Introduction
Infants in the NICU are patients that require specialized care with unique clinical considerations. Specific recommendations must be considered for all systems of NICU patients and the skin is not any different. Infants who are being cared for in the NICU, especially those that were born premature have an increased risk for skin trauma. With our last episode, we reviewed why term and preterm infants are at an increased risk for skin breakdown. If you have not yet, I encourage you to go and listen to Episode 34, Why Are Term and Preterm Infants at an Increased Risk for Skin Injury? For this podcast episode, we reviewed some of the skin care guidelines and recommendations available for clinical practice of NICU patients.
As NICU clinicians, is is important to not only be aware of the anatomical variations of a term and preterm infant’s skin, but to also know how that guides their clinical care and treatment plan. Many of the topics we cover on this episode have been standards of care for years, but there are also new recommendations for practice and products available based on recent research findings.
For NICU clinicians, it will be a great review but also offer up-to-date clinical recommendations for skin care of our specialized population in the NICU. For NICU parents, it will be beneficial to hear the current clinical practice guidelines and recommendations for term and preterm infants as well as some of the variations that may exist between different institutions.
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Episode 35
Clinical Guidelines for Skin Care in the NICU
Skin’s Functions
As I reviewed on our last episode, our skin is an important, protective barrier for us. Especially with infants, maintaining skin integrity is very crucial because it is the most effective barrier against infection, insensible water loss, protein loss, and it helps maintain euthermia. Proper skin care is a critical component of care that can directly reduce complications of prematurity and the associated intensive neonatal care that goes hand-in-hand with it. Care must be given when using adhesives, disinfectants, products, and emollients on the skin of infants, especially those being treated in the NICU.
Skin Care Guidelines
There is an evidence-based neonatal skin care guideline that was created through a collaboration between the National Association of Neonatal Nurses (NANN) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The clinical practice recommendations help to guide clinicians who care for newborns from birth to 28 days of age.
Tools and Identifying Risk Factors
It is important to start by evaluating the infant’s skin. There are some widely used tools, one being the Neonatal Skin Condition Score (NSCS) that was developed and validated as part of the AWHONN/NANN skin care guideline.
It is important to know and identify the risk factors that place certain infants at risk for skin trauma. As we have spoken about and you’ll continue to hear, premature infants are at an increased risk for skin damage due to their need for intensive care coupled with and the variations in their anatomy and physiology of their skin. Infants who receive specialized care in the NICU are at an increased risk due to the use of necessary monitoring equipment, adhesives used to secure lines or respiratory equipment, immobility due to either ECMO or high-frequency ventilation, particular medications, edema, and any devices with the potential for thermal injury.
Bathing
Most of the guidelines, especially for premature infants are consistent when it comes to bathing infants. Early bathing may result in forceful removal of the vernix, hypothermia, and it can lead to unstable vital signs. The AWHONN/NANN guidelines recommend that the initial bath in an infant with stable vital signs be delayed until 2-4 hours after birth. The guidelines created by the World Health Organization (WHO) recommend that the first bath be delayed until 6 hours of age. But, in general, the recommended time frame for the initial bath is 6-24 hours of age. Although it must be stated that neonates born to HIV-positive mothers or infants born to a mother with an unknown history, need their initial bath as soon as possible after birth. AWHONN also recommends that only sterile water be used to bathe infants less than 32 weeks gestation.
It is recommended to avoid detergents in all newborns until at least 2 weeks of age. In preterm infants greater than 32 weeks gestation, it is recommended to alternate the use of soap and water. For any soap that is used, it is recommended to use neutral pH soaps that are preservative free and to avoid the use of dyes and perfumes. Warm water sponge baths should only be given as needed in the first 2 weeks of life, with the goal of less than 5 minutes and they should be done in a draft-free area. Infants should not be fully submerged in a tub until the remnants of their umbilical cord has fallen off. Swaddle baths are recommended especially in premature infants to minimize both behavioral and physiologic stress. Daily bathing is not recommended and in general, bathing an infant two to three times per week is sufficient.
The waterproof features of vernix have been proven. It protects the skin from drying. Although it is not recommended practice to not remove the vernix, it is recommended to leave it intact as much as possible and to not remove it aggressively during the initial bath.
Tape and Adhesives
Now, if you’ve ever had an IV on your arm or even tape from a lab draw, you know the damage that tape can cause on anyone’s skin! But, special consideration must be given to infants, especially preterm infants when it comes to the use of tape. The best rule of thumb, use the minimal amount of tape needed! Infants have more fragile skin, especially premature infants. Due to the variations in the anatomy and structure of their dermis and epidermis, they are more prone to skin tears or epidermal stripping. If tape must be used, silk or paper tape is recommended. Non-adhesive products should be used when able in conjunction with transparent dressings when visibility is essential like for IV catheters and double-backed tape also prevents epidermal stripping.
Hydrogel and Hydrocolloid products
Alternatives to tape must be considered, especially in the NICU. Hydrogel and hydrocolloid adhesive products are great alternatives that can be removed easily with water. There are some companies that place the importance of skin integrity of NICU infants at the forefront when developing their products. Just as you read, our sponsor for this episode, NeoTech has developed a series of NICU products made with hydrocolloid that are designed to be gentle on an infant’s fragile skin including ECG leads, temperature probe stickers, nasal cannula holders, umbilical line holders plus more.
Hydrocolloid, when applied properly, is a long-lasting adhesive that minimizes skin damage. With its long-lasting nature, it also prevents skin breakdown because it does not have to be changed as frequently. For hydrocolloid products to work effectively, the skin needs to be clean and dry and the product should be warmed before it is applied as heat is the catalyst for the long-lasting effect. Hydrocolloid products also have protective qualities including its ability to prevent microorganisms, stop water losses and assist with healing.
Pectin barriers, or duoderm, which are hydrocolloid products should be used on the skin as a barrier under adhesive dressings that help secure monitoring or medical devices. To prevent traumatic removal of adhesives for securement of ng or og tubes, nasal cannulas, umbilical lines, or an endotracheal tube, the hydrocolloid dressing protects the skin from frequent removal of the adhesive. So if the tape or adhesive on top has to be changed, there is a barrier or “landing pad” over the skin to protect from epidermal stripping.
Removal of Adhesives
At any point that an adhesive needs to be removed, it should be done carefully and slowly with warm water to prevent epidermal stripping. Adhesive removers should not be used in term and preterm infants due to risk of toxicity.
Cord Care
In regards to umbilical cord care, it is recommended to not treat the cord with anything. Diapers should be lowered and kept below the level of the cord. If the area becomes soiled with urine or stool, it should be wiped gently with water. Routine application of alcohol is not recommended and may actually delay cord separation. Use of antibiotic ointments and/or creams is also not recommended. The cord should always be assessed closely to monitor for any swelling or redness at the base of the cord.
Humidity
Humidity use in incubators helps to maintain skin integrity while the infant’s skin is maturing. Humidification helps to decrease transepidermal water loss, maintain skin integrity, decrease fluid requirements, and minimize electrolyte imbalance. As you may recall from our last episode, the maturation of an infant’s skin is not fully complete until 2 to 4 weeks after birth once they have been exposed to the extrauterine environment.
There are not necessarily uniform protocols for humidity use in incubators for extremely premature infants in the NICU and each institution will have their own protocols. Therefore, the guidelines will vary in the duration of use, the weaning process, and for which gestational age the parameters are applied. It should be considered for infants < 32 weeks gestation or for infants that weigh < 1200 grams. Many units start with humidity at 60-80%, usually using 80% for infants < 28 weeks gestation. At an 80% humidity level, evaporation at the skin surface effectively ceases. The percentage of humidity used is usually maintained for the initial week followed by set weaning parameters.
Weaning the percentage of humidity should be gradual over a few days. Weaning can be done by decreasing the percentage by 5%-10% per day until 30 to 40% is reached. The infant’s temperature should be monitored closely during the weaning process and the isolette temperatures may need to be adjusted to ensure normothermia.
Some units maintain the humidity percentage around 70-80% for infants born extremely premature for longer periods of time before they begin to wean. This practice is more common for infants born less than 26 weeks who may require higher humidity to counteract the insensible water losses and elevated sodium levels. But, we must remember that prolonged humidity does delay maturation of the skin so it is a situation where the clinicians must evaluate the benefits compared to the risk.
Although the weaning parameters may vary, the humidity should be weaned once the infant’s skin is more mature or, once the clinician notes that the infant’s skin appears dry, thickened, and no longer shiny or translucent. This usually occurs around 10-14 days. It’s funny because when I read this as I was reviewing literature, there is a particular picture of my son, William that I recall, where his skin appeared very dry and scaly, so I went back and looked and sure enough, it was on his 15th day of life!
Prevention of Transepidermal Water Loss
As you may recall, on our last episode, I mentioned that infants have a much larger surface area in relation to body mass which places them at an increased risk for heat loss. To prevent this, consideration must be paid to resuscitate infants under a prewarmed radiant warmer, or to place them skin-to-skin with their mother immediately post delivery if they are stable. It is recommended to transition preterm infants into a heated and humidified incubator as soon as possible. Extremely premature infants or those < 32 weeks gestation, should be placed in a polyethylene wrap during resuscitation measures to prevent transepidermal water losses.
Additionally, any site on the infant’s body that previously had an adhesive attached to it then subsequently removed, is an area more prone to transepidermal water loss. So it reiterates the importance of minimal adhesive use as well as careful removal of each adhesive.
Neonatal Fluid Requirements
For infants in the NICU, especially those born prematurely, we as providers need to compensate for the fluid redistribution and transepidermal water loss that occurs over the initial extrauterine days. In addition to humidity provided, IV fluids are administered and may need to be modified based on the infant’s gestational age, electrolyte levels, weight loss and external factors including phototherapy lights.
Emollients
The use of emollients or topical ointments in NICUs also varies. Emollients like Aquafor and petroleum decrease transepidermal losses of water and some believe they protect against microbes. They also improve the condition of the skin and help with dryness, they help to stabilize surface temperature without changing the skin flora, and they protect against skin trauma. But, studies have shown that daily application of topical ointments increases the risk for hospital-acquired infections. Therefore, it is not recommended to use prophylactic application of topical ointments.
The consistent recommendation for emollients is to use them exclusively in cases of severe skin dryness, cracking of the skin and/or fissures. If used, there should be patient-specific containers or single-use to minimize the risk of contamination. Again, if any of these products are used, they should be free of perfumes, dyes, or preservatives.
Studies have also shown that routine use of mustard oil and olive oil can adversely alter the skin integrity, so they should not be used. But, the use of vegetable oils rich in linoleic acid like in sunflower oil and coconut oil have been shown to improve the barrier function and hydration.
Topical Disinfectants
As I spoke about on our last episode, it is necessary to cleanse the skin with antiseptic solutions prior to invasive procedures, but they can be absorbed into an infant’s skin and may also cause chemical burns, especially in premature infants. With the use of all topical disinfectants in the NICU, the clinician must evaluate the risk versus benefit with each procedure because effective skin antisepsis before central line insertions is paramount in the prevention of central line-related bloodstream infections or CLABSIs.
Chlorhexidine
Chlorhexidine is known to be superior for skin disinfecting in children and adults, but there is limited safety data for it with infants. Therefore, the CDC guidelines have said that there is insufficient evidence to make proper recommendations on the safety and efficacy of chlorhexidine in infants younger than 2 months of age. As a result, the use of chlorhexidine in the ELBW infant is controversial and should be used per each institution’s guidelines. Where I have practiced, it was recommended not to use chlorhexidine on infants who weigh < 1000 grams, but every institution is different.
Per the AWHONN/NANN guidelines, alcohol or chlorhexidine should be used as the primary disinfectants prior to any invasive procedures. In preterm infants, sterile water should be used to remove any residual disinfectant following the procedure to avoid the risk of chemical burns.
Povidone-Iodine
But as you may recall, even the use of povidone-iodine in preterm infants should be used cautiously due to their weak skin barrier and its ability to be absorbed leading to thyroid dysfunction. So when povidone-iodine is used, only the amount necessary should be applied, then it should be sponged off immediately with warm sterile water or saline after completion of the procedure.
Even with the use of alcohol, it should be used judiciously to prevent any potential complications. With the use of Chlorhexidine or Iodine, it should be applied gently and in a non-aggressive manner, do not allow the product to pool on the infant’s skin, especially the creases to minimize the risk of chemical burns.
Our Personal Experience
I am going to introject here and share my personal opinion as a mother of a micropreemie, not necessarily as a provider. If you listened to our last podcast episode, I shared with you that William has several, permanent scars on his body. He has a significant one on his abdomen and scattered scars throughout his arms, wrists, ankles, feet, etc from significant skin breakdown or due to monitoring equipment. And I cannot be 100% sure what caused each of his scars, but he was at a high risk for skin trauma.
To start with, he was a 23 weeker, with incredibly thin, delicate skin. He also had several pieces of equipment either for treatment or monitoring that he desperately needed including umbilical lines, PICC lines, pulse oximeters, endotracheal tubes, plus much more! But as I mentioned a few moments ago, with topical antiseptic solutions in neonates, the potential benefits must outweigh the risks and that has to be evaluated each time, for each baby, with each procedure.
For me personally and with my medical background, I know the devastation that can occur from a central line associated bloodstream infection (CLABSI) or a systemic infection. Therefore, as a mother, I personally would take the risk of a chemical skin burn that may result in significant breakdown over the risk of a systemic infection. Meaning, as a parent, I would rather have appropriate, proven topical disinfectants be used on my baby despite there being insufficient data on the safety than for him to have a serious systemic infection.
With that being said, my son actually had both. He did have a CLABSI that praise God we caught and treated in a timely manner so he did not suffer any significant major complications from it. And yes, his significant skin breakdown on his abdomen and up and down his arms could have also been devastating for him since they were open entries for pathogens. But, I would still take the risk of a chemical burn from using skin antiseptics to properly prevent a CLABSI before an invasive procedure is done, especially a central line insertion. But, as I said, that is my personal opinion as a parent. As a provider, I follow the institution’s guidelines where I practice and recommend that clinicians do the same.
Diaper Care
In regards to diaper care, for premature infants, especially those less than 28 weeks, it is recommended to only use warm saline wipes for the first 2 weeks of life. Beyond 2 weeks of age, use warm tap or sterile water and a soft disposable cloth. Based on the article from Advances in Neonatal Care, by Johnson, they also recommend to not use prepackaged diaper wipes until the corrected gestational age of 37 weeks to avoid sensitizing ingredients. And although they make extremely small diapers for extremely low birthweight infants, when my son William was born at 23 weeks, where I practiced, we did not diaper ELBW infants for 2 weeks. He just had a gauze in place of a diaper to prevent skin irritation and breakdown.
Clinical Considerations for Extremely Low Birthweight Infants
Here are some other more specific recommendations that can be used while caring for extremely low birthweight (ELBW) infants in the NICU. For the skin temp probe, as I mentioned previously, products made with hydrogel are recommended. Additionally, the smallest possible size should be used to minimize skin damage. With larger probes, this can be achieved by cutting the skin probe in half or cutting out a small circle.
ECG leads should be applied with as little adhesive as necessary and only with the manufacturer’s adhesive. Please do not apply or re-secure ECG leads or temp probes with tape. If the probe or lead is no longer sticking, then it is time to apply new ones. Consider using limb leads on extremely low birthweight infants (ELBW) and water-activated or hydrogel electrodes when possible.
With devices like the pulse oximeter, care should be given when applying it to prevent pressure sores. It is also very important to rotate the probe at a minimum of every 8 hours. When I was a NICU nurse, I made it a practice to rotate it with every assessment so every 3 to 6 hours. Even if preductal saturations are necessary, just rotate the probe between the right wrist and hand ensuring that the point where the probe meets the skin is different. I can tell you that personally, William has a very definitive scar on his wrist that is no doubt from a pulse oximeter probe. Again, it is just a scar and in the grand scheme of things very minimal, but we are lucky that he did not develop a pressure ulcer or significant breakdown there.
Blood pressure cuffs should always be removed after use, even if serial blood pressures are being monitored to prevent breakdown or skin tears. Avoid the use of any solutions that are likely to dry out the infant’s skin including soaps and alcohol. At any point that an adhesive needs to be removed, cotton balls soaked in sterile water should be used to gently remove adhesive tape, probe covers, and electrodes.
Sensory Considerations
Additionally, as I mentioned in our last episode, the sensory nerve endings are well-developed, even in extremely premature infants. By 20 weeks, a fetus can respond behaviorally, physiologically, and hormonally to touch and pain. The sensory nerve endings are well-developed in the newborn regardless of maturity, meaning they can feel positive nurturing touch as well as painful touch and procedures. Despite the sensory system being well-developed, the neurological system is still developing so the neurosensors on the skin are very sensitive. Simple, light touching can be irritating and overstimulating to the infant.
We must keep this in mind as we are caring for infants in the NICU. Interventions and treatments may cause pain and stress to infants negatively altering their neurodevelopment. It is recommended to care for infants based on their cues and to couple cares together while closely monitoring the infant for stress cues.
Some other general clinical guidelines to be reminded of include the importance of meticulous hand-washing prior to touching the neonate.
Skin-to-Skin Care
Also, we cannot close out this episode without briefly touching on the importance of skin-to-skin care. Kangaroo care should be practiced with all clinically stable term and preterm infants. If you need a reminder of all of the benefits, I urge you to go back and listen to Episode 14: Kangaroo Care in the NICU: How does it benefit the infant and the parent? But, for the purposes of this episode, I’ll just mention that it gives the infant positive touch and sensory stimulation. It also helps to reduce pain, improves bonding, and decreases stress in the infant. For parents, it improves mood, promotes attachment, and leads to more success and longer durations of nursing.
General Skin Care Guidelines
So to close out this episode, I’ll briefly review some basic skin care practices applicable to infants. As a reminder, your baby only needs to be bathed two to three times per week. If you choose to use skin products, only pick those with little to no additives that are free of perfumes with minimal fragrance. By using minimal products, it reduces the risk of contact sensitization of the skin by added chemicals. Remember, baby soft skin is a natural occurrence and additional products are not needed. Do not use powders on your infant due to the risk of lung inhalation. For your late preterm and term infants, change their soiled diapers frequently and try to use diapers that “wick” moisture away. If the infant’s skin becomes reddened or irritated, try changing diaper brands. Treat diaper rashes by using protective skin barriers like zinc oxide with each diaper change to prevent further injury. Also, clean waste on the skin barrier but do not clean off the skin barrier because this may disrupt healing or cause more breakdown. If the diaper rash has red bumps or you are concerned once your baby is home, contact your infant’s pediatrician. The umbilical cord will naturally dry and fall off around 10-14 days of life. To prevent rubbing or irritation, turn the diaper down and away from the cord until it falls off. If there is any excessive bleeding, drainage, or a foul odor, call your baby’s provider.
Remember, whether the baby is in the NICU or the well-baby nursery, it is up to the professionals to educate the parents about the recommended practices for bathing, cord care, and diaper care.
Closing
I hope you found this episode helpful. As I touched briefly on throughout this episode, infants in general, but especially premature infants are much more prone to skin trauma due to the variations in the anatomy and structure of their skin. For a more thorough review of what those specific variations are, I strongly urge you to go back and listen to our last episode: Why are Term and Preterm Infants at an Increased Risk for Skin Injury?
Bearing this information in mind, it helps to guide clinical decisions when caring for infants in the NICU, especially those born prematurely. Evidence-based practice helps to guide clinical decision-making in healthcare. instituting evidence-based practice, it improves patient safety and ultimately patient outcomes. So it’s important that we continue to take the information we know to be true like anatomy and physiology and combine it with what we have learned so far through research as well as what we will continue to study and learn in the future. So although there are still many practices that need future research like the use of Chlorhexidine in infants less than 2 months of age, there are also evidence-based clinical guidelines for optimal skin care of infants in the NICU.
For clinicians, as I mentioned, due to some variations between institutions, please check with your particular hospital regarding your protocols or guidelines. And for parents, please do not be afraid to ask questions about humidity or what products are being used on your infant, and if your baby is stable enough to do skin-to-skin care each day! Although we may downplay our skin and the importance of its role, it is very essential for the health of our babies, especially those we treat in the NICU.
References
Anic Jurica, S., Colic, A., Gveric-Ahmetasevic, S., Loncarevic, D., Filipovic-Grcic, B., Stipanovic-Kastelic, J., Resic, A. (2016). Skin of the Very Premature Newborn – Physiology and Care. Paediatrica Croatica, 60, 21-26.
Eichenwald, E., Hansen, A., Martin, C., & Stark, A. (2017). Cloherty and Stark’s Manual of Neonatal Care, 8th edition. Wolters Kluwer.
Gardner, S., Carter, B., Enzman-Hines, M., & Hernandez, J. (2011). Merenstein & Gardner’s Handbook of Neonatal Intensive Care. Mosby Elsevier.
Gomella, T., Eyal, F., & Bany-Mohammed, F. (2020). Gomella’s Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 8th Edition. McGraw-Hill.
Johnson, D. (2016). Extremely Preterm Infant Skin Care: A Transformation of Practice Aimed to Prevent Harm. Advances in Neonatal Care, 16(5), S26-S32.
Kaur, S. & Sidhu, N. (2021). Evidence Based Skin Care in Preterm Neonates – A Short Review. International Journal of Research and Review, 8(7), 381-385.
Oranges, T., Dini, V., & Romanelli, M. (2015). Skin Physiology of the Neonate and Infant: Clinical Implications. Advances in Wound Care, 4(10), 587-595.
Paternoster, M., Niola, M., & Graziano, V. (2017). Avoiding Chlorhexidine Burns in Preterm Infants. Journal of Obstetric, Gynecology, and Neonatal Nursing, 46, 267-271.
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