Diaper Duty: treating and preventing SBS diaper rash

One of the most frequent questions asked in our support groups is how to treat the severe diaper rash that is so common with Short Gut Syndrome. In response to your inquiries, our newsletter staff interviewed doctors, nurses and other professionals, done our reading, and put together an introductory guide to diaper rash prevention and treatment.

This article is not a substitute for the qualified advice of your child's doctor.

Why is diaper rash such a problem for children with Short Bowel Syndrome?

In a healthy digestive system, acid, bile, enzymes and bacteria work together in the intestine to break down food into nutrients that can be absorbed. When part of the intestine is missing, the careful balance of these digestive elements can be put out of balance. Acid may not be completely neutralized. Fluids and enzymes may not be reabsorbed. Normally healthy bacteria in the gut can grow in unhealthy proportions. The result is frequent, watery, acidic stool that can break down skin and, in some cases, lead to infection.

Children with Short Bowel Syndrome can experience more frequent and more severe diaper rash as a result. There are steps you can take, however, to limit diaper rash, even with the most severe of Short Bowel Syndrome.

your first line of defense: keep skin clean

Diaper rash is a result of contact with stool and urine. So, change diapers often. Of course this is harder when a child has Short Gut. Some children need diaper changes hourly, if not more often. Still, the sooner a dirty diaper is changed, the healthier the skin will be.

It's important to use the right diaper. You won't change every diaper immediately, so you need a diaper that fits your child and absorbs well. If your child is older and sleeps through the night, you may want to use an overnight diaper like Huggies Overnites that is designed to absorb more.

Your wipes matter, too. Fragrances and soaps found in commercial wipes can hurt a sore bottom. Sensitive baby wipes sting less, but even these can be irritating to some children. One option is to buy wipes and rinse them in water before using them. Another option is to use wet washcloths, either fabric or disposable. (Disposable washcloths are sometimes called water wipes).

Whatever wipe you choose, be aware that rubbing excoriated skin can cause further damage. If the skin is broken or bleeding, it is best to pat, not rub, the skin to clean it.

Use caution with spray cleansers. They sting and can slow healing! Try a warm bath instead.

Baby oil or mineral oil can remove excess diaper creams. If you feel that you need a cleanser, try spray dimethicone, like Baza Cleanse and Protect.

creams, powder, and pastes

Cleaning skin and changing diapers is rarely enough for a child with Short Bowel Syndrome. Remember, a child with SBS has acidic stool. To keep skin safe, you also need a protective barrier that keeps stool off of skin.

To be effective, a barrier cream should be applied every time the diaper is changed and after baths. The barrier cream should be applied in a thick layer. The makers of Desitin recommend that you imagine you are frosting a cake. Apply an even thicker coating at bedtime. Consistency is key. Especially with Short Gut, barrier creams should be applied even when the skin is healthy. Healing sore skin is much harder than protecting healthy skin.

There are many types of barrier creams, powders and pastes on the market. Finding the right one may require some trial and error. Since each child is different, no one solution will work for every child. This article will teach you a little bit about the different products so that, hopefully, you can find what works best for your child.

Over-The-Counter Diaper Creams: Over-the-counter creams and ointments protect against mild to moderate diaper rash. They are made of skin protectants like lanolin, petrolatum, zinc oxide, and beeswax that shield the skin from wetness and irritants. Vaseline and Aquaphor , for example, are made of petrolatum, which repels wetness. Some creams and ointments also contain moisturizers, vitamins, and other ingredients that promote healing and help soothe the pain and itch of diaper rash. Desitin, A&D Ointment , and Lanisoh are common brands that include a skin protectant and other healing ingredients.

Mix-and-match recipes: Mix-and-match recipes combine several over-the-counter products to make a more customized barrier cream. The choice of ingredients varies from recipe to recipe, however, most recipes mix at least a zinc oxide cream and a petrolatum ointment. Some recipes also include an antacid like Mylanta or a powder like baby powder or corn starch.

Talk to people your doctor, nurse, or other parents to find a recipe. Many hospitals use or have used their own recipes for diaper creams. Try asking your favorite nurse if she's ever made a "triple paste." (Traditionally these recipes had three ingredients. Be careful, though, not to confuse a mix-and-match recipe with Triple Paste Medicated Ointment. The latter is a commercial cream made for severe diaper rash. It, too, contains petrolatum and zinc oxide, though, so it may also be worth trying.)

Specialty Barrier Creams: Over-the-counter products don't work for all children. You may need to look outside the corner drugstore for help. There are a variety of specialty creams and ointments made specifically for issues like Short Bowel Syndrome. These are generally available through medical supply companies and hospital pharmacies. They more expensive than over-the-counter diaper creams. However, they may be covered by insurance.

There are dozens of products to choose from. Many are essentially the same as over-the-counter. However, a few unique products have proven very effective with SBS. (See the box below.)

Powders: Corn starch and baby powder have been used for generations to absorb wetness that causes diaper rash. They are no match for the diarrhea that comes with Short Gut. However, there is a type of powder used with stomas that can help. Made from pectin, stoma powder is proven to protect skin so it can heal, so long as it stays in place.

Diarrhea would wash away stoma powder if used alone. However, used in a method called "crusting," pectin powder creates an effective barrier. Crusting mixes stoma powder with a clear, thin liquid skin barrier film sold as "no-sting barrier wipes" or "no-sting skin prep/protectant spray". The best known brand of barrier film is 3M's Cavilon wipes and spray.

First, the barrier film is applied, then dusted over with a thin layer of stoma powder. The process is repeated two or three more times until several layers of powder have been applied.

"Crusting" can last up to three days. Like other methods, it is not recommended to try to remove crusting completely between uses, but you should reapply regularly.

Hydrocortizone: Sometimes, diaper rash can be calmed with hydrocortisone cream. Usually a 1% USP over-the-counter cream (not ointment) is sufficient. However, because hydrocortisone is a steroid, you should talk to a doctor before using it to treat diaper rash.

prescription creams

Your doctor may suggest a prescription cream or compound. The base ingredients of prescription creams are the same as most over-the-counter creams, but they may also include prescription medicines like antibiotics, antifungals, coticosteroids, and even medicines that bond to and protect ulcerated skin. Some are sold premixed while others are compounded, or mixed by the pharmacist.

A doctor can tell you best whether the special ingredients in a prescription cream are likely help your child's diaper rash.

a word about infections

Some diaper rashes are caused by a skin infection. Recognizing and treating an infection early can keep it from spreading or getting worse.

Yeast infections are characterized by a bright red rash. Often red, pimply bumps will also appear. Yeast tends to appear first in the folds of skin where heat and moisture are trapped. With bacterial infections, yellowish, fluid-filled bumps may appear, as may honey-colored crusty areas.

If you suspect an infection, your child should see a doctor. There are prescription and over-the-counter creams that can be used to treat infection. These can be mixed with your favorite barrier method to treat the infection while still protecting against further irritation.

finding help

You may have resources to help you to treat and prevent diaper rash. Find out if your hospital has a wound team, skin care team, or enterostomal team that can help you. (Enterostomal nurses specialize in skin care around ostomies and g-tubes where skin can be exposed to stomach acid. The same techniques can apply to the kind of diaper rash common with Short Bowel Syndrome.) For more help, visit our support groups to share ideas with other parents. Call a doctor if you see pimples, blisters, open weeping sores, boils, yellow crusts or red streaks. Also, call a doctor if diaper rash continues uncontrolled even after several days of treatment.

common diaper cream ingredients

Aloe - soothes, promotes healing
Beeswax -- skin protectant
Calamine -- soothes itching, prevents infection
Chlorothymol -- germicide
Citric acid -- astringent (reduces swelling)
Cod liver oil -- contains vitamins A & D
Dimethicone -- skin protectant, emollient moisturizer
Glycerin -- moisturizer
Lanolin -- skin protectant, emollient moisturizer
Menthol -- external analgesic (soothes pain), antipruritic (anti-itch), antiseptic (kills bacteria)
Mineral oil -- skin protectant, emollient moisturizer
Pectin -- skin protectant, promotes healing
Peruvian balsam -- moisturizer
Petrolatum -- skin protectant, emollient moisturizer
Sodium bicarbonate -- neutralizes acid
Thymol -- antibiotic and antifungal
Vitamins A & D - promote skin health
Zinc oxide -- skin protectant, promotes healing

Read about this topic on the web

http://www.childrenshospital.org/views/april04/diaper.html

http://grey.colorado.edu/shortgut/index.php/Stool_and_diaper_rash