Neonatal skin care: a concise review

Abstract

Skin care practices play an important role in the health of well newborns and hospitalized neonates. Fortunately, for many aspects of neonatal skin care, there exist evidence- or consensus-based recommendations to guide best practices. Based on our review of the recent medical literature, we include in this manuscript the current recommendations regarding neonatal skin cleansing and antisepsis; umbilical cord care; use of emollients; and prevention of diaper dermatitis. In addition, we review the recommended practices for preventing and treating pressure ulcers, wounds, and other skin injuries in hospitalized neonates.

Introduction

Traditionally, the neonatal period has been defined as the first 28 days of life. Although neonates seem quite passive and tranquil, they are challenged physiologically, intellectually, physically, and socially during the first days after they enter the world. Each organ system transitions from the in utero symbiosis of the maternal–fetal interface to a state of functional independence. Thus, skin of the neonate undergoes substantial developmental changes as the infant enters the dry postnatal world full of environmental challenges. An understanding of basic skin anatomy and physiology is imperative to identify risks for neonates and devise strategies for appropriate skin care. Frequently, skin care practices for infants are based on tradition, experience, and cultural factors. Current research has shown that variations in skin care practices can substantially affect neonatal health. This article reviews current evidence regarding aspects of neonatal skin care.

Methods

We searched the MEDLINE electronic database for English language articles reported between January 2006 and July 2010. The search terms used were neonate, infant, newborn, skin, skin care, dermatology, vernix, cleansing, soap, bathing, umbilical cord, emollient, oil, diaper, diaper rash, diaper dermatitis, wound, extravasation, skin injury, and pressure ulcer. In addition, several recently published textbooks on pediatric dermatology and neonatology were searched for relevant information.

Skin structure

Mature skin creates a barrier to minimize fluid and electrolyte losses, protect against infection, prevent absorption of toxic substances, and support thermoregulation. The skin barrier begins to function in utero. At 24 weeks’ gestation, the skin appears red, wrinkled, shiny, and transparent (Fig. 1). The stratum corneum is only one or two cell layers thick, and dermal elastic fibers are sparse. In addition, the connection at the dermal–epidermal junction is weak, with few hemidesmosomes and anchoring fibrils. These factors each contribute to abnormal dermal physiology in the neonate born prematurely, including increased transepidermal water loss (TEWL), invasion of microorganisms, and absorption of potential toxins from topically applied products. Thermoregulation also is difficult because of scant subcutaneous tissue and nonfunctional eccrine glands (in addition to the high body surface area-to-volume ratio in the neonate).¹ Functional integumentary maturity usually occurs by 34 weeks’ gestation, with the epidermis being fully keratinized and the dermal–epidermal junction strengthened. Skin maturation accelerates after birth, and even the earliest preterm infants have a functionally mature stratum corneum by the age of 2–8 weeks.² Nevertheless, the skin remains fragile and easily damaged (Table 1).³

Figure 1.  Premature skin in a 27-week gestational age neonate

Table 1. Structural and functional differences of adult, term, and preterm infant skin

Skin characteristic	Adult	Term	Preterm	Importance
Adapted from Cohen.^3 Used with permission.
Epidermal thickness	50 μm	50 μm	27.4 μm	Permeability to topical agents ↑Transepidermal water loss
Cell attachments	Normal	Normal	Fewer	↑Tendency to blister
Dermis	Normal	↓Collagen and elastic fibers	↓↓Collagen and elastic fibers	↓Elasticity ↑Blistering
Melanosomes	Normal	Fewer	One-third erm infant	↑Photosensitivity
Eccrine glands	Normal	↓Activity for 7–10 d ↓Neurologic control  for 2–3 years	Total anhidrosis	↓Response to thermal stress
Sebaceous glands	Normal	Normal	Normal	Possible barrier properties, lubricant, antibacterial
Hair	Normal	↓Terminal hair	Persistent lanugo	Helps to assess gestational age

Inadequate skin barrier function is associated with increased neonatal morbidity and mortality. Because of their immature skin structure and high body surface area-to-volume ratio, premature infants are susceptible to high TEWL. Elevated TEWL can lead to dehydration, electrolyte imbalances, and hypothermia. Preterm neonates experience up to 10 times higher TEWL than term infants. In addition, phototherapy increases TEWL as much as 20%.⁴ Skin polyurethane coverings as well as humidified incubator units have been used to help minimize TEWL in premature neonates.⁵

Poor skin barrier function may allow for percutaneous invasion by pathogens, resulting in neonatal infections.^6,7 At birth, skin pH is near neutral and becomes physiologically acidic (pH 5.4–5.9) over the first few days of life.⁸ For premature infants, it takes several weeks to develop this acidic skin surface pH, or “acid mantle.” The acid mantle is important for normal skin antimicrobial lipid and peptide processing and colonization of usual skin flora.¹ Soap, detergents, and even pure water temporarily raise skin pH in infants.⁸

An immature skin barrier also allows for variable percutaneous absorption. There have been numerous reports¹ of percutaneous poisoning from agents applied to the skin of infants. Both active ingredients and inactive components (e.g. emulsifier, fragrance, preservative) of a topical product can potentially cause toxicity. Common substances are listed in Table 2; these should be used with caution in neonates.¹ In preterm neonates, even commonly used povidone-iodine and alcohol-based solutions can be hazardous, causing caustic skin changes and systemic toxicity via percutaneous absorption.⁹

Table 2. Reported toxicities secondary to percutaneous absorption in pediatric patients

Compound	Toxicity
Data from Eichenfield et al.^1
Alcohols	Cutaneous hemorrhagic necrosis, elevated blood alcohol levels
Aniline	Methemoglobinemia, death
Adhesive remover solvents	Epidermal injury, hemorrhage, and necrosis
Benzocaine	Methemoglobinemia
Boric acid	Vomiting, diarrhea, erythroderma, seizures, death
Calcipotriol	Hypercalcemia, hypercalcemic crisis
Chlorhexidine	Systemic absorption but no toxic effects
Corticosteroids	Skin atrophy, striae, adrenal suppression
Diphenhydramine	Central anticholinergic syndrome
Lidocaine	Petechiae, seizures
Lindane	Neurotoxicity
Mercuric chloride	Acrodynia, hypotonia
Methylene blue	Methemoglobinemia
N,N-dimethyl-m-toluamide (DEET)	Neurotoxicity
Neomycin	Neural deafness
Phenolic compounds	Neurotoxicity, tachycardia, metabolic acidosis, methemoglobinemia, death
Phenylephrine	Vasoconstriction, periorbital pallor
Povidone-iodine	Hypothyroidism
Prilocaine	Methemoglobinemia
Salicylic acid	Metabolic acidosis, salicylism
Silver sulfadiazine	Kernicterus, agranulocytosis, argyria
Tacrolimus	Elevated blood levels
Triple dye (brilliant green, gentian violet, proflavine hemisulfate)	Ulceration of mucous membranes, skin necrosis, vomiting, diarrhea
Urea	Uremia

Vernix caseosa

Vernix caseosa is a creamy white surface biofilm that covers the skin of the fetus. It is composed of water, sebaceous secretions, detached fetal corneocytes, and lipids.¹⁰ Vernix caseosa is the natural skin covering of the fetus during the last trimester of pregnancy, but it is almost nonexistent in preterm infants.¹ Many believe that vernix provides a “waterproofing” layer in utero, to facilitate the formation and maturation of the skin.¹¹ During delivery, vernix caseosa acts as a lubricant, and it is usually wiped away during the initial stimulation and drying of the neonate. However, recent studies suggest that vernix caseosa has important hydration, thermoregulation, bacterial protection, and wound healing effects and should not be removed until the neonate is bathed.^12,13

Skin cleansing

For neonates, bathing can lead to hypothermia, respiratory distress, unstable vital signs, increased oxygen consumption, and behavioral disruption. For these reasons, the first bath should be delayed until the neonate’s temperature and cardiorespiratory status have remained stable for 2–4 hours and not before 6 hours of life.^5,13 Immersion bathing is preferred, when feasible, as neonates have demonstrated less heat loss and fluctuation in vital signs with this method.¹⁴ Immersion bathing involves placing the infant’s entire body, excluding head and neck, into a tub of water. The ideal water temperature is 38–40 °C, and bath time should be limited to 5–10 minutes every other day.⁵ Tap water is considered safe in most countries, but sterile water should be used if skin breakdown is present. Some cultures prefer to delay bathing until the umbilical cord has fallen off, but there is no definitive evidence showing this practice prevents umbilical cord infection or alters healing time.^14,15

The safest cleansing products for term neonates are mild, neutral pH cleansers without added dyes or fragrances. Classic soaps have a high pH (about 10) and can have a sustained negative pH impact on the skin.¹⁶ Mild liquid cleansers and synthetic detergent bars are formulated to a more neutral pH and are less irritating than soaps derived from lye.¹ Antimicrobial soap is not recommended for use in neonates because of its harshness and potentially untoward effect on skin colonization.⁵ Cleansing products should be used sparingly, on soiled areas only, and rinsed off completely. Infants <32 weeks’ gestation should be bathed only with warm water during the first week of life. Rubbing skin with a cloth is discouraged, as this action may cause epidermal injury.⁵ The infant’s scalp and hair should be cared for similarly, with the same gentle liquid cleansers. Addition of various oils to the bath water is not recommended because of the potential for skin irritation. Cocamidopropyl betaine and MIPA-laureth sulfate, both commonly used in infant shampoos and cleansers, are well-recognized allergens to avoid.^1,17

Umbilical cord care

Soon after delivery, the newborn’s skin and umbilical stump are colonized primarily by typically nonpathogenic bacteria, such as coagulase-negative staphylococci and diphtheroid bacilli. The presence of pathogenic bacteria (e.g. streptococci and coliform bacteria) on the skin may cause an umbilical stump infection.¹⁸ Umbilical cord care practices vary widely around the world and may include nonintervention (keeping the cord clean and dry) or the application of an antimicrobial agent. Commonly used antiseptics include isopropyl alcohol, silver sulfadiazine, povidone-iodine, chlorhexidine, hexachlorophene, triple dye (brilliant green, gentian violet, and proflavine hemisulfate), and bacitracin.^1,18,19 Adverse effects have been reported for many of these agents (Table 2). No single method of umbilical cord care has been shown to limit colonization and disease.¹⁹

In 2004, the World Health Organization published umbilical cord care guidelines.¹⁸ The guidelines emphasized the importance of clean cord care at birth and in the postnatal period. This includes proper hand hygiene, cutting the cord with a sterile instrument, and washing the cord stump as necessary with clean water and soap. The World Health Organization guidelines reported insufficient evidence to recommend the widespread use of topical antimicrobials on the cord stump. However, in areas at high risk for neonatal tetanus or where unclean substances are customarily applied to the cord stump, antimicrobial application is likely beneficial. In developed countries, there is no advantage of topical antiseptics or antibacterials over simply keeping the cord stump clean.

Skin antisepsis

For newborns, percutaneous invasion by pathogens may play an important role in infection and mortality risk.²⁰ Most neonatal infections occur in the first 2 weeks of life, when the epidermal barrier is immature and functionally compromised.⁷ Recent evidence suggests that full-body skin cleansing with chlorhexidine may reduce neonatal infection and mortality in developing countries.²¹ A trial in rural Nepal showed that a single chlorhexidine cleansing of the skin shortly after delivery reduced mortality by 28% among low-birth-weight infants.²² Chlorhexidine has a broad spectrum of activity, including both Gram-positive and Gram-negative organisms, yeasts, and some viruses.²¹ It binds strongly to the skin, which may help to reduce its absorption and increase local efficacy.

Chlorhexidine is also commonly used for procedural antisepsis, including central venous catheter insertion, catheter site maintenance, umbilical line insertion, and peripheral venous line insertion. According to the California Perinatal Quality Care Collaboration (CPQCC), “there are no data that show an antiseptic agent to be superior to chlorhexidine gluconate for skin antisepsis.”²³ However, because safety and efficacy data are lacking for the neonatal population, chlorhexidine is not approved by the US Food and Drug Administration for use in infants <2 months old.²⁴ Products containing both chlorhexidine and isopropyl alcohol appear to cause more skin irritation and systemic absorption.¹ Extensive chemical burns have been reported with 0.5% chlorhexidine in 70% alcohol, and great care must be taken to avoid ocular and inner ear exposure or pooling of the cleanser on the skin of the infant.^24,25 Systemic absorption of chlorhexidine has been documented but has not been shown to be associated with toxicity. Nevertheless, the CPQCC recommends neonatal skin antisepsis with a 2% chlorhexidine-based preparation before catheter insertion and during dressing changes.²³

Povidone-iodine is another common topical antiseptic used to cleanse the skin before procedures. A study comparing topical 0.5% chlorhexidine–70% isopropyl alcohol with 10% povidone-iodine found a similar reduction in bacterial counts on the skin of preterm infants with the two products.²⁶ However, iodine has caused many adverse reactions in neonates, such as local skin necrosis and hypothyroidism.¹ Povidone-iodine is another agent for neonatal skin antisepsis deemed acceptable for use by the CPQCC.²³

Alcohol is a commonly used antiseptic, but generous application followed by occlusion can lead to considerable percutaneous absorption. Alcohol can also enhance the absorption of other concomitantly applied products.¹ Alcohol is more drying to the skin and less efficacious than chlorhexidine and povidone-iodine.⁵

Diaper dermatitis

Diaper rash and irritant diaper dermatitis are nonspecific medical terms used to describe a spectrum of symptoms in the diaper area caused by inflammatory skin reactions.¹⁶ Diaper dermatitis is one of the most common dermatologic conditions encountered in infants, with an overall prevalence between 4 and 15% in the first month of life. The etiologic factors for diaper rash include skin wetness, biochemical irritants, and an increased skin pH due to exposure to feces and urine.¹ When urine encounters feces, the ureases in fecal microbes create ammonia. The resultant increase in pH can reactivate fecal proteases and lipases and subsequently degrade the proteins and lipids of the stratum corneum. This leads to skin breakdown and impaired barrier function.¹⁶ In addition, alteration of the skin’s acidic pH allows the growth of microorganisms, including Candida albicans, Staphylococcus aureus, and streptococci.¹ The first signs of diaper dermatitis include uncomfortable erythema and mild scaling. If left untreated, diaper dermatitis can progress to painful ulcerated lesions.⁵

Recently, major improvements in diaper technology have led to increased skin surface dryness. In the mid-1980s, a superabsorbent core material was developed for use in disposable diapers. Superabsorbent diapers were shown to be superior to cloth diapers in preventing diaper dermatitis.²⁷ Some diapers have lubricated inner top sheets to ensure the ongoing application of a small amount of petrolatum-based ointment.^1,16

Cleansing products facilitate removal of skin contaminants, restore physiologic skin pH, and apply skin care agents. Although water and a washcloth are the gold standard, disposable infant wipes have become a popular alternative. Evidence-based practice guidelines recommend a soft cloth or wipes free of alcohol and detergents.²⁸ Few reports have been published evaluating infant tolerance of commercial wipes, but the few studies available suggest no skin injury or irritation with the use of these products. Infant wipes may also provide pH buffering. Modern infant wipes usually consist of an emulsion-type watery or oily lotion, which serves as an emollient.¹⁶ They do contain preservatives and fragrance that may lead to contact sensitization.¹

To prevent and manage diaper dermatitis, diaper changes should occur every 3–4 hours or as soon as soiling occurs. Disposable wipes may be used for routine cleansing, but injured skin should be cleansed with lukewarm water and a soft cloth and subsequently patted dry. Experts discourage the use of a hairdryer, as thermal burns may occur. A barrier paste is recommended for prophylaxis and treatment of irritant diaper dermatitis. Preservative-free 20% zinc oxide ointment and petrolatum-based ointments are safe and inexpensive options.¹ Diaper dermatitis complicated by C. albicans typically manifests as a bright red eruption with satellite lesions and usually involves skin creases (Fig. 2). A low concentration of an antifungal in a zinc–petrolatum base is usually well tolerated and effective for treating diaper dermatitis complicated by C. albicans.⁵ Both powders and antibiotic ointments may cause irritant contact dermatitis and are generally unnecessary. Often, diaper dermatitis is associated with diarrhea, and treating the underlying cause of the stool abnormality is important.

Figure 2.  Candidal diaper dermatitis

Emollients

The use of topically applied emollients to prevent the entry of infectious organisms has been an area of particular interest, especially in developing countries where antibiotics are limited. A 2009 Cochrane Review identified four randomized controlled trials that assessed nosocomial sepsis rates in preterm infants after prophylactic application of topical ointment. A significantly increased risk (relative risk, 31%) of coagulase-negative staphylococcal infection was observed.² While infants receiving topical ointment application had improved skin condition and reduced TEWL, the authors state that these benefits did not outweigh the infection risks associated with prophylactic ointment use in premature infants.

Although emollients have not demonstrated the ability to prevent infections in neonates, their usefulness remains noteworthy. Topical ointment therapy protects the stratum corneum and potentially enhances skin barrier maturation and repair. Topical ointments with a physiologic balance of lipids (3:1:1:1 molar ratio of cholesterol, ceramide, palmitate, and linoleate) may support active lipid metabolism in the epidermis, allowing utilization of lipids derived from the emollients as fatty acid building blocks to form a healthy, functional epidermal barrier.^2,29 White petrolatum is a safe, inexpensive, and highly effective emollient. Other popular emollients have proven to reduce skin desquamation; however, they frequently contain lanolin alcohol, a wood alcohol that may cause contact sensitivity.³⁰

Massage using various oils is commonly practiced in cultures around the world. Sunflower oil has been shown to accelerate skin barrier recovery, possibly because of its high linoleic acid concentration.²⁹ Mustard oil, an emollient used in many developing countries, has been shown to slow skin barrier recovery and increase TEWL.²⁹ Other studies have questioned the utility of olive oil as an emollient for infants. A study in 2008 compared a panthenol water-in-oil emollient cream and olive oil cream (70% lanolin, 30% olive oil) as topical emollients for premature neonates (25–36 weeks’ gestation).³¹ Olive oil cream was more effective than emollient cream and both creams were more effective than routine skin care without emollients in preventing dermatitis. There was no difference in infection rates between the three groups.

Adhesive injury

In premature infants, the removal of tape and adhesive dressings can lead to major skin injuries. Neonates <27 weeks’ gestation are particularly at risk, given their weak dermal–epidermal junction, attenuated rete ridges, and minimal subcutaneous fat deposition. For these infants, the dermis lies directly over the muscle, and stripping of tape and adhesive dressings often results in full-thickness tissue destruction.⁹ A study of 30 neonates between 26 and 40 weeks’ gestation showed disrupted skin barrier function, with increased TEWL, after a single application and removal of two commonly used adhesives – plastic tape and pectin barrier.³² Epidermal stripping produces discomfort and an entry point for infectious organisms.⁹ Frequent removal and reapplication of adhesives in the same area also may result in hypopigmentation, which is particularly noticeable in infants with darker pigmentation.³⁰

Adhesives should be used sparingly to secure monitoring devices in newborns.⁵ Preventive measures for epidermal stripping include the use of an alcohol-free liquid skin barrier or hydrocolloid dressing, placed on the skin under adhesive dressings on neonates. Additional strategies include delayed removal of newly applied adhesives for a minimum of 24 hours and securing equipment with soft gauze wraps or foam strips. Nonadhesive-based products (e.g. hydrogel electrodes) are excellent alternatives but may not secure equipment as reliably. Adhesive removers and bonding agents should not be used in neonates because these products can increase the risk of epidermal stripping and may result in toxic percutaneous absorption.^9,30 Warm water-soaked cotton balls generally suffice for adhesive removal. Mineral oil, petrolatum, and emollients may be effective agents to facilitate adhesive removal, but reapplication of adhesive to the same area should be limited.³⁰ In addition, the horizontal stretch method employs slow, gentle peeling of the adhesive using parallel force and helps to limit trauma during adhesive removal.⁹ Of note, edematous skin is particularly vulnerable to damage and must be handled with care. Premature infants are at risk for anetoderma, or atrophic patches of skin with dermal thinning, related to placement of monitoring devices and adhesives.⁵

Extravasation injury

Fluid extravasation is the most common complication of peripheral intravenous therapy.³³ Extravasation injuries develop when intravenous fluid inadvertently leaks from a vein or cannula into the surrounding soft tissue via catheter dislodgment or erosion through the vessel.^9,34 These injuries can lead to considerable morbidity, including scarring, skin necrosis, infection, and contracture.¹ Extravasation injuries most frequently occur in neonates <26 weeks’ gestation because of their fragile, small-caliber peripheral veins and need for prolonged intravenous therapy.^33,34 Common sites for extravasation include the dorsum of the hand, antecubital fossa, and ankle. Signs of infiltration include swelling, leakage or discomfort at the site, erythema, and coolness of the skin. In severe cases, blanching of the overlying skin and blistering may occur. Skin sloughing or deeper tissue necrosis may become apparent later. If extravasation is identified, the infusion must be stopped immediately and the affected area elevated. Any locally constrictive materials should be removed.^1,34

To prevent extravasation injury, intravenous lines should be secured with sterile transparent dressings to allow for effective site inspection at least hourly.⁹ Tape should be placed loosely over bony prominences to prevent obstruction of venous return. When possible, placement of intravenous tubes in areas difficult to immobilize, such as flexural areas, should be avoided. Venous tolerance to an infusion is largely affected by osmolality of the infusate, and caution must be exercised with hypertonic solutions. Vasopressors and acidic solutions create ischemic necrosis when extravasated, and infusion of these solutions should be monitored closely.³⁴ Similarly, calcium is an extravasate notorious for causing severe skin injury in neonates. Calcium-induced necrosis may be prevented by withholding calcium from maintenance intravenous fluids and provision of intermittent calcium infusion as needed, as intermittent dosing would require a check of the catheter’s integrity.

Treatment of extravasation injuries varies depending on the degree of tissue damage. If an extravasation injury causes a diminished pulse or severe blanching of the skin, a multiple puncture technique may be used to provide an outlet for fluid drainage and to prevent necrosis. While maintaining a sterile environment, multiple skin perforations are made with a small stylet to the affected area, and the fluid is gently expressed. Saline-soaked gauze is then applied to the area to facilitate drainage.^1,34 Alternatively, in some cases of severe extravasation, liposuction or saline flush-out techniques are performed. With the liposuction technique, a cannula is inserted into the area of extravasation, and both infiltrated fluid and subcutaneous fat are removed.¹ The saline flush-out method employs hyaluronidase, an enzyme that reduces inflammation and increases the distribution and absorption of extravasated fluid.³⁵ Hyaluronidase is injected in small amounts around the perimeter of extravasation and may be used safely for most neonates.³⁴

For certain types of extravasation injuries, specific antidotes may be used. For instance, subcutaneous phentolamine is used to treat extravasation of α-adrenergic medications that cause tissue damage via vasoconstriction. Topical nitroglycerin has been used with success in neonates to enhance absorption of extravasated fluid through vasodilation.^34,35

Thermal injuries

Thermal burns can occur with the use of transcutaneous carbon dioxide monitoring, heating lamps and pads, phototherapy devices, radiant warmers, and, uncommonly, transilluminator devices.^1,9 Perman and Kauls³⁶ reported an outbreak of purpuric papules and vesicles in four neonates within a 72 hours period. This was subsequently linked to a faulty transilluminator device. Reducing temperature and limiting application time prevents neonatal burns from heat sources.⁹ Phototherapy lights should be positioned at the proper distance from the infant and monitored to prevent burns. The use of emollients does not increase the risk of burns during phototherapy.¹

Ultraviolet injuries

Owing to limited melanin production, infants and children are more susceptible to ultraviolet-induced skin damage. Given the increased incidence of melanoma in recent years, experts have begun to question the effect of blue-light phototherapy on neonatal skin.³⁷ We are aware of five studies that have evaluated the risk of developing benign or malignant melanocytic lesions after neonatal blue-light phototherapy, with conflicting results. Three studies showed an increased number of common or atypical nevi in children who were exposed to neonatal phototherapy, while two studies reported no difference in the number of nevi among children exposed to neonatal phototherapy and controls.³⁸

Environmental ultraviolet exposure is also a concern for neonates. For infants <6 months old, the safety of sunscreens has not been established. There is concern regarding the neonatal metabolism of p-aminobenzoic acid, a folic acid analog. In infants, the safest way to protect from ultraviolet exposure is sun avoidance, followed by the use of appropriate clothing and zinc oxide-containing sunscreens to areas not covered by clothing.¹

Pressure ulcers

Premature neonates exhibit limited spontaneous movement, have epidermal immaturity, and often receive inadequate nutrition – all of which are risk factors for pressure ulcers.³⁹ Pressure ulcer prevalence rates as high as 23% in neonatal intensive care units have been reported.⁴⁰ Pressure ulcers are believed to be formed when arterioles and capillaries collapse under external pressure.³⁹ Pressure injuries in neonates are most common on the occiput and ears and are especially prevalent in infants receiving high-frequency oscillator ventilation or extracorporeal membrane oxygenation.¹ Hypotension and postoperative immobility are also important risk factors.⁵

More than 50% of pressure ulcers in neonates are related to equipment and devices. Therefore, neonates require careful examination of high-risk areas (e.g. around blood pressure cuffs, pulse oximetry devices, endotracheal tubes, oral and nasogastric tubes, tracheostomy plates, and arm boards). Frequent inspection of the nares and nasal septum is crucial for patients receiving nasal prong or mask continuous positive airway pressure.³⁹ Transparent dressings may be placed over bony prominences, such as knees and elbows, to prevent friction injuries. Agitated infants, such as those with neonatal abstinence syndrome, are at higher risk of friction injuries. Very low-birth-weight infants are at risk for skin breakdown secondary to urine-induced injury in the groin and thigh area. This can be prevented by applying petrolatum in that area.⁵

For pressure ulcer prevention in infants, the Association of Women’s Health, Obstetric and Neonatal Nurses recommends the use of water, air, or gel mattresses and sheepskins designed for infants.⁵ Protective padding should be placed under devices to avoid friction. In addition, repositioning neonates every two hours is optimal for pressure ulcer prevention. Following the development of a pressure ulcer, the wound should be cleansed and necrotic tissue debrided. Care must be taken to optimize nutrition and prevent infection.⁴⁰ Pressure ulcers should be documented in accordance with National Pressure Ulcer Advisory Panel definitions.⁴¹

Wounds

Wounds in children and neonates exhibit faster rates of closure because of their greater number of fibroblasts and rapid production of collagen, elastin, and granulation tissue.⁹ However, this rapid wound healing is often compromised by malnutrition, vasopressors, edema, infection, and physiologic instability. Neonates are at high risk for bacterial proliferation within wounds, given their minimal exposure to antigens and immature immune system.

When colonization is suspected, the wound should be cultured. Antibiotic ointments (mupirocin, polymyxin B, or bacitracin zinc–polymyxin B sulfate) may be applied sparingly every 8–12 hours; however, the preparation combining bacitracin zinc, neomycin sulfate, and polymyxin B sulfate is not recommended because of its potential for ototoxicity and future sensitization. Antiseptics, including hydrogen peroxide and iodine, have been shown to delay wound healing and should be avoided.^1,9 Similarly, silver sulfadiazine is not recommended because of concern for transdermal absorption and subsequent systemic toxicity.⁴² Surgical consultation for debridement of necrotic skin is sometimes necessary.

For wound irrigation in neonates, experts recommend using normal saline at body temperature diluted 1:1 with sterile water. The cause of the skin breakdown often determines the optimal treatment strategy.⁵ Ideally, a dressing should protect the wound, facilitate atraumatic application and removal, and remain adherent in a humidified environment. Commonly used products for neonatal wound care include transparent polyurethane films, foam dressings, soft silicone dressings, liquid barrier films, hydrogels, and hydrocolloid dressings.¹

Conclusions

The unique physiology of neonates requires careful attention to skin care practices. Because of their immature skin and other factors, neonates have increased TEWL and thermal instability. Recommendations for neonatal skin cleansing and emollient use are constantly evolving. Immersion bathing is preferred to avoid excessive heat loss, and there is no definitive evidence to suggest delayed umbilical cord healing with this practice. Mild cleansing products are generally the safest for neonates, and antimicrobial soap should be avoided. Emollients have not been shown to prevent infections in neonates but may enhance skin barrier maturation and repair. Topical products must be used with caution because of the high risk for percutaneous absorption. Neonates should undergo frequent assessments for extravasation, pressure ulcers, and other types of injuries. Further investigation into various neonatal skin care practices is necessary to improve the overall health of infants.

Questions (see answers on page 22)

1. At 24 weeks’ gestation, what is true of skin structure?

A. Fully developed epidermis

B. Weak dermal–epidermal junction

C. Abundant dermal elastic fibers

D. None of the above

2. What is a consequence of inadequate skin barrier function?

A. High transepidermal water loss

B. Invasion of pathogens

C. Variable percutaneous absorption

D. All of the above

3. What is true of the recommended bathing strategy for term neonates?

A. Use soap with a high pH

B. Cleanse the skin with a cloth

C. Add oil to bathwater for skin lubrication

D. Use cleansing products sparingly

4. In 2004, World Health Organization guidelines reported insufficient evidence to recommend the widespread use of topical antimicrobials on the infant cord stump.

A. True

B. False

5. What is the recommended treatment for irritant diaper dermatitis?

A. Antibiotic ointment

B. Nystatin cream

C. Zinc oxide ointment

D. Medicated powder

6. A 2009 Cochrane Review showed that topically applied emollients reduced the risk of nosocomial infections in neonates.

A. True

B. False

7. What strategy (or strategies) may be used to prevent adhesive injuries in neonates?

A. Use an alcohol-free liquid skin barrier under adhesive dressings

B. Delay removal of adhesives for 72 hours after they are placed

C. Use an adhesive remover solution

D. Avoid the horizontal stretch method for removal

8. Which treatment method (or methods) is used for extravasation injuries?

A. Multiple puncture technique

B. Liposuction

C. Hyaluronidase injection

D. All of the above

9. What causes more than 50% of pressure ulcers in neonates?

A. Lying immobile

B. Equipment

C. Method of holding by caregiver

D. None of the above

10. Which topical treatment is recommended for neonatal wound care?

A. Mupirocin ointment

B. Hydrogen peroxide

C. Iodine

D. Bacitracin zinc–neomycin sulfate–polymyxin B combination ointment

Answer to Questions on page 20–21

1. B 2. D 3. D 4. A 5. C 6. B 7. A 8. D 9. B 10. A