Evidence-Based Objectives Skin Care for Newborns …pnann.homestead.com/Skin_Care_Update_Lockridge_PNANN...Skin integrity essential to survival any break is portal of entry Basic Components

Terrie Lockridge, MSN, RNC-NICwww.perinatalneonatalconsulting.comPacific NW Association of Neonatal Nurses, 2015 1

Evidence-Based Skin Care for Newborns

PNANN 2015

Terrie Lockridge, MSN, RNC-NICPerinatal Neonatal Consulting & Swedish Medical Center

[email protected]

Objectives

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

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

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

Factors that Influence Skin IntegritySkin 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


Factors that Influence Skin Integrity

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


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


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

2013Guidelines

Vernix

Bathing

Cord care

Circumcision care

Diaper dermatitis

Disinfectants

Adhesives

Skin breakdown

IV infiltrates

Emollients

TEW

Nutrition

Vernix: Nature’s Waterproofing

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

Bathing: General Considerations

Staff and family: hand washing with anti-bacterial cleanser prior to bathing

Community acquired infections

Tub disinfection


First Bath

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

Skin Cleansers

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

Product Selection

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

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

Routine Bathing: Term Newborns

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

Immersion Bathing

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)


Swaddle Bathing Routine Bathing: Preterm Infants

Should not be bathed daily “The bathing schedule for preterm

infants should be based upon the infant’s physiologic condition and behavioral state”

Routine Bathing: Preterm < 32 Weeks

Vulnerable to disruption and toxicityfrom 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

Bathing and Temperature Control

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

Cord Care Cord potential port of

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

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


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

Disinfectant Dilemma

Evidence is insufficient to recommend a single product for all newborns.

Efficacy

Potential for toxicity

Skin irritation or breakdown

Disinfectants: The Competitors

Isopropyl alcohol

10% Povidone-iodine (PI)

Chlorihexidine gluconate (CHG)

Isopropyl alcohol

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

Povidone iodine (PI)

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

2% Chlorhexidine Gluconate (CHG)

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


Meta-analysis of eight studies (n=4143 catheters) in adults determined CHG disinfection reduced BSI risk by 49%

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

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

2% Chlorhexidine gluconate (CHG) 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

Chlorhexidine Gluconate Options

2% Aqueous CHG, poured

onto applicators or 2X2’s

Chloraprep: 2% CHG in 70% isopropyl alcohol

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 Options: “Insufficient evidence to recommend a single product” Disinfectant Dilemma

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


Adhesives

Primary cause of skin breakdown

Strips epidermis, disrupts barrier

Use sparingly

Double back tape

Avoid bonding agents, solvents, bandages after drawing labs

Adhesive Damage is Painful

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

Adhesive Options

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

Pectin or Hydrocolloid Barriers

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

Silicone Based Adhesive Products

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

Minimize Risk of Breakdown

Reposition medical devices Water/air/gel mattress Sheepskin/soft surfaces Transparent dressings

over bony prominences Petrolatum-based

ointments to groin/thigh of VLBW infants


Skin Breakdown

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

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

Transparent dressings (Tegaderm)

uninfected wounds

Hydrocolloid (Duoderm)

deep and/or uninfected wounds

absorbs exudate and acts as barrier

Wound care options

Hydrogel (Vigilon, Flexigel or Transgel)

infected wounds in conjunction with antifungals or antibacterials

Mepitel, Mepilex soft silicone dressing

Emollients

Products should be petrolatum-based, water miscible, no preservatives, perfumes and dyes

Unit dose or single patient use

May be used with photoRX/warmers


Emollients 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

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

Early emollient studies showed no increase in colonization patterns (Lane & Drost, 1993, Nopper 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

Routine Emollient Use in VLBW

Benefits of emollient use for prevention of dermatitis and skin

breakdown should be weighed against risk of infection

Transepidermal Water Loss

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

Strategies to Reduce TEWL

Polyethylene wrap at birth

Supplemental conductive heat

Semipermeable transparent dressings

Polyethylene coverings or blankets


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

Strategies to Reduce TEWL

Humidity Newer isolette designs include servo-

controlled 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

NICU Best Practice Committee

Swedish Medical Center

Evidence-Based Care of Diaper Dermatitis

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

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). 2013. Neonatal Skin Care: Evidence Based Clinical Practice Guideline, 3rd Ed

Diaper Dermatitis

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

DD: Multifactorial Etiology

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


DD: Multifactorial Etiology

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)

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

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

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


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

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

2012,Literature Search

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

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

Barrier Products 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

http://www.ewg.org/skindeep


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 Changes & Barrier Products

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

Diaper Wipes

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)

Assessment: Intact SkinNo Erythema

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.

Assessment: After All Meconium PassedHigh Risk for BreakdownIntact SkinWith or Without Erythema

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: Intact SkinErythemaNo Candida

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: Intact SkinErythemaCandida

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

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 SkinNo Candida

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

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.

* Denuded skin: Moist, open, oozing ulcerations

Assessment: Denuded SkinCandida

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)

Documents

Evidence-Based Objectives Skin Care for Newborns …pnann.homestead.com/Skin_Care_Update_Lockridge_PNANN...Skin integrity essential to survival any break is portal of entry Basic Components