Skin care in the neonatal patient is often challenging. Skin is a protective covering to the body and provides an infection and temperature barrier. However, our tiniest infants do not have sufficient skin maturation to accomplish either of these. Both protecting the existing skin and helping it to mature in order to provide these functions is challenging when providing the intensive care that they also need.
I was fortunate to have been a part of the team that laid the foundation for the first AWHONN and NANN skin care guidelines. There were 51 sites that were a part of this project. Our responsibility was to obtain information about current practices, perform skin assessments periodically and implement some or all of the recommended evidence-based practices that had been compiled by the research team. That happened back in the late 1990’s with the resulting guidelines being published in 1999. An update of these guidelines has recently been published and is available at https://www.awhonn.org/store/ViewProduct.aspx?id=5151414.1
This experience sparked a great interest in skin care for me in these very vulnerable infants. This project and some clinical challenges that were literally staring me in the face! How do you stabilize the multitude of “life-sustaining” equipment needed without compromising skin integrity in an infant less than 28 weeks? Add to that the high levels of humidity that we knew were important in order to maintain fluid and electrolyte balances and enhance skin maturation. Maintaining skin integrity can be challenging even in sick term infants. In spite of our best efforts, sometimes infants have skin injury. Hopefully, it is minimal and heals quickly but in spite of minimal damage, it may result in pain, an infection and/or loss of fluid (increased transepidermal water loss) and temperature. So, even minimal damage can have significant consequences, particularly for the most vulnerable infants.
In an article regarding iatrogenic risks of the NICU, Kugelman et al found an incidence of iatrogenic harm or near misses at the rate of 57% for infants 24-27 wks gestation compared to 3% at term.2 This study did not specifically detail the incidence of skin injury and there was no category for this in their observations. Sardesai, Kornacka, Walas, & Ramanathan discuss skin injury specifically in their article.3 The overall incidence is really not known but I don’t think I have seen a single 24-27 week infant who has not had some skin injury, and often more than one! These infants often have multiple invasive procedures, very immature skin and simple procedures can result in some skin damage. Types of skin damage reviewed by Sardesai, Kornacka, Walas & Ramanathan included burn injury including thermal and chemical burns, skin injury from adhesives, intravenous extravasation, nasal injury (pressure) as well as a few others.3
For now, I’ll just focus on chemical burn injury. Several case studies have presented patients who have had chemical burns from various types of skin cleansing agents. Our efforts at decreasing the risk of infection through decontamination of the skin has, all too often resulted in injury. We have long been aware of the risk of skin integrity disruption when using povidone-iodine for skin cleansing. While it is one of the most effective skin cleansers, its drying effect on the skin can lead to compromised skin integrity as well as other systemic problems from absorption. Alcohol, the oldest agent used for skin cleansing has been shown, by itself, to cause injury to the fragile premature skin.4-6 Chlorhexidine gluconate has taken the place of povidone-iodine in many countries and in some U.S. NICUs for several years now. We have begun using CHG more in the U.S. due to reports of improved efficacy but most of the units using CHG use a product that is mixed in a base of 70% alcohol (ChloraprepÒ). There are reports of skin burns related to various CHG preparations.7. 8 By published and unpublished reports, most of these occurred in very low birth weight infants and in the abdominal area. Therefore, the usual practice is to use the CHG product with an alcohol base only in areas other than the abdomen and/or in older infants. More and more units in the U.S. are using the pure CHG product (ExidineÒ) in extremely low birth weight infants. The injury is most likely due to the alcohol content, not the CHG itself, although there is at least one published report of skin injury in a very premature infant with this product.9
What are the dangers of skin breakdown? First of all, skin breakdown is painful! Beyond that, the functions of the skin are thermoregulation and infection prevention. Just to highlight this relationship, the California Central Line Associated Blood Stream Infection (CLABSI) project which was a 7 year project, branched out in the last two years to address all blood stream infections (BSI). One area that was discovered as having a significant contribution to both CLABSI and non-CLABSI BSI was skin breakdown and loose/soiled central line dressings. This was found to contribute to about 15% of all CLABSI and/or BSI in our population. This highlights the need to pay attention to what might be even “minor” skin injury. Just overall good skin care is the starting point to prevent injury. A future blog will deal with management of skin injury and diaper rash.
While we may not often think of skin as an organ we need to “treat” like the immature lungs and gut of the newborn, it is an essential organ and severely under-developed in many of the infants we care for. The care we provide to these infants must consider the skin health as well as all other organs. The next blog will deal with adhesive use and skin protection.
1. Lund, C., Brandon, D, Holden, AC, Kuller, J., Hill, CM (2013). Neonatal Skin Care, 3rd ed. AWHONN.Available at: https://www.awhonn.org/store/ViewProduct.aspx?id=5151414
2. Kugelman A, Inbar-Sanado E, Shinwell ES, Makhoul IR, Leshem M, Zangen S, Wattenberg O, Kaplan T, Riskin A,Bader D. Iatrogenesis in Neonatal Intensive Care Units:Observational and Interventional, Prospective, Multicenter Study. Pediatrics 2008;122:550–555.
3. Sardesai SR, Kornacka MK, Walas W, Ramanathan R. Iatrogenic skin injury in the neonatal intensive care unit. The Journal of Maternal-Fetal and Neonatal Medicine. 2011; 24(2):197-203.
4. Watkins AM. Alcohol burns in the neonate. J Paediatr Child Health. 1992; 28:306-8.
5. Schick JB, Milstein JM. Burn hazard of isopropyl alcohol in the neonate. Pediatrics. 1981;68:587-588.
6. Reynolds PR, Banerjee S, Meek JH. Alcohol burns in extremely low birthweight infants: still occurring. Arch Dis Child Fetal Neonatal Ed. 2005;90(1):F10.
7. Mannan K, Chow P, Lissauer T, Godambe S. (2007). Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. Acta paediatrica. 2007;96:1536-1537.
8. Bringue Espuny X, Soria X, Sole E, Garcia J, Marco JJ, Ortega J, Ortiz M, Pueyo A. Chlorhexidine-methanol burns in two extreme preterm newborns. Pediatrics Dermatol. 2010;27(6):676-678.
9. Lashkari HP, Chow P, Godambe S. Aqueous 2% chlorhexidine-induced chemical burns in an extremely premature infant. Arch Dis Child Fetal Neonatal Ed. 2012;97(1):F64.
Looking for additional reading from Sandy Beauman’s professional perspective?
View her blog entry Infection Prevention Part I.