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Evidence-Based
Skin Care for Newborns
PNANN 2015
Objectives
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Terrie Lockridge, MSN, RNC-NIC
Perinatal Neonatal Consulting & Swedish Medical Center
[email protected]
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The skin is largest
organ in the body
Preterm skin makes
up 13% of weight,
versus 3% of adult
Skin integrity
essential to survival
 any break is
portal of entry
Basic Components of the Skin
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Discuss pertinent elements of national
guidelines related to NB skin care
Identify areas in your setting that might
be enhanced by use of guidelines
Format:
 basics of skin structure and function
 factors that influence skin integrity
 2013 guidelines on neonatal skin care
Epidermis: barrier against toxins and
bacteria, retains both heat and water
 exfoliating dead cells
Dermis: collagen and elastin fibers that
provide strength and elasticity
 blood vessels and nerves
 60% as thick as an adults
Subcutaneous tissue: insulation, shock
absorption and calorie storage area
 fatty connective tissue
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Factors that Influence Skin Integrity
Skin pH
 pH <5 offers bacteriocidal quality
 acid mantle = barrier to microorganisms
 term skin pH >6 at birth, <5 by 4 days
 preterm “mantle”, pH<5
not until ~ month
 with alkaline soap need
> hour to drop pH <5
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Factors that Influence Skin Integrity
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Skin Maturation
 fetal skin development
follows clear pattern
 at term, barrier function similar to adult
 preterm change from aquatic to aerobic
conditions accelerates maturation
 delayed in lower GA
Factors that Influence Skin Integrity
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Stratum corneum less keratinized and
thinner as GA decreases
 term 10-20 layers
 preterm 2-3 layers
Epidermis of preterms > 26 wks improved
barrier function within several weeks
 delayed to 30-32 wks if < 26wks
Preterm skin permeable to toxins &TEWL
Barrier function limited for first year
Factors that Influence Skin Integrity
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2013
Guidelines
Preterm Cohesion
 epidermis & dermis linked by thin fibrils
 stronger and more numerous with age
 diminished cohesion between layers, at
risk for epidermal stripping
 bond between skin and
adhesives may be stronger
than bond between skin layers
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Vernix: Nature’s
Waterproofing
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Decreases skin permeability and TEWL
Cleanses and moisturizes skin
Protects against infection
Reduces pH and creates “acid mantle”,
inhibits growth of pathogenic bacteria
Temperature regulation
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Vernix
Bathing
Cord care
Circumcision care
Diaper dermatitis
Disinfectants
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Adhesives
Skin breakdown
IV infiltrates
Emollients
TEW
Nutrition
Bathing: General
Considerations
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Staff and family: hand washing with antibacterial cleanser prior to bathing
 Community acquired infections
 Tub disinfection
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Skin Cleansers
First Bath
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Once thermal and CR stability achieved
Goal: Remove unwanted soils (meconium,
blood) and leave residual vernix intact
 Universal precautions
 Minimal amount of pH –neutral or
slightly acidic cleanser to assist with
removal of blood and amniotic fluid
Product Selection
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No specific products
Minimal product use
Potential toxicity, especially if preterm
Avoid unnecessary exposure to chemicals
A benchmark investigation of industrial
chemicals, pollutants and pesticides in
umbilical cord blood Environmental Working Group, 2005
 ~200 chemicals detected per baby
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Routine Bathing: Term Newborns
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Bathing is not an innocuous procedure
Daily bath not clearly justified for NB
May bathe every few days “to remove
debris and for general hygiene“
Shampoo X1-2/week
Immersion or swaddle
bathing preferred
over sponge bathing
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Cleansers with least irritating ingredients
 Neutral or mildly acidic pH (5.5-7.0)
 Preservatives with demonstrated
safety in newborns
 No antimicrobial soaps
 Avoid soap-based products
Baby Care Products: Possible
Sources of Infant Phthalate
Exposure, Pediatrics, Feb’ 08
Infants may be absorbing phthalates
through commonly used baby products
Authors recommend reducing exposure
Immersion Bathing
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Stable infants
safely immersed
No increase in rate of
bacterial colonization or infection of cord
Immerse entire body (except head and
face) with warm water (100.4ºF or 38 ºC)
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Swaddle Bathing
Routine Bathing: Preterm Infants
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Routine Bathing: Preterm < 32 Weeks
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Vulnerable to disruption and toxicity
from topically applied substances
 Water baths only during first week
 Warm sterile water if breakdown
Soft cloth, avoid rubbing
Sponge baths stressful
Swaddled or immersion
bathing preferable
Cord potential port of
Cord Care
entry for invasive
bacterial pathogens
Good hand hygiene to
avoid community-acquired
infections such as MRSA
Dry cord care leads to
shorter separation times
Topical drying agents: no
benefits on separation,
colonization, or infection
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Should not be bathed daily
“The bathing schedule for preterm
infants should be based upon the
infant’s physiologic condition and
behavioral state”
Bathing and Temperature Control
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After bath, dry/diaper baby
Double wrap in blankets with cap for head
Ten minutes later…dress the baby, change
the cap and wrap in dry warm blankets
 large drops in temp
noted 10 min post bath,
due to dampening of
clothing
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Cleanse cord during first bath with
water or cleanser of choice
 Dry thoroughly with clean gauze
If soiled, clean with water and dry
Keep cord clean/dry outside diaper
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Disinfectant Dilemma
Educate Parents about Cord Care
Hand hygiene
Keep clean and dry
Moist, mucky
appearance is normal
Redness, swelling and
drainage abnormal
Allow cord to fall off
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Evidence is insufficient to recommend a
single product for all newborns.
 Efficacy
 Potential for toxicity
 Skin irritation or breakdown
Disinfectants: The Competitors
Isopropyl alcohol
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Isopropyl alcohol
10% Povidone-iodine (PI)
Chlorihexidine gluconate (CHG)
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Povidone iodine (PI)
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10% aqueous solution
Single use products
Better than alcohol for skin disinfection
Apply and allow to dry for 30 sec
Remove completely after use
Risk of absorption: Elevated iodine levels
and thyroid suppression
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Drying to skin and is least effective
Avoid use as primary disinfectant
Don’t use to remove either CHG or PI
Chemical burns in preterms
Use to disinfect needleless connectors
and other access ports, preventing BSI
2% Chlorhexidine
Gluconate (CHG)
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Used in aqueous solutions and in
combination with isopropyl alcohol
Bactericidal properties, effective against
gram positive and negative organisms
Also binds to protein in stratum corneum,
leaving residual bactericidal effect that is
resistant to alcohol removal
5
Meta-analysis of eight studies (n=4143
catheters) in adults determined CHG
disinfection reduced BSI risk by 49%
2% Chlorhexidine gluconate (CHG)
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But, current CDC guidelines indicate that
there is insufficient evidence to make a
recommendation about safety or efficacy
of CHG products
in infants less than
two months of age
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2% Chlorhexidine gluconate (CHG)
Per 2012 FDA regulations, some
CHG/alcohol-containing products are
now labeled: ”Use with care in preterm
infants or in infants less than 2 months
of age. These products may cause
irritation or chemical burns”
NICU’s may use the
product “off label” as
indicated for disinfection
Chlorhexidine Gluconate Options
Systemic toxicity not yet seen in NB’s
 Local reactions to impregnated dressings
 European use for ~ 30
years, increasingly in US
& Canada in recent years
 Chemical burns in VLBW
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2% Aqueous CHG, poured
onto applicators or 2X2’s
Chloraprep: 2% CHG
in 70% isopropyl alcohol
Disinfectant Options: “Insufficient
evidence to recommend a single product”
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2% Aqueous CHG
Chloraprep for larger
infants, PI or 2%
Aqueous CHG for
infants < 1500 grams
10% PI for all NB’s, all
procedures
Disinfectant Dilemma
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Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
All have potential to damage skin and
interfere with tissue function
 Disinfectants kill bacteria
 Damage or destroy fibroblasts and
keratinocytes in healing wounds
Limit time and area of exposure
Remove with sterile water or saline
6
Adhesive Damage is Painful
Adhesives
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Primary cause of skin
breakdown
Strips epidermis,
disrupts barrier
Use sparingly
Double back tape
Avoid bonding agents,
solvents, bandages
after drawing labs
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Adhesive Options
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Pectin or Hydrocolloid Barriers
Hydrogel electrodes
Semipermeable dressings
 Allow skin to “breathe”
 IV’s, PICC’s, NG/OG’s
and nasal cannulas
Stretchy gauze to secure electrodes,
probes and limbs to armboards
“Tender grips” adhesive circles for NC
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Shown to improve adherence to wounds,
reduce discomfort during tape removal
Holds promise for new products that
adhere, with minimal trauma upon removal
Mepitac: soft silicone layer that provides
secure fixation but no epidermal stripping
Secure non-life
sustaining devices
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Shown to cause skin trauma equal to
tape when removed at 24 hours
Absorbs moisture, molds well to skin
surface, and prevents application of
tape directly to face
Useful with ETT, NC
for extended periods
Minimize Risk of Breakdown
Silicone Based Adhesive Products
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Remove using water-soaked cotton balls,
pull tape at low level, parallel to skin
 petrolatum if re-taping not anticipated
Anetoderma: Atrophic patches of skin
due to dermal thinning
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Reposition medical devices
Water/air/gel mattress
Sheepskin/soft surfaces
Transparent dressings
over bony prominences
Petrolatum-based
ointments to groin/thigh
of VLBW infants
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Skin Breakdown
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Culture and treat if
signs of bacterial or
fungal infection
Cleanse affected area
 Sterile water/saline
 No disinfectants
 Debride, don’t scrub
Moistening tissue
facilitates healing
“Moist Healing” Environments
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Dressing: Occlusive, nonadherent, and
provides moist healing that promotes
rapid migration of epithelial cells and
protects wound from further injury
Use hydrogel, transparent dressings and
hydrocolloids and leave in place for
extended periods (remoisten hydrogels)
Serous exudate often forms (leukocytes)
Wound care options
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Wound care options
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Hydrogel (Vigilon,
Flexigel or Transgel)
 infected wounds in
conjunction with
antifungals or
antibacterials
Mepitel, Mepilex soft
silicone dressing
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Transparent dressings
(Tegaderm)
 uninfected wounds
Hydrocolloid (Duoderm)
 deep and/or
uninfected wounds
 absorbs exudate and
acts as barrier
Emollients
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Products should be
petrolatum-based, water
miscible, no preservatives,
perfumes and dyes
 Unit dose or single
patient use
 May be used with
photoRX/warmers
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Emollients
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Protect integrity of stratum corneum and
enhance barrier function
Restore skin integrity
 Gentle application at first sign of
dryness, fissures or flaking
 Watch for signs of
systemic infections,
especially < 750 gms
Petrolatum-based ointments
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For uninfected or infected
lesions (after cleansing and
application of antibacterials)
Improves healing, reduces
skin growth of gram neg
organisms, and decreases
severity of dermatitis
Cautious use < 750 gms
Not for fungal lesions
Routine Emollient Use in VLBW
Routine Emollient Use in VLBW
Early emollient studies showed no increase
in colonization patterns (Lane & Drost, 1993, Nopper
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et al, 1996, Pabst et al, 1999)
RCT: Association between emollients used
twice daily X2 wks and coagulase-negative
S. epi in subset of infants < 750 grams.
No difference in gram-negative bacterial
or fungal infections Edwards et al, 2004
Emollients used to treat dry skin during
RCT did not increase infection rates
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Transepidermal Water Loss
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Increased TEW and evaporative
heat loss in infants <30 wks
 At 23-25 wks have TEWL X10 > term
Use a single method or combination of
techniques to limit TEWL and heat loss
 Need more fluids if TEWL not limited
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Benefits of emollient use for
prevention of dermatitis and skin
breakdown should be weighed against
risk of infection
Strategies to Reduce TEWL
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Polyethylene wrap at birth
Supplemental conductive heat
Semipermeable transparent dressings
Polyethylene coverings or blankets
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Humidity: Reducing TEWL
TEWL depends on ambient
water vapor pressure
Raising ambient humidity increases
water vapor pressure, and decreases
fluid and heat loss via evaporation
Humidity 70 - 90% for first 7 days
After first week, gradually reduce to
50% until baby is 28 days old
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Strategies to Reduce TEWL
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Humidity
 Newer isolette designs include servocontrolled humidification using
sterile water sources, eliminates
reservoir as source of contamination
 Actively generated humidification
systems don’t cause air-borne
aerosols that could be contaminated
with microorganisms
Evidence-Based Care
of Diaper Dermatitis
Heimall, et al. 2012.
Beginning at the
Bottom: EvidenceBased Care of Diaper
Dermatitis. MCN:
American Journal of
Maternal Child
Nursing, 37(1), 10-16
NICU Best Practice Committee
Swedish Medical Center
DD: Multifactorial Etiology
Diaper Dermatitis
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Acute inflammatory reaction of the skin
First signs are erythema and mild scaling
If not treated promptly, can progress to
painful excoriated or ulcerated lesions
Multifactorial etiology includes moisture,
warmth, friction, urine and feces
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Association of
Women’s Health,
Obstetric and
Neonatal Nurses
(AWHONN). 2013.
Neonatal Skin Care:
Evidence Based
Clinical Practice
Guideline, 3rd Ed
Trapped moisture (urine) against skin
 Increases pH of skin surface, limits
ability to maintain normal microflora
 Increases skin permeability
 Vulnerable to damage from friction
 Can activate fecal enzymes: irritants
that can cause skin destruction
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DD: Multifactorial Etiology
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Skin loses ability to act as barrier
against irritants and microbes
As skin becomes damaged, microbes are
more likely to cause inflammation
Can lead to development of secondary
infections (bacterial or fungal)
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Diaper Dermatitis Hurts
Erythema indicates
that epidermal layer
has been damaged,
and that the dermis
(with sensory nerve
endings) is exposed
to air, urine and stool
Candida is often opportunistic invader
when simple diaper rash is untreated
Common after antibiotic use
Beefy red skin
Oval/dotty lesions
scattered at edges
(satellite lesions)
Slightly raised
Often in skin folds
Skin may or may not be denuded
Goal: Prevent DD whenever possible, using
an evidence-based algorithm for every baby
Heimall, et al. 2012. Beginning at the
Bottom: Evidence-Based Care of Diaper
Dermatitis. MCN: American Journal of
Maternal Child Nursing, 37(1), 10-16
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
11
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Concern about prevalence of DD
 Incidence was 24% at onset of project
Numerous DD concoctions and “potions”
Treatment plan changed shift to shift
Interdisciplinary task force included
wound ostomy continence nurse, nurse
researcher, pharmacist, four CNS’s
(NICU, surgery, oncology, chronic care)
Focus groups with ~ 50 bedside nurses
2012,
Literature
Search
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Choosing our Barrier Products
Environmental Working Group
http://www.ewg.org/skindeep
 Petrolatum: Vaseline
 Minimal ingredients
 Preventive measure
 Zinc Oxide: Desitin Maximum Strength
Paste (40% zinc oxide)
 Highest concentration of zinc oxide
 Shorter term used anticipated
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Reviewed national skin care guidelines,
pharmacy and nursing list-serves
Consulted with topic experts and other
pediatric hospitals about their practices
Complete literature search
 Levels I-VII
 Very few systematic reviews or RCT’s
 Mostly nonrandomized trials, single
descriptive studies, expert opinions
Highest level evidence is unavailable
Consensus of lower levels of evidence
around effective barriers
Literature supports that petrolatum
and/or zinc oxide provide effective
barriers against potential perineal
skin irritants and maceration
 Vaseline and Desitin
Barrier Products
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Initial application to clean, dry skin
Prevent skin breakdown
Protect injured skin with thick layer
of barrier product: “Icing on a cake”
Allows “moist healing”
environment (not wet)
to protect healing skin
12
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Less comfortable
since it exposes
dermal layer to air
Exposes healing
tissue to re-injury
from irritants like
stool and urine
Prevents faster
healing from moist
wound healing
environment
Diaper Wipes
Diaper Changes & Barrier Products
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Prevent breakdown
Protect healing skin
Remove only soiled layer
Cleanse gently and avoid rubbing product
off, pat dry
Replace product prn to clean, dry skin
Parent teaching
Assessment: Intact Skin
No Erythema
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Goal: Prevent skin breakdown
Treatment: Vaseline
Application Instructions: Apply thick layer of
Vaseline over entire area to be protected (think
“icing on cake”).
With Diaper Changes: Try to remove only stool
Leave barrier of Vaseline on skin if possible
Replace any Vaseline that came off.
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Assessment: After All Meconium Passed
High Risk for Breakdown
Intact Skin
With or Without Erythema
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Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
Some contained preservatives, alcohol,
and perfumes that could irritate skin
Newer formulations with fewer additives
reported to be well tolerated and mild
Soft cloth with water, or mild cleanser
and water are also acceptable options
Frequent diaper changes (Q 1-3 hours
during day and at least once during night)
Goal: Prevent skin breakdown, Provide barrier
Treatment: Desitin
Application Instructions: Apply thick layer of
Desitin over entire area to be protected (think
“icing on cake”).
With Diaper Changes: Try to remove only stool
Leave barrier of Desitin on skin if possible
Replace any Desitin that came off.
13
Assessment: Intact Skin
Erythema
No Candida
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Goal: Prevent skin breakdown, Provide barrier
Treatment: Desitin
Application Instructions: Apply thick layer of
Desitin over entire area to be protected (think
“icing on cake”).
With Diaper Changes: Try to remove only stool.
Leave barrier of Desitin on skin if possible
Replace any Desitin that came off.
Assessment: Denuded Skin*
No Candida
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Goal: Prevent further breakdown, Provide barrier
Treatment: Adapt Stoma Powder, then Desitin.
If no improvement, use “sealing” technique
Application Instructions: Apply Adapt
powder to denuded areas. May use cotton
ball to spread evenly. Powder will stick to
open skin. Apply thick layer of Desitin on
top of powder.
Assessment: Denuded Skin*
Candida
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Goal: Prevent further breakdown, Treat candida,
Provide barrier
Treatment: Antifungal Powder, then Desitin. If
no improvement, use “sealing” technique
Application Instructions: Apply antifungal
powder to denuded areas. May use cotton
ball to spread evenly. Powder will stick to
open skin. Apply thick layer of Desitin on top
of powder.
Assessment: Intact Skin
Erythema
Candida
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Goal: Prevent skin breakdown, Treat candida,
Provide barrier
Treatment: Antifungal Ointment, then Desitin
Application Instructions: Apply antifungal as
ordered and cover with Desitin (“icing on cake”).
With Diaper Changes: Try to remove only stool.
Leave barrier of Desitin on skin if possible
Scheduled Antifungal Doses: Gently remove any
residual products to allow assessment of skin,
then reapply both antifungal, then Desitin
Assessment: Denuded Skin
No Candida
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Diaper changes: Try to remove only stool. Leave
barrier on skin if possible. Replace product that
came off. If skin showing: Replace Adapt powder,
then Desitin. If powder showing: Replace Desitin
“Sealing Technique”: Apply Adapt powder as
previously described, then dab on
No-Sting Barrier* to seal powder.
Allow to dry and repeat process.
Layer with Desitin
Assessment: Denuded Skin
Candida
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Diaper changes: Try to remove only stool. Leave
barrier if possible. Replace product that came
off. If skin showing: Replace antifungal powder,
then Desitin. If powder showing: Replace Desitin
“Sealing Technique”: Apply antifungal powder as
previously described, then dab on No-Sting
Barrier* to seal powder. Allow to dry and repeat
process. Layer with Desitin
(*No-Sting Barrier is for use in babies > 28 days, and can also be
applied prior to application of any barrier products)
* Denuded skin: Moist, open, oozing ulcerations
Terrie Lockridge, MSN, RNC-NIC
www.perinatalneonatalconsulting.com
Pacific NW Association of Neonatal Nurses, 2015
14