact of topical oils on the skin barrier: Possible implications for neonatal health in developing countries. Acta Paediatr, 91 (5): 546-554.

Fremont S, Errahali Y, Bignol M, Metche M, Nicolas JP. (2002) Allergenicity of oils (Article in French). Allergie et Immunologie, Mar; 34 (3): 91-94.

Field T, Schanberg S, Davalos M, and Malphurs J. (1996). Massage with oil has more positive effects on newborn infants.  Pre and Perinatal Psychology Journal, 11 73 – 78

Hefle SL. (1999) Impact of processing on food allergens. Advances in Experimental Medicine and Biology, 459: 107-119.

Hoath S, Narendran, (2000). Adhesives and emollients in the preterm infant. Seminars in Neonatology, 5: 289-296.

Hourihane J. Bedwani S. Dean T Warner T. (1997). Randomised, double blind, crossover challenge study of allergenicity of peanut oils in subjects allergic to peanuts.
 British Medical Journal  314; 1081-1088.

Kusmirek Jan (2002). Liquid Sunshine: Vegetable oils for aromatherapy. Floramicus ISBN 0-9543295-0-3.
 
Lack G, Fox D, Northstone K, Golding J. (2003) Factors Associated with the Development of Peanut Allergy in Childhood. The New England Journal of Medicine, 348 (11):977 -985.

Dr. G Lack - Consultant Paediatric Allergist. St. Mary’s Hospital London W2 1NY.

Lane A.T & Drost S. (1993). Effects of repeated Application of Emollient Cream to Premature Neonates’ skin. Pediatrics (92) 3; 415-419.

Lee E. Gibson R, & Simmer K. (1993). Transcutaneous Application of Oil and Prevention of Essential Fatty Acid Deficiency in Preterm Infants. Archives of Diseases in Childhood 68; 27-28.

Lovegrove J. & Morgan J. (1994). Feto-maternal Interaction of Antibody and Antigen Transfer, immunity and Allergy Development. Nutrition Research Reviews; 7:25-42.

Nguyen SA, More DR, Whisman BA, Hagan LL (2004) Cross-reactivity between coconut and hazelnut proteins in a patient with coconut anaphylaxis. Annals in Allergy, Asthma and Immunology, 92 (2):281-284.

Nooper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ, Lane AT. (1996). Topical ointment therapy benefits premature infants. Journal of Pediatrics,128 (5Pt 1): 660-669.

NMC - NURSING & MIDWIFERY COUNCIL: (Replaced the UKCC in  April 2002) It is the disciplinary body set up under the Nurses, Midwives and Health Visitors Act 1992.   23, Portland Place, London W1B 1PZ  TEL: 0207 637 7181  FAX: 0207 436 2927.     www.nmc-uk.org

Pourarian S, Mohammadi MK, (2006). Effect of Cutaneous Application of Sunflower-Seed Oil on Serum Triglyceride and Cholesteral Levels in Preterm Infants. Iranian Journal of Medical Science,31 (2) Email:porarish@sums.ac.ir

Price L. Price S. & Smith I. (1999). Carrier Oil for Aromatherapy & Massage. Riverhead publisher.

Rojas-Molina M,  Campos-Sanchez J, Analla M, Munoz-Serrano A, Alonso-Moraga A. (2005) Genotoxicity of vegetable cooking oils in the Drosophila wing spot test. Environmental & Molecular Mutagenesis,45(1):90-5.
Roux KH, Teuber SS, Sathe SK. (2003). Tree nut allergens. International Archives of Allergy and Immunology, Aug;131(4):234-44

Rutter N. Letter to Dr Nick Rutter – Professor of Paediatric Medicine, Nottingham City Hospital in May 1997.

SCOPA - The Seed Crushers and Oil Processors Association.
6 Catherine St., London WC2B 5JJ, United Kingdom  TEL: 44-171-836-2460; fax: 44-171-379-5735)or IASC, P.O. Box 252, Haywards Heath, West Sussex RH16 2YG, United Kingdom (phone: 44-1444-483786; fax: 44-1444-484068).
Sechi LA, Lezcano I, Nunez N, Espim M, et al. (2001) Antibacterial activity of ozonized sunflower oil (Oleozon).  Journal of Applied Microbiology, 90 (2):279-284.

Solanki K, Matnani M, Kale M, et al. (2005) Transcutaneous absorption of topically massaged oil in neonates. Indian Pediatrics 42 (10): 998-1005.

William Hodgson & CO., (Keith Mealand)
Alderly Edge, Cheshire, UK, Tel: 01625 599111

Zatz JL (1993). Scratching the surface: rational and approaches to skin permeation. In: Zatz JL (ed) Skin permeation: fundamentals and application. Allured, Wheaton p 28.

Zitouni N, Errahali Y, Metche M, Kanny G, Moneret-Vautrin DA, Nicolas JP, Fremont S. (2000) Influnce of refining steps on trace allergenic protein content in sunflower oil. Journal of Allergy and clinical Immunology, Nov; 106 (5): 962-967.

This information sheet is compiled from the above resource references and from:

Essentially Oils Limited, 8-10 Mount Farm, Junction Road, Churchill, Chipping Norton, Oxfordshire, OX7 6PN. UK.     Web: http://www.essentiallyoils.com
Tel: 01608 659544.        Fax: 01608 659566.  E-mail: sales@essentiallyoils.com

This sheet is subject to alteration; please feel free to contact me with comments and updates.

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