J Wound Ostomy Continence Nurs. 2014;41(3):219-221.
Published by Lippincott Williams & Wilkins
CHALLENGES IN PRACTICE
Application of a Pectin Barrier for
Medical Adhesive Skin Injury (Epidermal
Stripping) in a Premature Infant
Amanda O’Neil  Bette Schumacher
■ ABSTRACT
BACKGROUND: Premature infants require, as part of their
care, devices such as monitors and temperature probes
to be attached to their skin. However, because of im-
maturity of the skin, they are especially vulnerable to
medical adhesive-related skin injury.
CASE: This case discusses the application of a hydrocol-
loid (pectin) barrier between the adhesive surface of a
silver reflective patch covering thermistor probe and the
neonate’s skin resulting in medical adhesive skin injury
(epidermal stripping).
CONCLUSIONS: The use of this pectin barrier proved to be
a suitable surface to secure the temperature probe and
avoid further medical adhesive-related skin injury.
KEY WORDS: Premature infant, Skin barrier, Skin stripping
■ Introduction
Because of advances in neonatal care, more immature in-
fants are receiving care in neonatal intensive care units
(NICUs). Immaturity influences multiple body systems
including lungs, the gastrointestinal tract, and skin.
Immature skin lacks connecting fibrils, layers of the stra-
tum corneum, and collagen, which can increase the risk of
medical adhesive-related skin injury associated with ap-
plication and removal of the continuous monitoring
equipment and adhesives.1
The immature skin of the premature infant is fragile
and development of this organ is incomplete. The protec-
tive top layers of the epidermis, known as the stratum cor-
neum, are often absent or sparse in the premature infant’s
skin. These layers take weeks or months to develop fully.2,3
Premature infants often have fewer fibrils that connect the
dermis to the epidermis. Skin injury, from adhesives from
devices attached to the infant’s skin, can result when the
bond between the adhesive and the epidermis is greater
than the bond between the epidermis and the underlying
dermis.1,3 Attachment of monitoring devices to the skin is
Copyright © 2014 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00072.indd 219
a routine part of care for immature infants. We describe a
case of epidermal stripping that occurred after the removal
of a device and a method to prevent it.
■ Case Presentation
Baby boy Smith was born after a 24-week pregnancy. His
mother had no prenatal care and initially presented for
care in active labor. Prior to delivery, she received a single
dose of an antibiotic and dexamethasone, a medication
given to increase infant lung maturity. In addition, Apgar
scores were calculated at 1 and 5 minutes. The Apgar scor-
ing system is a screening tool to evaluate a newborn’s con-
dition at birth and need for intervention.4 The following
5 variables are included: heart rate, respiratory effort, mus-
cle tone, reflex irritability, and color. A numerical score of
0 to 2 is assigned in each category for a maximum score of
10; higher scores (≥7) are considered within normal range
and lower scores indicate poorer overall condition. Baby
boy Smith’s Apgar scores were 5 at 1 minute and 7 at
5 minutes; the score of 5 at birth was attributable to
1 point off for all variables, indicating the need for inter-
vention. He was intubated at delivery and lung surfactant
was administered in the delivery room via tracheal tube to
alleviate breathing problems related to his immature
lungs. His birth weight was 650 g (1 lb 6 oz). His appear-
ance was typical for a very immature infant; he was ob-
served to have a hairless body and smooth, red, wrinkly,
nearly gelatinous skin. He required an isolette (incubator)
type bed to regulate his temperature. Attached to his skin
were 3 electrocardiography leads, an oxygen saturation
 Amanda O’Neil, RN, MS, Staff Nurse, and Nurse Practitioner Masters
Student, Sanford USD Medical Center, Sioux Falls, South Dakota.
 Bette Schumacher, RN, MS, CPN, Clinical Nurse Specialist, Sanford
USD Medical Center, Sioux Falls, South Dakota.
The authors declare no conflict of interest.
Correspondence: Bette Schumacher, RN, MS, CPN, Sanford USD
Medical Center, Sioux Falls, SD 57110 (Bette.Schumacher@
SanfordHealth.org).
DOI: 10.1097/WON.0000000000000029
J WOCN ■ May/June 2014 219
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 220 O’Neil and Schumacher
monitor, tape to secure the tracheal tube, and a reflective
patch to cover a temperature probe. An umbilical catheter
was stabilized on his abdomen.
Baby Smith required full ventilator support, vasopres-
sors, parenteral nutrition, and other medications. He did
not tolerate handling and bathing was deferred. The re-
flective patch was removed after 8 days when he was more
stable. A circular erythematous area approximately 1.5 cm
in diameter was noted on his skin surface after patch re-
moval, and epidermal tissue was noted on the reflective
patch. The circular wounded surface had small pinpoint
areas of bleeding with uniform redness over the entire
area. Within his wound, an indentation corresponding to
the size and location of the temperature probe was
observed. Electrocardiography leads were removed and
repositioned without evidence of skin damage. The elec-
trocardiography leads used at out facility do not contain
adhesive (Neotrode II, ConMed Corp, Utica, New York).
Rather, their backing has thin hydrocolloid as the “glue”
that attaches them to the infant’s chest.
All subsequent applications of the temp probe for Baby
Smith were done using the method described. No further
episodes of epidermal stripping resulted for this infant.
His injured area healed well without scar formation. No
other injuries were noted to his skin under the area of the
probe. Based on the experiences with Baby Smith, we have
implemented a change in practice to prevent epidermal
stripping with these fragile infants.
■ Discussion
Full-term infants are unable to create heat by shivering like
adults do. The primary mechanism to generate heat is called
nonshivering thermogenesis5; this process breaks down a
special type of fat (brown fat) that produces heat. Therefore,
because immature infants lack brown fat, they require a
neutral thermal environment that requires minimal oxy-
gen and calories in order to maintain body temperature.6
Neonatal intensive care units use special incubator-type
beds to maintain a neutral thermal environment.5
Temperature probes are commonly used in NICUs na-
tionwide in incubator-type beds and warmers. They mea-
sure skin temperature and act as feedback mechanism to
regulate the infant’s body temperature. The probe is usu-
ally covered with a silver reflective patch, enabling it to
measure the heat of the infant’s skin rather than the tem-
perature of the heat source. The surface of the reflective
patch is attached to the premature infant’s skin via an ad-
hesive. Placement of the probe is important because of its
influence on the accuracy of skin temperature measure-
ment. It should be secured at or about the costal margin of
the chest, midway between the xiphoid and the navel,
about the right upper quadrant of the abdomen. The tem-
perature probe does need to be repositioned to provide a
complete skin assessment and when bathing the infant. In
addition, these fragile infants should not lie on probes,
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00072.indd 220
J WOCN ■ May/June 2014
intravenous tubing, or other wires, as these can cause
device-related pressure ulcers.
Skin Care in the Premature Infant
Allwood7 reviewed the literature and concluded that re-
search focusing on skin care in premature infants is sparse.
Allwood discussed two studies by Lund and colleagues,3,8
which remain the most comprehensive studies to date. In
addition, a lack of published studies on the effects of topi-
cal agents on neonatal skin, particularly adequately sized
randomized controlled trials, has been noted.2,7 Use of
pectin barriers to protect the skin of premature infants was
first described by Dollison and Bestrand.9 Although this
practice is also recommended by Lund, universal adoption
of this practice is lacking.7
Protecting the epidermis from medical adhesive skin
damage can be facilitated through the use of a barrier
product. Morris and colleagues10 examined dressings with
soft silicone adhesive technology for pediatric patients.
A product option they described (Mepilex, Mölnlycke
Health Care, Norcross, Georgia) also might be used for
the purpose described in this case study. We did not trial
the silicone adhesive dressings for this purpose, as a pectin
product (DuoDERM Signal by ConvaTec) was readily
available and more familiar to us (Figure 1). Pectin barriers
(Hollihesive, Hollister, Libertyville, Illinois; Duoderm,
Step 1
Using a thin barrier wafer product, trace the
silver temperature relective patch and cut it out.
Step 2
Cut a slit up middle of barrier circle patch that
is about the size of the temperature probe.
Step 3
Place the barrier circle patch on infant.
Step 4
Place the temperature probe in the slit.
Step 5
Place the silver reflective temperature patch
over top of barrier circle patch and probe. Use
the thinnest reflector patch available.
Change barrier and temp patches every 7 days.
Document date to be changed in kardex. You
may also write the date to be changed on the
temp patch itself.
Finished Product!
FIGURE 1. Application of a pectin barrier.
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 J WOCN ■ Volume 41/Number 3
ConvaTec/Bristol-Myers Squibb Co, Princeton, New
Jersey) are available in a variety of sizes and thicknesses.
These dressings are made from a layer of gel-forming ma-
terial attached to a semipermeable film or foam backing.
Some are designed for specific areas of the body such as
the adult sacrum or heel. Some thinner dressings have ta-
pered edges that make them less likely to wrinkle or roll up
at the edges. These thinner products may also be semi-
transparent allowing the nurse to see the skin without the
need to remove the dressing.
Placing a thin barrier product underneath the area of
the adhesive lessens stripping as bonding between the skin
and the adhesive is prevented.7,9 The thin barrier pectin
product allows direct contact of the temperature probe to
the skin when cut as illustrated in Figure 1. However, care
must be taken to alternate the position of the temperature
probe, reflective cover, and barrier product to prevent the
pressure injuries from the temperature probe. Our nursing
protocol permits leaving the patch and probe in place for
up to 1 week. Nurses may reposition the probe and patch if
the baby’s temperature is not reading well.
This innovative practice impacted nursing practice
throughout our facility via a process of Shared Governance.
Our nursing practice council maintains an online informa-
tion site that is accessible to all the nursing staff. Electronic
instructions and pictures were posted to the site.
Information was shared at unit meetings. In addition, we
collaborated with Education Council to provide bathroom
posters: “Potty Ponders” as well as “Just in time” education
for those nurses who admitted babies to the NICU.
■ Summary
The case discussed in this “Challenges in Practice” column
illustrated the use of a thin hydrocolloid product to pro-
tect the skin from an adhesive surface required for place-
ment of a thermistor probe. After implementation of this
practice change, we no longer noted skin stripping due to
patch application and removal for this infant or others.
Rotation of the site of the temperature probe is important
Copyright © 2014 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00072.indd 221
O’Neil and Schumacher 221
to be able to assess all of the skin, as well as to prevent
pressure injuries. Adapting a hydrocolloid product in the
fashion demonstrated by us is not recommended to secure
life-sustaining equipment, such as an endotracheal tube,
as other devices are available designed specifically for this
purpose.11
■ References
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patient safety: state of the science. Consensus statements for
the assessment, prevention, and treatment of adhesive-related
skin injuries. J Wound Ostomy Continence Nurs. 2013;40:365-
380.
2. Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia
Bartels N. Skin care practices for newborns and infants: review
of the clinical evidence for best practices. Pediatr Dermatol.
2012;29(1):1-14.
3. Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin
care: the scientific basis for practice. Neonatal Netw. 1999;19(4):
15-26.
4. Rubarth L. The Apgar score: simple yet complex. Neonatal
Netw. 2012;31(3):169-176.
5. Knobel R, Holditch-Davis D. Thermoregulation and heat loss
prevention after birth and during neonatal intensive-care unit
stabilization of extremely low-birthweight infants. Adv Neo
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6. Baumgart S. Iatrogenic hyperthermia and hypothermia in the
neonate. Clin Perinatol. 2008;35:183-197.
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gestation: a review of literature. Neonatal Paediatr Child Health
Nurs. 2011;14(1):20-27.
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