Challenges in Neonatal Nursing:

Providing Evidence-Based Skin

Care
Authors:Susan Arana Furdon, MS, RNC, NNPFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED
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:

 Prevented pressure on the nares

 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