Improving Neonatal Skin Care

2

Improving

Neonatal

Skin Care

Gayla Eppinger, NNP-BC

Emory University

Atlanta GA

Improving Neonatal Skin Care

Learning Objectives

·  Describe the structure and function of neonatal skin

·  Explain and apply the Neonatal Skin Condition Scale

·  Identify clinical practice goals related to neonatal skin care

·  Describe recommended skin care practices

·  Understand new evidence-based research and recommendations

Function of the Skin

1)  Serves as barrier against infection and protects internal organs

2)  Plays major role in thermoregulation and storage of fat

3)  Regulates insensible water loss, also secretes electrolytes & water

4)  Provides tactile sensory input and sensations of touch, pressure, temperature, pain & itch

a)  Difference in Neonatal Skin

i)  Skin of the premature neonate accounts for 13% of their body weight as compared to 3% of the body weight of an adult

ii)  Premature neonate has body surface/weight ratio ~ five times greater than that of an adult

iii)  The skin of a premature neonate is 40-60% thinner than adult skin

Anatomy of the Skin

1)  Epidermis: functions as a barrier, preventing penetration and absorption of potential toxins and microorganisms, as well as retaining heat and water.

a)  Stratum Corneum: outermost layer of cells forming the epidermis. Non-living layer made up of dead cells constructed like a wall of bricks and mortar

b)  Forms part of the vernix caseosa, controls transepidermal water loss (TEWL), prevents absorption of toxic substances

c)  Difference in Neonatal Skin

i)  10-20 layers of stratum corneum in full-term infants and adults

ii)  Neonate <30 weeks gestation has only 2-3 layers and at 23-24 weeks virtually no stratum corneum

iii)  Maturation rate of stratum corneum varies based on the gestation age:

At <27 weeks the process is slowed;

At 23-25 weeks it takes 8-10 weeks to develop the function of full term skin;

At >27 weeks approaches full-term skin function by ~10 days postnatal age

d)  Risks of underdeveloped Stratum Corneum

i)  Infections and skin irritation

ii)  Increase in insensible water loss

iii)  Increased evaporative water loss

iv)  Toxicity from topically applied substances

v)  Epidermal stripping

Note: Percutaneous absorption of Neomycin (topical antibiotic) has been reported to cause neural deafness.

Bacitracin has been noted as one of the 12 most frequent allergens causing a positive patch test reaction in patients ages 8-92 years. Marks, et al (1995). North American Contact Dermatitis Group standard patch test results. American Journal of Contact Dermatitis, 6, 160-165.

2)  The Basal Layer: near the junction of the epidermis and dermis, is the bottom layer of the epidermis. A source of renewal for the epidermis. Living cells which replace cells of the stratum corneum.

a)  Difference in Neonatal Skin

i)  Dermal-epidermal junction is connected by fibrils which are fewer and more widely-spaced in premature infants than in full-term infants

ii)  As gestational and postnatal age advances, fibrils become stronger

b)  Risks of fewer fibrils

i)  Diminished cohesion between dermis and epidermis places premature at higher risk for injury

ii)  Bond between adhesives and epidermis may be stronger than the cohesion between dermis and epidermis, resulting in epidermal stripping when adhesives are removed

iii)  Premature infant at greater risk of blistering from friction or thermal insults

3)  Dermis: under the epidermis. Composed of collagen and elastin fibers. Contains nerves, blood and lymph vessels, mast cells and inflammatory cells. The carrier of heat, pressure and pain.

a)  Difference in Neonatal Skin

i)  Premature infants prone to edema due to less collagen and fewer elastin fibers in the dermis

ii)  Edema places the neonate at increased risk of ischemic injury and pressure necrosis due to reduced blood flow to the epidermis

iii)  Full-term infant’s dermis is thick and well-organized, but, thinner and higher water content than adult’s

4)  Subcutaneous: fatty connective tissue. Heat insulator, shock absorber, and caloric reservoir. Fat deposition occurs primarily in last trimester

Characteristics of Neonatal Skin

1)  Skin appearance: soft, wrinkled, velvety, covered with vernix caseosa

a)  Difference in Premature Skin

i)  More transparent, gelatinous and wrinkle-free

ii)  Lanugo present in varying degrees

iii)  Subcutaneous edema may be present

2)  Skin pH: alkaline skin surface with mean pH of 6.34. During next four days, skin pH falls to mean of 4.95 creating “acid mantle”. Provides protection against microorganisms, particularly pathogenic bacteria and fungus.

a)  Difference in Premature Skin

i)  Skin pH greater than 6.0 at birth

ii)  Declines to 5.5 over the first weeks, and gradually declines to 5.0 over the first month

3)  Nutritional stores: fat and trace mineral zinc accumulates during the third trimester. Necessary to prevent nutritional deficiencies that cause skin disruptions.

a)  Breast milk or infant formulas contain adequate levels of nutrients

b)  Premature and sick neonates at risk for fatty acid deficiency

c)  Infants requiring TPN need adequate replacement of fat and zinc in IV solutions

4)  Difference in Neonatal Skin: premature and sick newborns are vulnerable to infection due to

a)  Immature immune system

b)  Invasive tubes and catheters

c)  Frequent use of antibiotics

d)  Immature skin structure and function

e)  Excoriations and other sites of skin trauma

f)  Changes in skin pH

5)  What Families Need to Know: Skin of the premature newborn is different than that of the full-term newborn. All neonates admitted to the NICU are at risk for developing skin conditions which may require special skin care.

Goals of Neonatal Skin Care

1)  Reduce traumatic injury

2)  Prevent dryness

3)  Avoid exposure to toxins

4)  Minimize exposure to unnecessary substances

5)  Promote normal skin development

First Bath and Routine Bathing

1)  First Bath: should be given once the newborn’s condition, vital signs and temperature have been stable >2 – 4 hours.

a)  Recommended Practices

i)  Wear gloves and implement universal precautions before and during first bath

ii)  Removing all vernix is not necessary for hygienic reasons

iii)  Do not use antiseptic soaps or cleanser

iv)  Use warm water

v)  Use cotton balls or soft cloth

vi)  Avoid rubbing skin surfaces to prevent chafing and irritation

2)  Routine Bathing: main purpose is to remove debris. A time for contact between newborn and caregiver, which, if not handled properly, can result in physiological and behavioral problems for the newborn.

a)  Recommended Practices

i)  Use cleansers with a neutral pH with minimal dyes and perfumes to lessen the impact on the acid mantle, and reduce the risk of future skin sensitization

ii)  Avoid rubbing skin surface as it can cause chafing and irritation

iii)  Rinse with water

b)  Recommended Practices for Infants < 32 Weeks Gestation

i)  Bathe with warm water and cotton balls or soft cloth during first few weeks of life

ii)  Use warm sterile water on areas of breakdown

3)  Immersion Bathing: placing the infant’s entire body, with the exception of head and face, into a tub of water.

a)  Recommended Practices

i)  Use water at a temperature of 100.4 degrees (38 degrees C) to ensure an even temperature and decrease evaporative heat loss

ii)  After the bath: dry, diaper, and double-wrap (with cap)

iii)  After 10 minutes: dress, change the cap, and wrap in dry warm blankets

4)  What Families Need to Know: gather all supplies and clothing prior to starting the bath; perform bath in draft-free location; avoid using soaps and lotions with perfumes and dyes to prevent sensitizations later in life.

Cord Care

1)  Studies have shown that disinfectants do not affect bacterial colonization or cord and skin infections

2)  Certain antiseptic ointments and isopropyl alcohol have been shown to delay cord separation

3)  Recommended Practices

a)  Clean cord and surrounding skin with skin cleanser used for first or routine bath and rinse thoroughly

b)  Alternatively, clean cord with sterile water

c)  Keep cord clean and dry

d)  Fold diaper below umbilicus

e)  Clean cord with water if soiled with urine or stool

4)  What Families Need to Know: normal cords may seem moist and “mucky” in appearance. Educate them about the normal process of cord healing.

Circumcision Care

1)  Before the procedure

a)  Disinfect penis and surrounding skin

2)  After the procedure

a)  Remove disinfectant with water, focus on leg creases, buttocks, and lower back

b)  Cover penis with petrolatum-impregnated gauze strips or sterile gauze pads over petrolatum for the first 24 hours

c)  Do not use petrolatum or other lubricants if the circumcision was performed using the PlastiBell technique

d)  Cleanse with water only for 3-4 days to prevent irritation from cleansers

e)  No proven benefit to using antimicrobial ointments as compared with petrolatum

3)  What Families Need to Know: use petrolatum product and gauze first 24 hours. For the next 3-4 days, clean penis with warm water only.

Diaper Dermatitis

1)  Causes

a)  Exposure to stool and fecal enzymes. Prolonged contact with urine-soaked diaper leads to skin becoming moist and macerated and more susceptible to injury

b)  Skin pH rises – as the skin becomes more alkaline, fecal enzymes and bile salts that cause skin breakdown become activated

2)  Identify and treat underlying conditions (malabsorption, diarrhea, intestinal resection, opiate withdrawal)

3)  Recommended Practices

a)  Preventative Strategies: keep skin surface dry

i)  Change diapers frequently

ii)  Use super absorbent gel disposable diapers

iii)  Apply petrolatum to slightly reddened, intact skin

b)  Treatment After Skin Breakdown: protect skin from more injury

i)  Generously apply skin barriers containing zinc oxide

ii)  Apply pectin paste without alcohol followed by a greasy coating with petrolatum or zinc oxide to prevent diaper from sticking to the barrier

iii)  Remove as much waste material as possible when changing diaper, and re-apply barrier in a thick layer

iv)  Exposure to air and light is not as effective, re-injury occurs when stool contacts injured skin

v)  Use anti-fungal ointment or creams to treat candida diaper dermatitis

4)  What Families Need to Know: how diaper dermatitis develops and proper preventative and treatment strategies. Avoid products with perfumes and dyes.

Emollients

1)  Purpose: to protect and restore skin integrity

a)  When applied twice daily to neonates with birth weights 500-1000 grams, emollient use resulted in reduced visible dermatitis and improved skin integrity

b)  Have been shown to reduce transepidermal water loss in neonates <32 weeks gestation, but the effect diminishes after 6 hours

c)  May be safely used on neonates under radiant warmers and phototherapy

d)  Caution: with twice daily use, higher risk of coagulase-negative Staphylococcus epidermidis sepsis in infants <750grams

2)  Recommended Practices

a)  Use emollients that are petrolatum-based, water miscible, and free of preservatives, dyes and perfumes

b)  Use on skin that is dry, with scaling, fissures or visible cracking

c)  Use to protect skin that is prone to breakdown (in groin or thigh)

d)  Use single patient tubes to prevent cross-contamination

Diaper Rash Products and Emollients: Composition and Cost

Product / Manufacturer / Ingredients / Cost/Oz.
A&D ointment / Schering-Plough Memphis, Tenn / Cholecalciferol, fish liver oil, petroleum, fragrance, lanolin, mineral oil, paraffin / 2.12
Aloe Vesta Protective ointment / ConvaTec
Princeton, NJ / Propylparaben, aloe vera gel, quaternium-15, water, hydroxylated lanolin, ozokerite, glycerin, fragrance / 1.02
Aquaphor / Beiersdorf, Inc
Norwalk, Conn / Petrolatum, mineral oil, mineral wax, wool wax alcohol / .68
Aquaphor Natural Healing ointment / Beiersdorf, Inc
Norwalk, Conn / Petrolatum, mineral oil, mineral wax, wool wax, alcohol, panthenol, bisabolol, glycerin / .68
Baby Magic Baby Lotion / Mennen
Morristown, NJ / Water, glycerin, glyceryl stearate, cetyl alcohol, mineral oil, Peg-100 stearate, lanolin alcohol, fragrance, lanolin, methylparaben, lapyrium chloride, propylparaben, benzalkonium chloride, diazolidinyl urea / .28
Balmex
Diaper Rash ointment / Block Drug Company
Jersey City, NJ / 11.3% zinc oxide, balsam of Peru, beeswax, benzoic acid, bismuth subnimitrate, mineral oil, purified water, silicone, synthetic white wax / 1.47
Cholysteramine in Aquaphor / Bristol-Myers Squibb
Princeton, NJ; Beiersdorf Norwalk, Conn; locally compounded / 15% cholestyramine liquid (aspartame, citric acid, A&C yellow #10, FD&C red #40, flavor, propylene glycol alginate, colloidal silicon dioxide, sucrose, xanthan gum) in Aquaphor / 8.40
Critic-aid / Sween Products
N. Mankato, Minn / Benzethonium chloride in a soothing, occlusive moisture-resistant paste of proprietary ingredients / 2.91
Desitin Diaper Rash ointment / Pfizer
New York, NY / 40% zinc oxide; BHA, cod liver oil, fragrance, lanolin, methyl paraben, petrolatum, talc, water / 1.72
Dr. Danis Buttocks Cream / Compounded at St. John’s Mercy Medical Center, St. Louis, Mo / 32g zinc oxide, 32g starch, 32g talc, 60 ml glycerin, 112 g Aquaphor / 13.50
Dyprotex / Blistex
Oakbrook, Ill / 40% micronized zinc oxide, 37.6% petrolatum, 2.5% dimethicone, cod liver oil, aloe / 2.85
Elase ointment / Fujisawa
Deerfield, Ill / 1U fibrinolysin and 666.6 U of deoxyribonuclease in a base of petrolatum and polyethylene / 52.72
Eucerin cream / Beiersdorf
Norwalk, Conn / Water, mineral oil, isopropyl myristate, Peg-40 sorbitan peroleate, glyceryl lanolate, sorbitol, propylene glycol, cetyl palmitate, magnesium sulfate, aluminum stearate, lanolin alcohol, BHT, methylchloroisothiazolinone, methylisothiazolinone / .84
Happy Hiney / Bristol-Myers, Squibb Princeton, NJ; Beiersdorf Norwalk, Conn compounded at Carbondale Memorial Hospital / 12 x 4.1 g packets of Questran powder (cholestyramine resin, acacia, citric acid, D&C yellow #10, FD&C yellow #6, flavor, polysorbate 80, propylene glycol, alginate, sucrose) compounded in 1 pound of Aquaphor / 2.50
Ilex Paste / Calgon-Vestal
St. Louis, Mo / Petrolatum, calcium/sodium PVM/MA copolymer, DMDM hydantoin, iodopropynyl-butycarbamate, mineral oil, peppermint oil, sodium carboxymethyl cellulose / 5.75
Neosporin Plus Maximum Strength ointment / Burroughs-Wellcome
Triangle Park, NC / Polymyxin B sulfate 10,000U, bacitracin zinc 500U, neomycin 3.5mg, lidocaine 40mg, in a special white petrolatum base / 22.50
Nystatin cream / E. Fougera
Melville, NJ / 100,000U Nystatin, polysorbate 60, aluminum hydroxide compressed gel, titanium dioxide, glyceryl monostearate, polyethylene glycol monostearate 400, simethicone, sorbic acid, propylene glycol, ethylenediamine, polyoxyethylene fatty alcohol ether, sorbitol solution, methyl paraben, propyl paraben, hydrochloric acid, white petrolatum, purified water / 11.78
Nystatin ointment / E. Fougera
Melville, NJ / 100,000U Nystatin per gram, in a polyethylene and mineral oil base / 11.78
Proshield / Health Pointe Medical
Forthworth, Tx / Cleansing foam: purified water, glycerine, cocoamphodiacetate, polaxymer 188, cocamidopropylpeg-dimmiumchloride phosphate, DMSM hydantoin, laureth-23, citric acid, fragrance / 6.09
Super Dooper Diaper Doo / Peacock Pharmaceuticals
Springfield, Mo / Lanolin, petrolatum / 5.75
Vaseline / Cheseborough-Ponds
Greenwich, Conn / White petrolatum USP / .29
Zinc oxide ointment / E. Fogera
Melville, NY / 20% zinc oxide, mineral oil, white wax, white petroleum base / .56

Eichenfield, LF, Frieden, IJ, Esterly, NB. 2001. Textbook of Neonatal Dermatology. Philadelphia: WB Saunders.