Dr Tobias Strunk (centre) with fellow researchers (l to r) Dr Jennifer Wood, Dr Sanjay Patole, Dr Ashok Buchiboyina, Dr Mary Sharp

For nine months they’ve been putting coconut oil on the skin of premature infants at King Edward Memorial Hospital. German-born neonatologist Dr Tobias Strunk is involved and he knows about 50% of late septicaemia in premature infants is likely to come from their skin. It is still early days but by mimicking what they do in some Asian countries, they may lessen this tendency dramatically.

Of the roughly 2000 infants admitted to the often above-capacity Neonatal Intensive Care Unit (NICU) at KEMH each year, most qualify for coconut oil on their skin. It is used twice daily (everywhere but the scalp) as routine prophylactic care for infants under 30 weeks gestation as well as any infant with dry skin.

What’s special about coconut oil?

Apparently, it contains at least one fatty acid, monolaurin, that is active against bugs that cause septicaemia in premature infants, and an exciting recent study suggests this effect may come from that fatty acid entering the blood stream. More of that later. Tobias explains:

“Around the NICU you will see infants with an immature epidermis and dry skin which becomes flaky and sometimes cracks. Mineral oils were tested and we found that sepsis risk might increase. We then came across a study from Pakistan where they used coconut oil in premature infants and discovered a dramatic decrease in NICU-acquired infections.”

“In many Asian countries, the massage of neonates with coconut oil is tradition. Triggered by this knowledge and the Pakistan experience we set up a pilot trial where the primary outcome was an improvement in the skin integrity.”

They used the well-validated Neonatal Skin Condition Score to assess the skin –  two independent people assess dryness, redness, and breakdown of the infant’s skin.

Some lab testing completed the picture.

“Some of coconut oil’s components are very active against NICU bugs, particularly Staphlococci.” But this is old news. Tobias found that the FDA in the US had already approved isolated monolaurin in an anti-Staph cream and for impregnation of tampons to prevent toxic shock syndrome.

They went ahead and sourced “squeaky clean” coconut oil from Fiji and applied it twice-daily to the skin for 36 infants born between 23 and 30 weeks gestation. Another 36 infants, acting as controls, received routine care. They applied the coconut oil within 24 hours of birth and for a further three weeks.

“During the intervention period we observed the skin remained healthy. The nurses and parents saw the benefits – their hands improved and they saw how the skin of the baby was visibly improved. It also offered a great opportunity for the parents to get involved with their babies, which is a great thing.”

“We hope to get funding for a larger random controlled trial to show if we can reduce blood infections by applying coconut oil to the skin, which would be an awesomely simple, safe and affordable.” The trial will be suitably powered and they are not sitting on their hands waiting.

“We are awaiting results of swabs on baby’s skin that we think will show less colonisation post-coconut oil. It is pretty exciting!”

Necrotising enterocolitis (NEC)

With up to 8% of infants of >35 weeks gestation receiving empirical antibiotics for suspected early onset septicaemia, Tobias is more mindful of the use of antibiotics, even those of obvious benefit.

“About 50% of septicaemias in infants come from the gut.”

Reduce the incidence of NEC and you may decrease late onset septicaemias?

“KEMH was the first NICU to reduce the incidence of necrotising enterocolitis (NEC), approximately halving the rate seen in Australia.” It has done this by feeding premature babies probiotics and by encouraging breast feeding and perhaps using the breast-milk bank.

Tobias is in step with the human biome and Mother Nature, and respectful of the clever work done by his colleagues at KEMH that has helped to make probiotic supplementation a routine intervention in many NICUs around the world.

“Like all organ systems, the gut is immature at 28 weeks and the mixture of bacteria that colonises the gut is very different to term breast-fed infants. We don’t know exactly what causes NEC, but bacteria are important.”

“Unpasteurised mothers milk is very beneficial, and next is pasteurised donor breast milk. From an evolutionary point of view breast milk was never meant to be sterile,  For example, bacteria on the areola, which is transferred via breastmilk to colonise the infant’s gut.”

“With a few exceptions we do know that breast feeding establishes the most healthy microbiome. As well, it is easily disrupted by giving the mother or baby antibiotics. We are learning more and more how fragile this balance is and how easy it is to disrupt it.”

His views on the infant’s gut microbiome and interaction with mother’s birth canal are similar.

“It is important to be aware that caesarean sections are associated with risks such as a higher incidence of respiratory tract infections most likely related to a substantially different microbiome between infants delivered vaginally and by caesarean section. This is something that is only being appreciated recently.”

“By promoting breastfeeding and giving probiotics to the preterm infant we are looking after the gut.”

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