Clinical Guidelines (Nursing)

Neonatal & infant skin care

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Links

    Evidence Table

    References


    Introduction

    Preservation of skin integrity, reduction of the potential development of atopic dermatitis (eczema) and education of parents is a key nursing priority in the care of the term and preterm infant. 
    The Stratum Corneum is the outermost layer of the epidermis which acts as mechanical barrier. It protects against toxins, irritants, allergens and pathogens, retains heat and water as well as maintaining a normal microbiome. 
    Understanding the physiological and anatomical skin differences of preterm and term baby skin is important to the Neonatal Intensive Care Nurse aiding thorough assessment and appropriate management of the skin. 
    This guideline is directed towards neonates (birth to 28 days of age) of all gestational ages.
    Please see Key differences in Infant Skin for further information on the structure and function of newborn skin.

    Aim

    To maintain skin integrity and minimise heat loss in the infant requiring hospitialisation. This is achieved by understanding the key differences of preterm and term infant skin enabling the NICU nurse to appropriately assess and manage our neonatal population using evidence based practice. 

    Definition of Terms

    • Atopy - Family history of eczema, asthma or allergic rhinitis
    • Stratum Corneum - The outer most layer of the epidermis acting as a mechanical barrier
    • pH - A figure representing the acidity or alkalinity of a solution on a logarithmic scale where 7 is neutral, < 7 is more acidic and > 7 more alkaline.
    • Vernix Caseosa - Waxy white substance on newborn skin
    • Layers of the Skin - Epidermis, Dermis and Subcutaneous tissue

    Neonatal Layers of skin

    Assessment

    Assessment of infant skin should be undertaken daily, or more frequently as clinically indicated. Infants at increased risk of systemic infection and longer hospital stays will be identified promptly. The Neonatal Skin Condition Score (NSCS) may be used to measure skin condition objectively.

    NSCS Criteria

    Dryness:
    1 = Normal, no signs of dry skin
    2 = Dry skin with visible scaling
    3 = Very dry skin with cracking and/or fissures present *

    Erythema:
    1 = No evidence of erythema
    2 = Visible erythema ( <50% body surface)
    3 = Visible erythema (>50% body surface)*

    Breakdown:
    1 = None evident
    2 = Small and/or localized areas
    3 = Extensive

    Interpretation of the results
    The relevant medical team must be notified if an infant scores a single score of 3 in one area or a combined score of 6 and above. A dermatology referral may also be appropriate.

    Management 

    The following guidelines apply to all neonates. Additional considerations for the preterm infant and product examples for use are identified in the boxes below each section.

    NAPPY CARE

    • The perineal environment is prone to changes in the skin barrier causing skin irritation. Increased moisture, prolonged contact with irritants, and an alkaline skin surface may contribute to skin breakdown.
    • Nappy changes should occur at regular intervals (where clinically appropriate) to avoid irritation to the perineal skin environment
    • Evaluation of the perineal area is required at each nappy change to ensure early identification of perineal dermatitis and candida infections 
    • Disposable nappies are preferred
    • Cotton balls or disposable towels (i.e. Rediwipes) with warm water are the preferred cleansing method
    • Olive oil or a pH neutral cleanser may be used if stools are dry and difficult to remove
    • Wipes should be avoided (if required they should be free from alcohol and fragrance)
    • Barrier creams should be used on all infants at risk of perineal dermatitis at every nappy change as well as at the first sign of erythema or skin breakdown
    • The removal of barrier creams between nappy changes is not necessary, rather apply another layer. Barrier creams containing plant extracts and/or fragrance should be avoided
    • Risk factors for perineal dermatitis include: Frequent stooling; antibiotic use; malabsorption; opiate withdrawal; abnormal rectal sphincter tone
    PRETERM INFANT CONSIDERATIONS
    Nappy care for the preterm infant is as above and assessed on an individual basis


    PRODUCT EXAMPLE
    Cleansing: Rediwipes, cotton wool, pH neutral cleanser (as below in bathing section)
    Barrier Creams: 10% Zinc and Olive oil paste, SudoCream

    BATHING

    Bathing should occur daily if possible.     
    FIRST BATH

    • Should occur once the infant has achieved cardiorespiratory and thermoregulatory stability 
    • Use plain water only  
    • If required a pH neutral cleanser may be used to assist in the removal of blood and amniotic fluid
    • Keep it to a short duration (approximately 5 minutes)
    • Infection control measures (including the use of gloves) should be used
    •  Avoid removing vernix caseosa

    DAILY BATHS

    • Use warm tap water (38 - 40°C) 
    • Water depth should be deep enough to allow the infants shoulders to be well covered
    • Add a capful of bath oil to the water. A pH neutral cleanser may be used if needed
    • Maintain an adequately heated external environment, with an ideal room temperature of 26 - 27°C (close the doors to the room to minimise convective heat loss)
    • Ensure all skin folds are dried thoroughly (armpits, groin, neck and behind the ears)
    • Disinfect the bath before and after each use
    • As per COCOON, encourage, support and involve parents in the bathing of their infant  

    PRETERM INFANT CONSIDERATIONS
    - Less than 32 weeks gestation: Gently cleanse with warm water and soft materials (cotton wool balls) when clinically appropriate. No cleansing products. Avoid rubbing.
    - More than 32 week’s gestation:  pH neutral cleansers may be utilised. Infants may be bathed every 2-3 days.
    If skin is dry, flaking or cracked after the bath, an emollient may be applied to the skin


    PRODUCT EXAMPLE
    Cleansing: QV Wash, QV Gentle Cleanser, QV Bath Oil, Hamilton Wash, Hamilton Bath Oil, Cetaphil Gentle Cleanser, Avene Trixera Cleansing Gel, Kenkay Body Wash, Kenkay Bath Oil, Mustela Stelatopia Cream Cleanser
    Emollients: As per Emollient box below

    ADHESIVES

    A number of measures can be undertaken to ensure a reduced incidence of skin trauma with the use of adhesives in NICU.

    • Choose adhesives that cause the least trauma whilst still effectively securing medical devices
    • Consider protecting the skin with silicone-based skin protective films
    • Tape should be backed with cotton wool where possible
    • Avoid removing adhesives until at least 24 hours after application
    • Remove adhesives horizontally using warm water with soft paraffin
    • Avoid using Solvents (Convacare wipes)
    • If an adhesive remover is required, consider the use of a silicone based adhesive remover (ConvaTec Niltac)

    ETT/NPT STRAPPING

    • Use a silicone-based skin protective film (i.e. Comfeel or Duoderm)
    • Ensure tapes are cut to an appropriate size and mirror the size of the skin protective film

    ECG DOTS

    • Consider if ECG dots are truly necessary; the infant may be safely monitored using a saturation probe only.
    • Exclusive use of hydrogel electrodes
    • Assess electrode site regularly
    • Replace electrodes every 7 days or after bathing
    • Remove electrodes using the ‘horizontal method’, slowly and gently with a moistened gauze square

    TRANSCUTANEOUS MONITORING (TCM)

    • Rotate between two sites every 2 hours
    • Avoid having more than two TCM sites at any one time
    • Decrease the TCM site temperature if redness at the site develops

    TAPING (Venous and Arterial Access)

    Current best practice exists for the taping of venous and arterial lines, however the following are general considerations.

    • Continual reinforcement of a CVAD dressing is not recommended as this leads to an increased risk of infection, skin breakdown and CVAD dislodgement
    • Use Steri -Strips to strap around intravenous cannula 

    INTRAOPERATIVE EYE TAPING

    • Silicone tapes are the preferred product for taping infant eyelids intraoperatively
    • If silicone tapes are unavailable, standard acrylate adhesive tapes are preferred (Micropore)

    PRETERM INFANT CONSIDERATIONS
    Tegaderm and Leukoplast tapes are to be avoided in infants less than 27 weeks (at minimum all leukoplast is to be ‘double backed’ or dabbed with cotton wool to reduce adherence to surface area.


    PRODUCT EXAMPLE
    Dressings:  Comfeel, Duoderm, Transparent adhesive dressings (Tegaderm), Hydrocolloids, Gel electrodes, Silicone based tapes (Siltape, Mepitac, 3M Kind Removal Silicone Tape)

    DISINFECTANTS

    Very little data is available on what disinfectants are best suited to the infant skin, in particular preterm infant skin. 

    • If a disinfectant is required in infants less than 14 days of age and/or less than 30 weeks gestation, gently cleanse the skin with sterile water after the procedure.
    PRETERM INFANT CONSIDERATIONS
    Chlorhexidine Gluconate aqueous solutions (0.1% Chlorhexidine Gluconate) are preferred in the preterm infant. The surrounding area should be cleansed thoroughly with a moistened gauze square after use. A number of studies have shown chemical burns in preterm infants where Povidone-Iodine and Isopropyl Alcohol were used, this should therefore be avoided.


    PRODUCT EXAMPLE
    Disinfectants: 0.1% Chlorhexidine Gluconate, 0.5% Chlorhexidine in 70% isopropyl alcohol

    UMBILICAL CORD CARE

    • Keep the cord area clean with water. Do not use alcohol wipes
    • Cleanse with water and a pH neutral cleanser if soiled with urine or stool
    • Cord clamp may remain in situ until separation
    • Where possible the umbilical stump should be kept exposed to air or loosely covered with clean clothing to avoid irritation and promote healing
    • Avoid exposing the periumbilical skin to chemicals in order to prevent periumbilical burns
    • Regular assessment is necessary to differentiate between normal umbilical cord healing and potential problems including infection

    EMOLLIENTS

      Emollients restore lipid levels, improve hydration, preserve natural moisturising factors and offer significant buffering capacity to normalise skin pH and maintain skin microbiome.

    • Apply an emollient twice daily at the first sign of dryness, fissures or flaking
    • Emollients should be applied as a preventative therapy daily to newborns with a family history of atopy
    • Maintain sterility by ordering patient specific containers or decanting products on to paper towel prior to application
    • Emollient use is not associated with negative thermal effects or burns when used in conjunction with phototherapy or radiant heat
    • Emollient use may interfere with the use of adhesives  
    PRETERM INFANT CONSIDERATIONS
    Some evidence states that prophylactic emollient use in preterm infants weighing 750 grams or less is associated with an increased risk of infection. Emollient use in this population should be weighed against the risk of infection and be in consultation with the Neonatologist


    PRODUCT EXAMPLE
    Emollients: QV Cream, Cetaphil Cream, Hydraderm Cream,  Kenkay Extra Relief Cream, Mustela Stelatopia Moisturising Cream, La Roache Posay Lipikar Baume AP, Bioderma Atoderm crème, QV kids balm

    Common newborn rashes

    ERYTHEMA TOXICUM NEONATORUM

    A common condition affecting as many as half of all full term newborn infants. Most prominent on day 2, although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs. Palms and soles are not usually affected. 
    Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual for an individual lesion to persist for more than a day. 
    Treatment: The infant is otherwise well and requires no treatment. 

    Figure 1. Erythema Toxicum Neonatorum

    Figure 1. Erythema Toxicum Neonatorum.
    (Source: http://www.huidziekten.nl/afbeeldingen/erythema-toxicum-neonatorum-2.jpg)

    NEONATAL MILIA

    Affects 40-50% of newborn babies. Few to numerous lesions.
    Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk.
    Treatment: Lesions will heal spontaneously within a few weeks of birth.

    Figure 2. Neonatal Milia

    Figure 2. Neonatal Milia
    (Source: http://www.forestlanepediatrics.com/wp-content/uploads/2014/04/Milia.jpg

    MILIARIA (HEAT RASH)

    Arises from occlusion of the sweat ducts. In infants, lesions commonly appear on the neck, groins and armpits, but also on the face.
    Clinical features: 1-3mm papules (vesicular or papular).
    Treatment: Remove from heated humid environment or adjust incubator temperature. Cool bathing or apply cool compresses. Topical steroids may be used to facilitate relief while the condition resolves.
    Figure 3 4 Miliaria

    Figure 3 & 4 Miliaria 
    (Source: http://www.leememorial.org/HealthInformation/graphics/images/en/2892.jpg)

    PITYROSOPRUM FOLLICULITIS

    Infantile acne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the newborns' sebaceous glands cause inflammation and folliculitis.
    Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops, commonly affecting the cheeks, nose and forehead. This rash is not itchy.
    Treatment: Will resolve within weeks without treatment or may be treated with ketoconazole shampoo (i.e.  Sebizole shampoo) diluted 1:5 with water. Apply with a cotton bud twice a day. Rinse off with water after 10 minutes. Or apply Hydrozole cream bd to the affected areas until the rash has resolved. 

    Figure 5 6  Pityrosoprum Folliculitus

    Figure 5 & 6  Pityrosoprum Folliculitus

    (Source: Images courtesy of of Dr David Orchard, Dermatologist RCH)

    Links


    Evidence Table

    Evidence table for the Neonatal and Infant Skincare guideline can be viewed here


    References

    • Allwood, M. (2011). Skin care guidelines for infant’s 23-30 week ‘gestation: a review of the literature. Neonatal, Paediatric and Child Health Nursing, 14(1), pp. 20-27.
      Association of Women’s Health, Obstetric and Neonatal Nurses (2013). Neonatal Skin Care (Third Edition) – Evidence Based Clinical Practice Guideline. 
    • Blackburn, S. (2007). Maternal, Fetal & Neonatal Physiology: A clinical perspective. Missouri: Saunders Elsevier.
    • Clemison, J., & McGuire, W. (2016). Topical emollient for preventing infection in preterm infants (review). Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD001150. DOI: 10.1002/14651858.CD001150.pub3.
    • Expert Forum: Neonatal Skin Health and Skin Care Symposium 2015. www.researchreview.com.au
    • Gregory, J., Anschau, N., McCutchan, D., Patterson, J., Martin, S., & Allwood, M. (2011). Skincare Guidelines for babies in NICU. Kaleidoscope, The Children’s health network.
    • Horimukai, K., Morita, K., Masami, N., & Mai, K., et al. (2014). Application of moisturizer to neonates prevents development of atopic dermatitis. Journal Allergy and Clinical Immunology, 134, pp. 824. 
    • Lund, C., Nonato, L., Kuller, J., Frank, L., Cullander, C., & Durand. (2010) Disruption of barrier function in neonatal skin associated with adhesive removal. Journal of Pediatrics, 131 (3), pp. 367 – 372.
      New Zealand Dermatological Society (NZDS), http://dermnetnz.org/, May 2013
    • Simpson, E., Chalmers, J., Hanifin J., & Thomas, K., et al. (2014).  Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. Journal Allergy and Clinical Immunology, 134, pp. 818 - 823.
    • The Royal Children’s Hospital. Clinical Practice Guidelines - Nappy Rash. Retrieved from: http://www.rch.org.au/clinicalguide/guideline_index/Nappy_Rash/
    • The Royal Women’s Hospital (2016). Clinical Practice Guideline - Skin Care for Newborn Babies. 
    • Varda, K., & Behnke, R. (2000). The effect of timing of initial bath on newborn’s temperature. Journal of Obstetric, Gynecologic & Neonatal Nursing, 27 (32). 

    Please remember to read the disclaimer

    The development of this clinical guideline was coordinated by Alanah Crowle, Clinical Support Nurse, Neonatal Intensive Care and Robyn Kennedy, Nurse Consultant, Dermatology. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. Revised guideline published April 2017.