Challenges in Neonatal Nursing:

Providing Evidence-Based Skin Care Susan Arana Furdon, MS, RNC, NNP

Authors and Disclosures

Posted: 11/25/2003; Updated: 12/18/2003

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In 1997, the Association of Women's Health, Obstetric and

Neonatal Nurses (AWHONN) and the National Association of

Neonatal Nurses (NANN) began the development of a research

utilization project called Neonatal Skin Care. The evidence-based

clinical practice guideline provided recommendations for neonatal

skin care that were initially implemented in 58 participating

institutions and then described and disseminated in the

literature.[1-3] Skin care recommendations were ambitious,

covering topics of skin assessment, bathing, cord care,

circumcision care, disinfectants, diaper dermatitis, emollients,

adhesives, transepidermal water loss (TEWL), skin breakdown,

intravenous infiltration, and skin nutrition.

Since the publication of the initial evidence-based clinical

guideline, additional research related to neonatal skin care has

been published and new products are available. Evaluating that

research and defining care practices within each of our institutions

continues to be a challenge for the neonatal care team. NANN's

Annual Meeting provided the forum for presentation of new skin

care research and quality improvement initiatives as well as an

evaluation of the current literature related to skin care practices.

New Skin Care Research

Carolyn Lund, MS, RN, FAAN, Children's Hospital, Oakland,

California, a member of the Evidence-Based Clinical Practice

Development team, presented a poster on the clinical outcomes

of the AWHONN/NANN clinical practice guideline.[4] The clinical

practice guideline provided the studied institutions with a

foundation for practice that was integrated into care. Statistically

significant changes in practice were described after

implementation of the skin care guideline: bathing frequency

decreased and emollient use increased yet there was no increase

in positive blood cultures. Using a standardized assessment

score, the Neonatal Skin Condition Score (NSCS), there was a

statistically significant improvement in skin condition noted in both

well newborns and premature newborns after implementation of

the evidence-based neonatal skin care guideline.

Dolores Quinn, RN, NNP,[5] UCSF Medical Center, San Francisco,

California, presented the results of a randomized controlled trial

that compared the impact of bathing every other day vs every

fourth day on skin flora type and colony count in premature infants

25 to 33 weeks of gestation. There was no statistical significance

between the groups. Skin flora and colony count did not increase

with the increased interval between bathing. The limitations of the

study include the small sample size. This research supports the

skin care practice recommendation related to bathing, which limits

bathing frequency to 2-3 times per week and attempts to define a

bathing timetable that is safe, as defined by increase in skin

colony counts and infection.

Quality Improvement Initiative: Skin Care and

NCPAP

Tissue irritation and pressure necrosis of the nasal septum related

to the use of nasal continuous positive airway pressure (NCPAP)

has been discussed among nurses and other professionals but

not extensively described in the literature. Figure 1 illustrates

septal erosion as a result of pressure necrosis from an NCPAP

device.

Figure 1. Note septal erosion as a result of pressure necrosis

from NCPAP device. Photo courtesy of Dr. David A. Clark,

Pediatric Department Chairman @ Albany Medical Center,

Albany NY

Clinically, there are morbidities associated with nasal skin

breakdown that include infection, scarring, reintubation, and

prolonged time of intubation. There is no published research,

however, that evaluates the effect of specific nursing practice on

preventing or reducing breakdown due to nasal prongs. Linda

Dickison, RN, CCRN, and Laura Garland RN,[6] Alta Bates Summit

Medical Center, Berkeley, California, provided an exciting

overview of this institution's quality improvement initiative to

reduce nasal skin breakdown. Individual initiatives to improve skin

care (various skin barrier materials) did not relieve the problem of

pressure on the skin and septum. A team of nurses on all shifts

utilized the Plan-Do-Study-Act (PDSA) model for improvement.

Nursing management was modified to include the following:

Adjusting the height and level of the bed in the isolette to

maintain the tubing circuits on a direct path from nares to

NCPAP driver, which:

o Prevented pressure on the nares

o Provided an additional benefit of less "rain out" from the

tubing, thereby reducing the need for suctioning

Using a checklist at the bedside to provide consistency of

practice related to positioning, skin assessment, and sizing

of the NCPAP bonnet

Use of a plastic wheel to provide support for the NCPAP tubing

actually resulted in a decrease in flexibility of the tubing when the

infant moved. As a result, the use of the wheel for stabilization

was disbanded.

The researchers tracked 90 infants requiring NCPAP over 9

months (mean time on NCPAP: 23.7 days). Infant weights were

500-1250 g. During that time, there were no new cases of skin

breakdown. Future challenges include replication of this quality

improvement initiative at other institutions.

Update on Neonatal Skin Care Guideline

Carolyn Lund, RN, MS, FAAN,[7,8] provided a half day overview of

evidence that supports current neonatal clinical skin care practice.

An evaluation of recent research was discussed.

Bathing: The consequences of routine bathing include dryness,

irritation, and destabilization of vital signs and temperature. In

addition, rubbing of skin is very painful for the newborn. The first

bath should be done after the infant's temperature has stabilized

for 2 to 4 hours. Warm water (without soaps) the first week of life

is optimal. Thereafter, recommendations for bathing include:

Using cleansing agents with neutral pH

Reducing prolonged skin contact with cleansing agents by

rinsing the skin

Bathing only 2 to 3 times per week

Skin disinfectants: Isopropyl alcohol is a poor skin disinfectant

and has been associated with the greatest amount of tissue

damage in newborn infants.[9] Povidone iodine is more efficacious

than isopropyl alcohol[10]as a disinfectant, but povidone iodine can

be absorbed systemically and alterations in newborn thyroid

function can result.[11] This disinfectant can also cause skin

irritation and tissue damage, as seen in Figure 2. Efficacy of

chlorhexidine (CHG) in reducing infection has been demonstrated

in adults and newborns.[12,13] Skin damage specific to CHG has not

been noted clinically. Both safety and efficacy of a product are

important considerations in choosing an antiseptic for clinical use.

For neonates, isopropyl alcohol or products containing isopropyl

alcohol are not recommended in the skin care guideline. Povidone

iodine or CHG solutions are recommended but require complete

removal after the procedure with sterile water or saline to prevent

absorption.

Figure 2. Abdominal skin tissue injury as a result of topical

application of a disinfectant.

Photo courtesy of Dr. David A. Clark, Pediatric Department

Chairman @ Albany Medical Center, Albany NY

Adhesives: The infant has increased evaporative losses after

adhesive tape removal. Adhesives become more aggressive over

time.[14]However, solvents are highly toxic and are absorbed

through the skin, so should not be used in newborns. Skin

stripping and tearing as well as chemical irritation are seen with

the use of bonding agents. Figure 3 shows electrodes with

adhesive bonding leading to skin tissue injury. Preventing skin

injury is a nursing art:

Minimize the use of tape or "double-back" the tape

Use pectin barriers under adhesives

Use hydrogel or karaya electrode leads

Figure 3. Electrodes with adhesive bonding caused this skin

tissue injury. The skin care guideline recommends the use of

hydrogel electrodes. Photo courtesy of Dr. David A. Clark,

Pediatric Department Chairman @ Albany Medical Center,

Albany NY

Emollients: Emollients prevent desquamation of the stratum

corneum, the outer layer of cells that form the epidermal

barrier. Aquaphor ointment can be used on an "as-needed" basis

to treat dryness and prevent cracking of skin. Prevention of

excoriation is seen with the use of Aquaphor ointment on the

groin and thighs. There may be a possible increase in coagulase

negative staph (CONS) infection in infants < 750 g with

the routine topical application

of Aquaphor ointment.[15] Aquaphor must be applied every 6 hours

to be effective in reducing TEWL.

Skin maturation and TEWL: Postnatal maturation of the stratum

corneum affects the rate of water loss. The skin barrier matures

between 30 and 32 weeks corrected gestational age. Skin

maturation is not based on the number of postnatal

days.[16] Relative humidity decreases transepidermal fluid losses

and required fluid intake. The recommendation for humidity is >

70% relative humidity for the first week and 50% to 60% for the

rest of the first month. A bedside hydrometer assists the nurse in

reaching humidity goals better than visualizing condensation.

Skin breakdown: Adhesive tape removal is the primary risk

factor for traumatic injury to the newborn. Ulcerative erosions are

often associated with systemic bacterial or Candida sepsis, with

areas of skin breakdown as the portal of entry.[17] Early recognition

of skin breakdown and identification of the pathogen with a Gram

stain can be essential elements in the reduction in mortality.

NCPAP and skin: Key elements related to NCPAP and skin care

are:

Use appropriate sized prongs to make a seal for the

transmission of pressure

Do not create seal from pressure on the nares

Use the equipment manual to define practices related to

securing the device

Suction and inspect the skin every 4 hours

Massage the skin with each inspection

Guidelines for Clinical Practice

Evaluation and implementation of research-based evidence is the

foundation of nursing care. Implementation of the AWHONN-

NANN Skin Care Guideline improves overall skin condition of

newborns and reduces iatrogenic injury. Nurses need to continue

to review and evaluate new research and products for

implementation in their practice as well as conduct/support new

research that describes skin care practices with clinical outcomes.

References

1. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines

DA. Neonatal skin care: clinical outcomes of the

AWONN/NANN evidence-based clinical practice guideline.

Association of Women's Health, Obstetric and Neonatal

Nurses and the National Association of Neonatal Nurses. J

Obstet Gynecol Neonatal Nurs. 2001;30:41-51. Abstract

2. Lund CH, Kuller J, Lane AT, Lott JW, Raines DA, Thomas

KK. Neonatal skin care: evaluation of the AWHONN/NANN

research based practice project on knowledge and skin care

practices. Association of Women's Health, Obstetric and

Neonatal Nurses/National Association of Neonatal Nurses. J

Obstet Gynecol Neonatal Nurs. 2001;30:30-40. Abstract

3. Lund C, Kuller J, Lane L, Lott JW, Raines DA. Neonatal skin

care: the scientific basis for practice. J Obstet Gynecol

Neonatal Nurs. 1999;28:241-254. Abstract

4. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines

DA. Neonatal skin care: clinical outcomes of the Association

for Women's Health, Obstetric and Neonatal Nurses

(AWHONN) and the National Association of Neonatal

Nurses (NANN) Clinical Practice Guideline. Program and

abstracts of the National Association of Neonatal Nurses

19th Annual Conference; October 8-11, 2003; Palm Springs,

California. Poster #103.

5. Quinn D. Effect of less frequent bathing on premature infant

skin. Program and abstracts of the National Association of

Neonatal Nurses 19th Annual Conference; October 8-11,

2003; Palm Springs, California. Poster #117.

6. Dickison, L. Garland L. Nursing management of NCPAP in

preterm neonates: evidence based reduction of skin

breakdown. Program and abstracts of the National

Association of Neonatal Nurses 19th Annual Conference;

October 8-11, 2003; Palm Springs, California.

7. Lund CH. Update on the neonatal skin care guideline:

bathing, disinfectants, adhesives, emollients, diaper

dermatitis and IV infiltrates. Program and abstracts of the

National Association of Neonatal Nurses 19th Annual

Conference; October 8-11, 2003; Palm Springs, California.

8. Lund CH. Special skin care issues for the ELBW infants:

TEWL management, emollients and infection, invasive

fungal dermatitis and NCPAP. Program and abstracts of the

National Association of Neonatal Nurses 19th Annual

Conference; October 8-11, 2003; Palm Springs, California.

9. Darmstadt G, Dinulos J. Neonatal skin care. Pediatr Clin

North Am. 2000;47:757-782. Abstract

10. Choudhuri J, McQueen R, Inoue S, Gordon RC.

Efficacy of skin sterilization for a venipuncture with the use of

commercially available alcohol or iodine pads. Am J Infect

Control. 1990;18:82-85. Abstract

11. Linder N, Davidovitch N, Reichman B, et al. Topical

iodine-containing antiseptics and subclinical hypothyroidism

in preterm infants. J Pediatr. 1997;131:434-439. Abstract

12. Maki D, Ringer M, Alvarado C. Prospective randomized

trial povidone-iodine, alcohol and chlorhexidine for

prevention of infection associated with central venous and

arterial catheters. Lancet. 1991;338:339-343.Abstract

13. Garland JS, Buck RK, Maloney P, et al. Comparison of

10% povidone-iodine and 0.5% chlorhexidine gluconate for

the prevention of peripheral intravenous catheter

colonization in neonates: a prospective trial. Pediatr Infect

Dis J. 1995;14:510-516. Abstract

14. Hoath S, Narendran V. Adhesives and emollients in the

preterm infant. Semin Neonatol. 2000;5:112-119.

15. Edwards W, Conner J, Gerdes J, et al. The effect of

Aquaphor ointment on nosocomial sepsis rates and skin

integrity in infants of birthweights 501-1000g. Program and

abstracts of Hot Topics Neonatology Conference; December

3-5, 2000; Washington, DC.

16. Agren J, Sjors G, Sedin G. Transepidermal water loss

in infants born at 24 and 25 weeks of gestation. Acta

Paediatr. 1998;87:1185-1190. Abstract

17. Rowan JL, Atkins JT, Levy ML, Baer SC, Baker C.

Invasive fungal dermatitis in the < or = 1000 gram neonate.

Pediatrics. 1995;95:682-687. Abstract

Contents of Highlights of the National Association of Neonatal Nurses (NANN) 2003 Annual Conference

1. Challenges in Neonatal Nursing: Providing Evidence-Based Skin Care

2. Stemming the Rising Tide of Prematurity 3. Embracing the Future of Neonatal Nursing