Neonatal Skin Care:The Scientific Basis for Practice

caro/yn Lund RN, MS, FUN, /aanne Ku&r, RN, MS,

Alfred Lane, MD, FAA8 Judy %%ght Loft, RNC, NNP, DSN,Deborah A. Rakes, X15&2, PhD

Publisher’s Note: Althou@ it is ummal for Neonatal Network@ to reprint anarticle, we believe the request by NANN and AWHONN to publish the followingarticle simultaneous& with its publication in the Journal of Obstetric, Gynecologic,and Neonatal Nursing (JOGNN) is wmtbwbile. It is ourgoal to improve the qualityof neonatal care. We believe simultaneous publication of this article furthers thisnoal._

Charles Rak, RN, Ptrbkber

ABsTRAcrObjective: To review the literature addressing the care of neo-natal skin.Data Sources: Computerized searches in MEDLINE andCINAHL, as well as references cited in articles reviewed. Keyconcepts in the searches included neonatal skin differences; neo-natal skin and care practices for skin integrity; neonatal skin andtoxicity; permeability; and contact irritant sensitization.Study Selection: Articles and comprehensive works relevant tokey concepts and published after 1963, with an emphasis onnew findings from 1993 to 1999. One hundred two citationswere idenri6ed as usell to this review.Data Extraction: Data were extracted and organized under thefollowing headings: anatomy and physiology of the skin; physio-logic and anatomic differences in neonatal skin; nutritional deli-ciencies; skin care practices; and care of skin breakdown.Data Synthesis: Newborns’ skin is at risk for disruption of nor-mal barrier f&&ion because of trauma. In light of available evi-

.- dence about differences in neonatal skin development, clinicalpractice guidelines are suggested for baths, lubrication, antimi-crobial skin-disinfection, and adhesive removal. In addition,basic care practices are suggested for maintaining skin integrity,reducing exposure to potentially toxic substances, and promot-ing skin health beyond the neonatal period. Preventive care rec-ommendations are made for reducing trauma, protecting theskin’s immature barrier function, and promoting skin integrity.Conclusions: This review generated evidence with which tocreate a new and comprehensive practice guideline for clinicians.Evaluation of the guideline is under way at 58 U.S. sites.

Accepted for publication February 1999.

THE SKIN IS A VITAL ORGAN WITH MANY ROLES ANDfunctions. These include thermoregulation; provision

of a barrier against toxins and infections; water and electrolyteexcretion; fat storage and insulation; and tactile sensation.Preserving skin integrity is an important aspect of nursingcare across the life span for all patients, but is of particular sig-nificance in newborns, who are adapting from the uterineaquatic environment to the aerobic environment.

During care practices such as bathing, lubrication, antimi-crobial skin disinfection, and adhesive removal, the skin ofnewborns is at risk for disruption of normal barrier hmionand trauma. Although this is particularly true of full-term andpremature newborns in the neonatal intensive-care unit(NICU), even well newborns can experience skin disruptionand its consequences. For many years, nurses relied primarilyon trial and error, traditions, or myths to guide skin care prac-tices. However, heightened interest and concern about neo-natal skin, stimulated in part by the increased survival ofsmaller and less mature newborns, has resulted in researchthat can guide care.

After a discussion of basic anatomy and physiology, thisarticle reviews the following: (a) current research about skindevelopment and the characteristics of neonatal skin; and (b)basic care practices and their effect on skin integrity, potentialfor toxicity from permeability, and implications for healthy

The AWHONN/NANN Neonatal Skin Care Project is funded by an cduca-tionai grant from Johnson & Johnson Consumer Products Company, Inc., adivision ofJohnson & Johnson Consumer Companies, Inc.

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FIGURE 1 n Skin layers.

Epidermis

Dermis

.subcutaneouFatty Tissue

Sweat gland

From: Principles of lnfunt Skin Care: A Current Guide for the Healthcare Professional, p. 9.Copyright 1994 by the Johnson & Johnson Consumer Products Company Inc.Reprinted with permission.

skin beyond the neonatal period. Preventive care recommendations arepresented for reducing trauma, protecting immature barrier function, andpromoting skin integrity. These recommendations have been integratedinto a comprehensive neonatal skin care guideline and are being imple-mented and evaluated in a research-based-practice project cosponsored b!the Association of Women’s Health, Obstetric and Neonatal Nurses(AWHONN) and the National Association of Neonatal Nurses (NANN).

ANATOMY AND PHYSIOLOGY OF THE SKINThe layers of the skin include the epidermis, dermis, and subcutaneous

layer (see Figure 1). The epidermis functions as a barrier, preventing pene-tration and absorption of potential toxins and microorganisms and retain-ing water, heat, and other substances. Keratinocytes are the major cells ofthe epidermis. The basal cell layer, located near the junction of the epider-mis and dermis, is the source for renewal of the epidermis. The basal celllayer is constantly dividing and growing new keratinocytes. Basal cells alsoare present within hair follicles and sweat glands. The new keratinocytesmature and form the stratum corneum, or outer barrier of the epidermis.

The stratum corneum is the outermost layer of cells forming the epider-mal barrier, only 0.05-0.1-mm thick. It is constructed like the bricks andmortar of a wall; individual keratinocytes are the bricks and lipid betweenthe cells is the mortar. Injury to the epidermis is followed by growth andmaturation of additional keratinocytes from the basal layer, hair follicles,and sweat glands. The basal layer of the epidermis is attached to the nextlayer, the dermis, by fibrils constructed of protein.

The dermis is composed predominantly of collagen and elastin fibersenclosed in a gel continuum of mucopolysaccharides. This fibrous com-plex gives the dermis great mechanical strength and elasticity to withstandsevere frictional stress yet to extend easily over joints. Elastin, collagen, andmucopolysaccharide gel are all produced and secreted by cells called fibro-blasts. Although the principal mass of the dermis is collagen and is acellu-

lar, other elements present include mast cells,inflammatory cells, blood and lymph vessels, andcutaneous nerves. The subcutaneous layer ismade up of fatty connective tissue; fat depositionprimarily occurs in the fetus in the last trimesterbefore birth. Functions of the subcutaneouslayer include heat insulation and serving as acaloric reservoir (Weston, Lane, Sr Morelli,1996).

The skin of full-term newborns is coveredwith vernix caseosa, a cheesy substance com-posed of sebum from sebaceous glands, bro--ken-off lanugo, and desqtiamated cells fromthe amnion. Vernix starts to form between17-20 weeks, becomes a thick coveringbetween 36-38 weeks, and by 40 weeks isfound primarily in creases. It protects againstmaceration from amniotic fluid and prevents

FIGURE 2 n Photomicrograph of stratum corneum inan adult, in a fullterm newborn, and in apremature infant of 28 weeks gestationalaqe. .

From: “A Histological Comparison of Infant and AdultSkin,” by K. A. Holbrock, 1982. In Neonatal Skin:Structure and function, H. I. Maibach and E. K. Boisits(editors) (p.9). Reprinted courtesy of Marcel Dekker, Inc.

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chafing caused by crowding in utero (Moore & Persaud,1998). After the delivery, vernix is either worn off orremoved from the newborn, and desquamation appears aspeeling of the skin surface during the first days of life. Theti&term newborn’s skin is well-developed, opaque with fewveins visible, has limited pigmentation and wrinkles aroundjoints, and is without edema.

Premature infant skin is thinner than that of fullterm new-borns and looks transparent or even gelatinous in extremelyimmature in&ants. Typically, the ruddy appearance is due tofewer layers of stratum corneum; thus, skin color is a poortool for assessing oxygenation of very immature infants.Fewer wrinkles appear on skin surfaces, and the skin is COV-ered by lanugo on the upper back, arms, and forehead tovarying degrees, depending on maturity. Premature infantsare ofcen edematous because of excess cutaneous water andsodium (Solomon & Esterly, 1973).

PHYSIOLOGIC AND ANATOMICDIFFERENCES IN NEONATAL SKIN

FIGURE 3 m Arrows indicate anchoring fibrils at dermo-epidermaliunction in full-term and oremature infants.

j PREMATURE ~.:~,;__ - __. -

Underdevelopment of the Stratum CorneumThere are lo-20 layers of stratum comeum in adults and

full-term infants, which provide control of evaporative heatloss and transepidermal water loss (TFWL). Premature infantshave fewer layers of stratum comeum; at less than 30 weeksgestational age they may have only 2-3 layers (see Figure 2),and extremely premature infants less than 24 weeks gestation-al age may have virtually no stratum corneum (Holbrook,1982; Nonato, 1998). Protective functions of the stratumcorneum, including protection against toxins and infectiousagents such as bacteria, fungi, and viruses, are deficient in pre-mature infants.

The barrier function of the stratum comeum matures at anaccelerated rate during the first l&l4 days of life for a pre-mature infant (Evans i% Rutter, 1986a; Harpin & Rutter,1983). Other studies report a slower process in prematureinfants who are less than 27 weeks gestational age. WhenTEWL was used to assess the barrier function of the stratumcorneum, premature infants less than 27 weeks gestationalage were found to have water losses nearly double adult lev-els, even at 28 days of life (Sedin, Hammarlund, Nilsson,Stromberg, & ijberg, 1985). Recently, research involvingdaily TEWL and impedance spectroscopy measurements ofthe thickness of the stratum comeum demonstrated that adultlevels of maturation were evident at 30-32 weeks postconcep-tional age regardless of the infant’s postnatal age (Kalia,Nonato, Lund, Sr Guy, 1998). Thus, the maturation processmay take as long as 8 weeks in an infant of 23 weeks gesta-tional age, or 3 weeks in an infant of 28 weeks gestationalage. Skin care practices that protect the developing stratumcomeum and protect against toxicity and infection may benecessary until maturation is complete.

From: “A Histological Comparison of Infant and Adult Skin,” by K. AHolbrock, 1982. In Neonatal Skin, Structure and function, H. 1. Maibach andE. K. B0isit.s (editors) (p. 12). Reprinted courtesy of Marcel Dekker, Inc.

Diminished Cohesion BetweenEpidermis and Dermis

Fibrils connect epidermis to dermis at the dermo-epider-mal junction of the skin. These are widely spaced and fewer innumber in premature infants (Holbrook, 1982) (see Figure3), but become stronger with advancing gestational and post-natal age. Because of this diminished cohesion, prematureinfants are at higher risk for injury from adhesive removal andfor potential blistering from friction or thermal injury. Certainadhesives may have a stronger bond to the epidermis thanthat of the epidermis to the dermis, and epidermal strippingmay result during adhesive removal.

DermaI InstabiliryCollagen is deposited in the dermis of the fetus during the

last trimester of pregnancy and prevents the accumulation offluid in this layer. Premature infants exhibit edema because ofless collagen and fewer elastic fibers in the dermis (Dietel,1978). Edema may put them at risk for ischemic injurybecause of reduced blood flow. Protection from pressure andinjury includes routine turning and repositioning and the useof surfaces that minimize pressure points in neonates withexcessive edema.

Skin pHAn acid skin surface (pH < 5), seen in children and adults

(Behrendt & Green, 1971), has protective qualities againstsome microorganisms. This acid mantle is a function of chem-ical and biologic processes at the skin surface. If the pH shifts

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from acidic to neutral there may be an increase in total num-bers of bacteria and a shift in species. There also may be anincrease in TEWL, indicating an alteration in skin barrierfunction when the skin pH rises (Wilhelm & Maibach, 1990).

At birth, full-term newborns have an alkaline skin surfacewith a mean pH of 6.34. Within 4 days the pH falls to a meanof 4.95. Bathing and other skin care practices alter skin pH; itmay take an hour or longer to regenerate the acid mantleafter bathing with an alkaline soap (Peck 8r Botwinick, 1964).

Skin pH recently was reported in 40 premature newbornsof 24-34 weeks gestational age. The pH on the 1st day of l&ewas greater than 6.0 and decreased markedly during the 1stweek to 5.5, with a gradual decline to 5.0 during the next 3weeks (Fox, Nelson, & Wareham, 1998). Gestational age didnot influence the initial or subsequent pH readings, but par-ticipants weighing more than 1,000 g had somewhat lowerpH levels. This study did not describe the type of skin carethe participants received, such as bathing or the use of emol-lients during the period of pH measurements, nor provideinformation about skin colonization relative to pH changes.

NUTRITIONAL DEFICIENCIESFat and zinc accumulate in the fetus during the last

trimester of pregnancy and are necessary components formaintaining intact, healthy skin. Premature infants maydevelop skin problems because of deficiencies in either ofthese nutrients. Deficiencies also are seen in full-term new-borns who are unable to receive adequate enteral nutritionunless appropriate parenteral supplements are provided.

Essential fatty acid (EFA) deficiency can occur in prematureand postmature infants because of decreased fat stores. In themost severe cases there is superficial scaling of the skin, withdesquamation and irritation in the neck, groin, or perianalareas. Thrombocytopenia and impaired platelet aggregationalso may be seen because EFAs are needed to promote plateletfunction (Friedman, 1980). Administration of intravenouslipid solutions at a total dose of 0.5 g/kg/day can preventEFA deficiency in newborns who cannot digest adequateamounts of enteral nutrients. When EFA deficiency occurs, useof intravenous lipids can reverse the process in l-2 weeks.

Zinc, an essential trace mineral, is a co-factor in a numberof metabolic processes, including lymphocyte transformationand metabolism of protein, nucleic acids, and mucopolysac-charides of skin and subcutaneous tissues. Zinc is required fornormal wound healing (Dixon, 1987). Intrauterine zincaccretion accelerates between 28 and 36 weeks gestation(Reifen 8r Zlotkin, 1993).

Premature infants and infants with chronic diarrhea, shortbowel syndrome, or ileostomy are at increased risk for zincdeficiency. Zinc deficiency occurs when there are abnormallosses of zinc in stool or urine; low or absent stores as in pre-mature newborns; or increased demands, such as during rapidgrowth, stress, or extensive tissue healing.

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Zinc deficiency is manifested by erythematous, scaly skinexcoriations of the groin and perianal areas, neck folds, andcircumoral area and at sites of trauma, such as areas of adhe-sive removal (Esterly & Spraker, 1985). Other symptomsinclude lethargy, poor growth, alopecia, and diarrhea.Prevention of zinc deficiency for infants on total parenteralnutrition includes zinc supplementation with 150-350mcg/kg/day (Zlotkin & Buchanan, 1983). Some prematureinfants also have developed zinc deficiency while receivingbreast &, in select cases, they may require an oral zinc sul-fate supplement (Zimmerman et al., 1982).

SKIN CARE PRACTICES --..

BathingBathing newborns has multiple purposes, including

removal of waste materials, general aesthetics, and potentiallyreducing microbial colonization. The bath also is a time forcontact between newborn and caregiver, rich with tactilecommunication and interaction. However, during the firstbath as the newborn transitions to extrauterine life, or in pre-mature or ill newborns with physiologic instability, bathingcan have deleterious effects. These include absorption ofchemicals, contact with irritating substances, hypothermia,and the general destabilization of vital signs.

Studies of antimicrobial bathing practices have shown that,although hexachlorophene does reduce numbers ofStaphylococcus aureus strains, toxicity is associated with itsabsorption, especially in premature infants (Kopelman, 1973;Sarkany & Arnold, 1970). Chlorhexidine and povidone-iodine soap can reduce colonization for up to 4 hours(Davies, Babb, & Ayliff, 1977) but can also be absorbed(Cowen, Ellis, & McAinsh, 1979). Because the reduction inmicrobial colonization lasts only 4 hours, antiseptic baths donot confer lasting protection for newborns and are not indi-cated in daily care.

There is concern, however, about the vertical transmissionof infections such as human immunodeficiency virus (HIV)through maternal vaginal secretions, and many hospitals con-tinue to require that the initial bath be given with antisepticssuch as chlorhexidine or povidone-iodine. There are no stud-ies to support using antimicrobial solutions or cleansers forthis purpose, nor are there recommendations from either theCenters for Disease Control and Prevention or the AmericanAcademy of Pediatrics in this regard (American Academy ofPediatrics, 1997; Centers for Disease Control, 1988).

The first bath should be given after the nelvborn’s temper-ature has stabilized in the normal range for 24 hours becausehypothermia can result in increased oxygen consumption andrespiratory distress (Penny-MacGilli\,ray, 1996). Excessivevernix can be removed from the newborn’s skin; however,removal of all vernix is not necessary for hygienic reasons. Infact, some studies indicate that \rernix may provide antibacte-

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rial protection and promote wound healing (Joglekar, 1980;Ritzmiller, Highby, 81 Lucas, 1973). Vernix also may con-tribute to the development ofepidermal barrier function, reg-ulating postnatal surface adhesion properties, heat flux, andsurface electrical activities (Hoath, 1997; Okah, Wickett,Pompa, & Hoath, 1994). Further research about the benefi-cial effects of vernix would be useful.

Products used for skin cleansing include soaps createdfrom an alkali acting on animal fat or vegetable oils and syn-thetic detergents derived from alkali interactions with sodiumlauryl sulfate or other similar chemicals. Deodorant soapscontain antimicrobial properties (Morelli & Weston, 1987).Most commercially available products used for bathing areclassified as synthetic detergents by the Food and DrugAdministration. All are at least mildly irritating and drying toskin surfaces (Frosch & Kligman, 1979; Tupker, Pinnagoda,Coenraads, & Nater, 1990), and the degree to which the skinis irritated depends on the length of contact and the frequen-cy of bathing.

No studies are available that compare different cleansingagents, bathing techniques, or the effects of different prod-ucts on skin pH in premature or full-term newborns.However, the existing literature includes recommendationsthat incorporate principles to reduce the potentially harmfuleffects of bathing. Cleansing agents that have a neutral pHand minimal dyes and perfumes to reduce risk of limue aller-gic sensitization to topical agents (Cetta, Lambert, & Ros,1991) are chosen for bathing the newborn, and the frequencyshould be only 2-3 times per week. For extremely prematureinfants (less than 26 weeks gestational age) sterile water aloneis the safest choice. Rinsing skin surfaces well after bathingwill reduce contact with chemicals that are drying or potentialirritants. Rubbing skin surf&es should be avoided to preventchafing and irritation.

When clinically feasible, immersion bathing may be benefi-cial. Immersion bathing has been described as more soothingto the infant from a developmental perspective (Als et al.,1986) and may have positive effects on the skin, such asremoval of excess creams, sloughing of cells, and rehydrationof skin surfaces (IMalloy-IMcDonald, 1995) (see Figure 4).

. EmollientsHydration of the stratum comeum is essential for an intact

skin surface and normal barrier function. This involves pre-venting dry, scaly skin. The skin surface of full-term newbornsis drier than that of adults, but becomes gradually morehydrated as the eccrine sweat glands mature during the 1styear of life (Mize, Aguirre Vila-Coro, & Prager, 1989).Moisturizers and emollients or lubricants counteract dry skinand improve lubrication. Emollients hydrate the skin by con-serving the water content of the stratum corneum, whereasmoisturizers add water to the stratum corneum (Jackson,1992). Petrolatum is an emollient with excellent hydrating

NEONATALVOL. 18, NO. 4, JUNE 1999

FIGURE 4 n Patient in neonatal intensive-care unit during immersionbathino.

and healing properties (Ghadially, Halkier-Sorensen, SC Elias,1992; Wigger-Alberti, & Elsner, 1997); it is an ingredient inmany products such as Aquaphor ointment (Beiersdorf,Norwalk, CT) and Eucerin cream (Beiersdorf, Norwalk, CT).

Recent studies of emollient use on premature infants offerencouraging information about how routine applicationimproves skin integrity In one report (Lane & Drosr, 1993),premature infants 29-36 weeks gestational age were treatedwith Eucerin cream twice daily and had less dermatitis as mea-sured by a visual grading scale; no differences. in TEWL. asmeasured with an evaporimeter were detected. A prospectiverandomized study of 60 premature infants of less than 33weeks gestational age who were treated with Aquaphor oint-ment showed improvement in both TEWL and visual scaledermatitis (Nopper et al., 1996). Aquaphor ointment wasselected because it is preservative-free, petrolatum based, andwater miscible; it can be removed with cleansers and water,and potentially can be compounded with other water-solublematerial. There was no evidence of any negative thermaleffects or burns when infants were treated under photothera-py lights or radiant warmers. Neither study found anyincrease in bacterial or fimgal colonization on skin treatedwith emollients. In fact, fewer infants treated with Aquaphorhad positive blood or cerebral spinal fluid cultures comparedwith infants in a control group. This intriguing finding sug-gests that promoting an intact skin surface may reduce sys-temic infection in this vulnerable population. A large multisitestudy is currently under way to look at the effect of Aquaphoruse on infection.

Routine use of an emollient such as Aquaphor ointmentcan prevent excessive drying, skin cracking, and fissures inpremature infants. Emollients can also be used to treat areasof extreme dryness in older premature and full-term new-borns. Avoiding products with perfumes or dyes is prudent,

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because these can be absorbed and are potential contact irri-tants (Cetta et al., 1991).

Skin Disinfection SolutionsIn nurseries, decontamination of skin is routine before

invasive procedures such as venipuncture, circumcision, lum-bar puncture, or placement of umbilical catheters and chesttubes. Anecdotal reports of skin injury from skin disinfectantsolutions include blistering, burns, and sloughing from bothisopropyl alcohol and povidone-iodine use in prematureinfants (Harpin & Rutter, 1982; Schick & Milstein, 1981).There also have been case reports of high iodine levels, iodinegoiter, and hypothyroidism associated with povidone-iodineuse in premature infants (Chabrolle 8: Rossier, 1978; Jackson& Sutherland, 1981; Pyati, Ramamurthy, Krauss, & Pildes,1977). A number of prospective studies of povidone-iodineuse in intensive-care nurseries (Linder et al., 1997; Parraviciniet al., 1996; Smerdely et al., 1989) and one in presurgicalskin preparation of infants under 3 months of age (Mitchell,Pollock, Jam&on, Fitzpatrick, & Logan, 1991) found eleva-tions in serum iodine levels, increased urinary excretion ofiodine, and potential systemic thyroid effects from povidone-iodine exposure.

When skin disinfectant solutions are being selected, theirefficacy is another consideration. During routine skin prepara-tion before blood culture sampling in pediatric patients, lessmicrobial colonization was seen with povidone-iodine com-pared with isopropyl alcohol (Choudhuri, McQueen, Inoue,8r Gordon, 1990). When a 10% povidone-iodine solution wascompared with a 0.5% chlorhexidine in 70% isopropyl alcoholsolution in 35 premature infants, no differences were found insterilization rates or reduction of bacterial colony counts(Malathi, Millar, Leeming, Hedges, & Marlow, 1993).However, longer periods of cleansing (more than 30 seconds)or two consecutive cleansings resulted in maximal reductionsof colonization. In a prospective, randomized study of 70%isopropyl alcohol, a 10% povidone-iodine solution, and a 2%chlorhexidine cleanser for disinfection of 668 insertion sites inadults with central venous catheters during insertion and rou-tine dressing changes, chlorhesidine was more effective inreducing catheter-related infections (Maki, Ringer, &Alvarado, 1991). In a sequential study comparing povidone-iodine use with that of 0.5% chlorhexidine in 70% isopropylalcohol for insertion of peripheral intravenous catheters in 254premature and full-term infants in the NICU, catheter colo-nization was reduced in the sites prepared with the chlorhexi-dine solution: to 4.7% in the chlorhexidine group versus 9.3%in the povidone-iodine group (Garland et al., 1995).

Skin disinfection practices for newborns include usingpovidone-iodine or chlorhesidine solutions (although nochlorhexidine product is commercially available in pledgetform in the United States). Solutions should be applied andallowed to dry for at least 30 seconds before the procedure.

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The solution should then be completely removed, using ster-ile saline solution or water, to prevent any further absorption.Use of isopropyl alcohol is questionable in the NICU becauseit is less effective than either povidone-iodine or chlorhexidinein reducing bacterial colonization or infection (Choudhuri etal., 1990; M&i et al., 1991). In addition, alcohol-containingdisinfectants have been shown to cause the greatest amountof permanent damage to tissues in study animals comparedwith disinfectants such as povidone-iodine, but all causedsome degree of tissue injury (Branemark & Ekl$m, 1967).

Adhesive Application and RemovalAdhesives are applied and removed daily .in the NICU to

secure endotracheal tubes, intravenous devices, monitoringprobes, and electrodes. Yet adhesive removal can cause dis-ruption to skin surfaces. Alteration in skin barrier function,documented by elevated TEWL measurements, has beenshown in adults after 10 consecutive removals of adhesivetape (Lo, Oriba, Maibach, & Bailin, 1990) and in prematureinfants after one removal of adhesive tape (Harpin & Rutter,1983) (see Figure 5).

Strategies to reduce trauma from adhesive removal includethe use of skin barriers such as karaya rings and pectin prod-ucts under adhesives to protect the peristomal skin in adultostomy patients. A comparison of regular adhesive electrodesand karaya electrodes in premature infants found less skin dis-ruption, measured by TEWL, from karaya electrodes(Cartlidge & Rutter, 1987). However, because in some pre-mature infants skin irritation was seen fi-om using the karayaelectrodes, they are no longer available. Newer hydrogel andhydrocolloid adhesives currently are used for cardio-respiratory monitoring in many nurseries.

Pectin barriers (Hollihesive, Hollister, Libertyville, IL;Duoderm, Convatec/Bristol-Myers Squibb Co., Princeton,NJ) have been used beneath adhesives in premature infantsand are reported to leave less visible skin trauma whenremoved (Dollison 8r Beckstrand, 1995; Lund, Kuller, Tobin,Lef?ak, & Franck, 1986; McLean, Kirchhoff, Kriynovich, &VonDerAhe, 1992). However, a controlled trial of pectin bar-rier (Hollihesive), plastic tape (Transpore, 3M Health Care,St. Paul, MN), and hydrogel adhesive in 30 premature infantsless than 1 week of age found significant skin disruption, asmeasured by TEWL, calorimeter, and visual inspection, afterremoval of both the pectin barrier and plastic tape (Lund etal., 1997). Because the adhesives were left in place 24 hoursprior to removal, a time effect of peak adhesive aggressivenessmay have been reached. Significant changes were identifiedafter a single adhesive removal in the three weight groupsstudied (less than 1000 g, 1001-1500 g, more than 1501 g),indicating that even larger premature infants are at risk forskin injury from tape removal. Although the hydrogel did notcause trauma, it is important to note that in 7 of the 30infants, the gel fell off before 24 hours. Thus, gel adhesives

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should be used only in situations in nhich secure adherence isnot critical.

Adhesive removal is sometimes facilitated by the use ofsol-vents to prevent discomfort and skin disruption. Ho\vever,solvents present a danger of tosicin, to the premature infantwho has an underdeveloped stratum corneum and increasedskin permeability. VVhen solvents are absorbed through theskin there is the potential for the same toxicity that occurswhen these substances are ingested. Although full-terminfants may absorb much less than premature infants, theirrenal and hepatic immaturity make it difficult to clear anytoxin from their bloodstream. Epidermal injury, hemorrhage,and necrosis resulting from the use of a solvent in a former26-week-gestation&age premature infant at 87 days of agehas been reported (Ittman & Bozynski, 1993). Other sub-stances, such as mineral oil, may be helpfGI in removing adhe-sives, but not if the site must be used again for reapplyingadhesives, as when retaping an endouacheal tube.

Skin bonding agents include liquid preparations such as tinc-ture of benzoin and Mastisol (Femdde Laboratories, Ferndale,MI) and promote adhesive adherence. HowelTer, in prematureinfants these agents may create a stronger bond between adhe-sive and epidermis than the fragile cohesion of the epidermis tothe dermis and may result in epidermal stripping during adhe-sive removal. Plastic polymers are reported to reduce skin trau-ma by providing a plastic coating under adhesives (Evans SCRutter, 1986b). ,4 nonalcohol version, No Sting SkinProtectant (3M Health Care, St. Paul, I&IN), is available com-mercially. Testing has shown this product to cause less injury toskin surfaces in adults; no studies are yet available on its use ininfants or newborns (Grove Sr Leyden, 1993).

To help prevent skin trauma from adhesive removal, tapeuse should be minimized when possible by using smallerpieces, backing the adhesive with cotton or pieces of tape, anddelaying tape removal until at least 24 hours after application.Pectin barriers placed on skin surfaces underneath adhesivesmay prove helpful because they mold and adhere well to bodycontours and help the adhesives to adhere better in moist con-ditions. Removal of tape and pectin barriers should be delayedfor more than 24 hours after application, if possible. Otherstrategies to protect skin from adhesives are the use of softgauze wraps to secufe probes and hydrogel adhesives for elec-trocardiogram electrodes. Slow and careful removal of adhe-sives with warm water and cotton balls is safest; mineral oil oran emollient -may facilitate adhesive removal, but should notbe used if reapplication of adhesives to the site is necessary.

Control of Transepidermal Water LossPremature infants who are less than 30 weeks gestational

age exhibit water losses as much as 15 times greater than thatof full-term infants because of their immature stratumcorneum; losses ranging from 40-129 ml/kg/day have beenreported (Sedin et al., 1985). Strategies to reduce TEVVL and

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FIGURE 5 n Infant with epidermal stripping resulting from adhesive

removal.

prevent estreme heat and fluid losses in premature infantsyounger than 30 weeks gestational age include the use ofdouble-walled incubators, increased ambient humidity, trans-parent adhesive dressings, and coating the skin with emol-lients. There is research to support each of these methods,but no studies have compared one method to another foreffectiveness.

Although previous studies found decreased insensiblewater loss when infants were placed in double-walled incuba-tors compared with radiant warmers, a recent study foundthat TEWL. depends on the ambient water vapor pressure,irrespective of whether the infant is under a radiant warmer orin an incubator (Kjartansson, Arsan, Hammarlund, Sjors, &Sedin, 1995). The higher rate of evaporation during careunder a radiant warmer is caused by the lower ambient watervapor pressure and not by any direct effect of the nonionizingradiation on the skin.

Raising the ambient humidity increases water vapor pres-sure and decreases fluid and heat loss via evaporation(Hammarlund, Xilsson, Oberg, & Sedin, 1977). Measure-ments in premature infants at different levels of ambienthumidity showed a linear relationship between TEWL andrelative humidity: A much higher TEVVL rate existed at alower (20%) humidity than at a higher (60%) humidity (Sedinet al., 1985).

Whether the infant is on a radiant warmer or in an incuba-tor, providing elevated ambient humidity can reduce TEWL.One study documented a 50% reduction in TEWL in inf;ultsplaced in incubators with 85-90% humidity, but recommendsreducing the humidity at 7 days of life because of infectionrisks (Harpin & Rutter, 1985).

Recent innovations in incubator design include servo-con-trolled humidification using sterile water sources, thus removing

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the reservoir as a source of bacterial contamination. A hygrome-ter built inside the incubator allows the clinician to monitor theamount of humidity and regulate-s delivery of a preset amount.Monitoring the humidity in the environment surrounding eachinfant has not been standard NICU practice, but may provideinformation about the infant’s microclimate. This informationmay lead to strategies that reduce the drying effects of warmingdevices at excessively high temperatures, such as the use of sup-plemental conductive heat (Topper & Stewart, 1984) and plas-tic wraps or body hoods (LeBlanc, 1991).

Transparent adhesive dressings can be used to preventexcessive skin water losses in premature infants (Bustamante& Steslow, 1989; Knauth, Go&n, McNelis, & Baumgart,1989; Man&i, Sookdeo-Drost, Madison, Smoller, & Lane,1994; Vernon, Lane, Wischerath, Davis, & Menegus, 1990);TEWL is reduced by as much as 50% by the creation of thissecond skin. Cultures obtained from covered and uncovered

skin showed no increase in either bacterial or fungal coloniza-tion under the dressings. However, if dressings are removed,a significant amount of skin trauma will occur. The questionof whether transparent adhesive dressings affect fluid statusand prevent hypernatremia was recently examined byDonahue, Phelps, Richter, and Davis (1996). They found nodifference in fluid intake on the highest serum sodium levelswhen they compared small premature infants who had dress-ings applied to chest, abdomen, and back sites to infants withno dressings.

Coating the skin surfaces with emollients can also reduceTEWL. In the previously mentioned study using Aquaphorointment in extremely low-birth-weight infants, TEWL wassignificantly reduced immediately after application of theemollient, but this effect was less at 3 and 6 hours after appli-cation (Nopper et al., 1996). Fluid intake and serum sodiumlevels were not reported, so the effect on these outcomes can-not yet be concluded.

CARE OF SKIN BREAKDOWNSkin breakdown can occur fi-om a variety of causes, mclud-

ing trauma from adhesive removal, infection, friction, pm-sue sores, and diaper dermatitis. The degree of breakdowncan range horn surface excoriations to full thickness woundsinvolving the dermis.

Skin excoriations are cleansed with warmed sterile waterand may be covered with some type of coating or dressingthat keeps the wound moist. Frequent irrigation uith sterilenormal saline or half-normal saliie solutions, using a X-30-ml svringe and a 20-gauge blunt needle or Teflon catheter, iseffective in flushing out debris and dead tissue from an infect-ed or “dim” wound, alloLling a better surface for healing.nlc: nloistenin~ of tissue even 4_6 hours aids b the

Pea. where= dying impedes the migration of cells.healing

skin ~WV _Wm *+ and potassium h&oxide prepa-nh h cr)+em=o= or purulent e&-&ions can be

beneficial to identify organisms that later may be responsiblefor systemic disease, especially in premature infants.Cutaneous manifestations ofien may precede systemic bacteri-al or fUngal disease (Baley & Silverman, 1988); invasive fun-gal dermatitis is recognized as an early form of fungal diseasein extremely low-birth-weight infants (Rowen, Atkins, Levy,Baer, & Baker, 1995).

Petrolatum-based emollients and ointments are used tocover the wound with a semiocclusive layer that facilitates themigration of epithelial cells across the surface and may actuallybecome part of the stratum corneum layer during the healingprocess (Ghadially et al., 1992). Antibacterial ointments suchPolysporin (Warner Wellcome, Morris Plains, NJ), Bacitracin(Barre-National, Inc./NCM Laboratories, Inc., Baltimore,MD), or Bactroban (SmithKline Beecham, l?hiladelphia,‘PA)are useful to treat gram-positive organisms, but can actuallypromote growth of gram-negative organisms (Smack et al.,1996). Neosporin (Warner Wellcome, Morris Plains, NJ) isnot recommended because of the potential for developinglater sensitization to the ingredients in this ointment, althoughsensitization to Baciuacin also is being reported with increas-ing frequency (Marks et al., 1995). If fimgal infection is sus-pected, an antifungal ointment is recommended and also canbe applied to surrounding intact skin to prevent extension ofthe infection. In general, translucent ointments with a petrola-nun base are preferable to creams because of their improvedcoating and healing properties.

Other types of dressings used to treat excoriations includetransparent adhesive dressings (Biocclusive, Johnson &Johnson, Skillman, NJ; Tegaderm, 3M Health Care, St. Paul,MN; OpSite, Smith & Nephew, Inc., Largo, FL); hydrogel(Vigilon, C. R Bard, Inc., Murray Hill, NJ); and hydrocol-loid dressings (Duoderm, Convatec/Bristol-Myers Squibb,Princeton, NJ) (Eaglstein, 1985; Krasner, Kennedy, Rolstad,& Roma, 1993). These dressiigs provide for “moist healing,”which promotes rapid migration of epithelial cells.Transparent adhesive dressings are used on uninfectedwounds because bacteria and fi.m_gus can proliferate under thedressing. A serous or milky exudate often forms under thedressing and is composed of leukocytes that aid in preventinginfection. The dressings can be left in place for days at a time;removing and reattaching the dressings on a daily basis is notrecommended because the adhesive can injure the intact skinaround the wound and impede healing.

Hydrogel dressings prolvide a moist epithelial bed forhealing and can be used in conjunction with antibacterial orantifungal ointments if the lvound is infected. These dressingsneed to be changed often, every 6-8 hours, because they dryout and may injure the healing tissue if removed while dry.Care should be taken not to place these dressings on intactskin surfaces because they can macerate the skin and therebyreduce skin barrier function. Hydrocolloid dressings, used fordeep, uninfected wounds, can be left in place 5-7 days.

JUNE 1979, VOL. 18, NO. 4

Care for Diaper DermatitisDiaper dermatitis has a number of causes in infants and

affects the perineum, groin, thighs, buttocks, and anal region.The underlying skin condition and certain medical conditionsof the infant contribute to the degree of diaper dermatitis thatOCCUIYS.

The development of diaper dermatitis is induenced by thedegree of wetness of the skin. Skin that is moist and macerat-ed becomes more permeable and susceptible to injury (Berg,Buckingham, SC Stewart, 1986) and more heavily colonizedwith microorganisms. Because skin pH rises when exposed tourine and changes from acid to alkaline levels, skin is morevulnerable to injury and penetration by microorganisms (Berget al., 1986; Leydon, Katz, Stewart, & Kligman, 1977). Analkaline pH activates the fecal enzymes protease and lipase,which break down protein and fat, building blocks of the stra-tum corneum, and also may activate bile salts that can causeinjury (Buckingham & Berg, 1986). This is the primarymechanism for direct contact dermatitis from exposure tostool, the most common form of diaper dermatitis.

Prevention of diaper dermatitis includes maintaining a dryskin surface with a normal (acidic) skin pH. Superabsorbentgelled diapers keep skin surfaces dry by “wicking” the mois-ture away from the skin (Campbell, Seymour, Stone, &Milligan, 1987; Davis, Leyden, Grove, & Raynor, 1989).Moisturizers such as petrolatum provide protection from wet-ness and help mildly irritated skin to heal.

After skin has been injured by diaper dermatitis the prima-ry goal of treatment is prevention from reinjury. Generousapplication of protective skin barriers that contain zinc oxideprevents further injury while allowing the skin to heal.Keeping the buttocks exposed without a covering or skin bar-rier may not be effective, because reinjury can occur when theinfant has a stool and there is fecal contact to the alreadyimpaired tissue. Protective barriers coat the injured tissue andprotect it from fecal contact even when a diaper is worn. It isnot necessary or desirable to completely remove skin barrierswith diaper changes because this may disrupt healing tissue.Instead, with each diaper change as much waste material aspossible should be removed and the barrier reapplied to theaffected areas.

Antibacterial ointments are not indicated because diaperdermatitis is not associated with increased numbers of bacteriabut can be associated with candida albicans. If candida albi-cans is involved in the diaper dermatitis, an antifungal oint-ment or cream should be used. If the dermatitis is both fun-gal and a contact irritant dermatitis, it may be necessary toapply a layer of antifungal powder or cream under the zincaside-based skin barrier ointment.

Extremely severe diaper dermatitis can result from intesti-nal malabsorption syndromes if there is constant dribbling ofstool in infants with spina bifida or bladder exstrophy, or dur-ing severe opiate withdrawal. With malabsorption, the stool

may have a higher than normal pH because of rapid transitfrom the small bowel with significant amounts of undigestedcarbohydrates, fecal enzymes, and bile salts, as well asincreased stool frequency. Severe diaper dermatitis in this casecan be a symptom of more severe nutritional deficiency, oreven dehydration, and needs thorough medical evaluation.Infants with severe opiate withdrawal will require treatmentwith appropriate medications until symptoms subside.

While optimal nutritional therapy is being addressed withspecial diets, parenteral nutrition, or medication, skin protec-tion from injury should be started. Products such as pectinpaste without alcohol (Ilex Paste, Convatec/Bristol-MyersSquibb Co., Princeton, NJ) are sturdier barriers for infantsreceiving such nutritional therapy than are zinc oxide prepara-tions. The skin should be thoroughly cleansed before a verythick application of the pectin paste. Then a greasy ointmentshould be applied over this to keep the pectin paste fromadhering to the diaper. When the infant has a stool, it is notnecessary to completely remove the barrier paste; the stoolcan be wiped away as much as possible before reapplying athick coating. The skin will heal under this covering as long asit is protected fi-om reinjury.

.Cord and Circumcision Care

Cord care options include using isopropyl alcohol, tripledye (brilliant green, gentian violet, and proflavine hemisul-fate), povidone-iodine solution, antimicrobial ointment, or nointervention at all. The use of antimicrobial interventionswere adopted to control nosocomial outbreaks of staphylo-coccal and streptococcal infections. However, practices aregenerally continued based on nursery tradition.

An initial application of triple dye, isopropyl alcohol, orantimicrobial ointment is common practice in many nurseries.Isopropyl alcohol may be less effective in reducing microbialcolonization or infection than either triple dye or antimicro-bial ointment, although triple dye is not effective againstgram-negative organisms (Andrich & Golden, 1984; Faucher& Jackson, 1992; Freeman & Poland, 1992; Verber & Pagan,1993; Wald, Snyder, & Gutberlet, 1977). Contact with tripledye or other alcohol-containing soIutions on abdominal orperineal skin should be avoided to prevent irritation(Branemark & Ekholm, 1967; Lineaweaver et al., 1985).

The cord should detach from the umbilicus by 2 weeks ofage (Arad, Eyal, & Fienmesser, 1981), but care practices canaccelerate or delay the process up to 15 days or more (Wilsonet al., 1985). Drying, infarction, bacterial contamination, andgranuiocyte influx influence the timing of separation.

A recent study compared the efficacy of daily treatment withisopropyl alcohol versus wiping with sterile water in 148 infants(Medves & O’Brien, 1997). The cord separation time waslengthened by 2-3 days with isopropyl alcohol use.Colonization with microorganisms was different between thetwo groups, but no pathogens or umbilical infections occurred.

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In a larger study, 1,8 11 infants were randofnized to receiveeither alcohol treatment to the umbilical cord with each dia-per change or natural drying without special treatment. Therewere no umbilical infections in either group, and cord separa-tion was significantly shorter in the air-drying group, 9.8 ver-sus 8.16 days (Dore et al., 1998). Thus, routine use of alco-hol for cord care is not indicated.

Infants may have umbilical catheters placed for blood sarn-pling, blood pressure monitoring, or administration of intra-venous fluids if NICU care is required. No research is avail-able about cord care in this situation, and in many nurseriesthere is no routine topical treatment.

During circumcision, the penis is prepared with antimicro-bial solutions. The same concerns about absorption exist inthis application as with other invasive procedures, and thesolution (povidone-iodine or chlorhexidine) should be com-pletely removed after the procedure is completed.

After circumcision, emollients such as petrolaturn-impreg-nated gauze, petrolatum alone, or Aquaphor ointment areused to facilitate healing and prevent pain during urination;these also prevent the diaper from adhering to the open cir-cumcision site. Use of antimicrobial ointments are notrecommended because of the risk of sensitization and lack ofbenefit (Smack et al., 1996). Emollients or other topicalagents are not recommended for use after circumcisions withthe Plastibell (Hollister, Libertyville, IL) technique, accordingto the manufacturer’s recommendations, as they can dislodgethe appliance. Cleansing the newly circumcised penis withclear water for 3-4 days after the procedure will reduce irrita-tion (Gelbaum, 1993; Gorrie, McKinney, & Murray, 1998).

SUMMARYA significant amount of research is available to neonatal

nurses about skin development, physiology, and care practicesfor both premature and full-term newborns. This review doc-uments a substantial part of this body of knowledge and pro-vides a scientific basis for a comprehensive skin care guidelineto use in the daily care of newborns. The implementation ofthis guideline will be the focus of the Association of Women’sHealth, Obstetric and Neonatal Nurses’ and NationalAssociation of Neonatal Nurses’ research-based practice pro-ject to be evaluated in 58 sites in the United States.Improving the skin condition of newborns, reducing iatro-genie complications, and identifying areas of future researchby increasing knowledge are the desired outcomes. Results ofthe project will be released in 1999.

R E F E R E N C E SAh, H., Lawhon, G., Brown, E., Gibes, R, Duffy, F. H., McAnult?:

G., 8: Blickman, J. G. (1986). Individualized behavioral and envi-ronmental care for the very low birth weight preterm infant athigh risk for bronchopulmonary dysplasia: Neonatal intensive careunit and developmental outcomes. Pediatrics, 78, 1123-l 132.

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American Academy of Pediatrics. (1997). Red book: Report oftheCommittee on Infectious Diseases (24th cd.). Elk Grove Viiage, IL:Author.

Andrich, M. l?, & Golden, S. M. (1984). Umbilical cord care. Astudy of badtracin ointment vs. triple dye. Clinical Pediatrics 23,342-344.

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Baley, J. E., & Silverman, R. A. (1988). Systemic candidiasis:Cutaneous manifestations in low birth weight infants. Pediatrics,82,211-215. -I

Behrendt, H., & Green, M. (1971). Panems of skin plrfrom birththou@ adolescence. Springfield, IL: Charles C. Thomas.

Berg, R W., Buckingham, K. W., & Stewart,‘R L. (1986). Etiologicfactors in diaper dermatitis: The role of urine. PediatricDermatology, 3,102-l 06.

Branemark, l? I., & Ekholm, R (1967). Tissue injury caused bywound disinfectants. Journal of Bone and Joint Surgery, 49, (l),48-62.

Buckingham, K. W., & Berg, R W. (1986). Edologic factors in dia-per dermatitis: The role of feces. Pediatric Dermatology 3,107-112.

Bustamante, S. A, & Steslow, J. (1989). Use of a transparent adhe-sive dressing in very low birthweight infants. Journal of

Perinatolor, 9, 165-l 69.

Campbell, R L., Seymour, J. L., Stone, L. C., & MilIigan, M. C.(1987). Clinical studies with disposable diapers containingabsorbent gelling materials: Evaluation on infant skin condition.Journal of the American Academy of Dermatology, 17,978-987.

Cartlidge, l? H., & Rutter, N. (1987). Karaya gum electrocardio-graphic electrodes for preterm infants. Archives of Disease inChildhood, 62,1281-1282.

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Choudhuri, J., McQueen, R, Inoue, S., 8r Gordon, R C. (1990).Efficacy of skin sterilization for a venipuncture with the use ofcommercially available alcohol or iodine pads. American Journal ofInfection Control, l&82-8 5.

Cowen, J., Ellis, S. H., & McAinsh, J. (1979). Absorption ofchlorhexidine from the intact skin of newborn infants. Archives ofDisease in CL&hood, 54, 379-383.

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Davis. J. A., Leyden, J. J., Grove, G. L., 8r Raynor, W. J. (1989).Comparison of disposable diapers with fluff absorbent and fluff

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plus absorbent polymers: Etfects on skin hydration, skin pH, anddiaper dermatitis. Pediatric Dcrmatolom, 6,102-108.

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Evans, N. J., & Rutter, N. (1986b). Reduction of skin damage f?omtranscutaneous oxygen electrodes using a spray on dressing.Archives of Disease in Childhood, 61, 881-884.

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iodine-containing antiseptics and subclinical hypothyroidism inpreterm infants. Joamal of Pediatrics, 131,434439.

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