Newborn infant skin: physiology, development, and care

Thermoregulation, incubator humidity, and skincare practices in appropriate for gestational age ultra-low birth weight infants: need for more evidence

BACKGROUND

Although not universal, active care is being offered to infants weighing < 500 g at birth, referred to as ultra-low birth weight (ULBW) infants appropriate for gestational age. These infants have the greatest risk of dying or developing major morbidities. ULBW infants face challenges related to fluid and heat loss as well as skin injury in the initial days of life from extreme anatomical and physiological immaturity of the skin. Although there is an emerging literature on the outcomes of ULBW infants, there is a paucity of evidence to inform practice guidelines for delivering optimal care to this cohort of infants.

DATA SOURCES

A comprehensive review of the literature was performed using the PubMed and Embase databases. Searched keywords included "thermoregulation or body temperature regulation", "incubator humidity", "skin care", "infant, extremely low birth weight" and "ultra-low birth weight infants".

RESULTS

Evidences for thermoregulation, incubator humidity, and skincare practices are available for preterm infants weighing < 1500 g at birth but not specifically for ULBW infants. Studies on thermoregulation, incubator humidity, or skincare practices had a small sample size and did not include a sub-group analysis for ULBW infants. Current practice recommendations in ULBW infants are adopted from research in very and/or extremely low birth weight infants.

CONCLUSIONS

This narrative review focuses on challenges in thermoregulation, incubator humidity, and skincare practices in ULBW infants, highlights current research gaps and suggests potential developments for informing practices for improving health outcomes in ULBW infants. Video abstract (MP4 1,49,115 kb).

Neonatal innate immunity response in invasive candidiasis

Infections caused by Candida spp. are frequent in critically hospitalized patients, especially among premature neonates, representing one of the most common healthcare-related infections. Although there is considerable production of current knowledge about the mechanisms of immune response, aspects involved in the newborn's innate defense are not fully understood. The aim of this study was to describe the innate immune mechanisms involved in the defense of neonates against invasive candidiasis. This is an integrative literature review from the Scopus, Scifinder, Medline, Web of Science databases and the electronic libraries ScienceDirect and Scielo, in the period between 2002 and 2020, with rescue based on primary descriptor Immunity Innate plus secondary descriptors Candidiasis Invasive AND Infant Newborn. We have observed the involvement of various mechanisms in the neonatal response against invasive candidiasis, including the recognition, signaling, recruitment, and initiation of an effective immune response. These mechanisms encompass the presence of antimicrobial peptides, phagocytosis, synthesis of reactive oxygen species, inflammatory mediators, and complex cell signaling systems mediated by Pattern Recognition Receptors (PRRs). With this study, it is expected to contribute to the expansion of knowledge about the immunological mechanisms involved in the innate immune response of the newborn against disseminated infections caused by Candida species, and in the same sense, highlight the importance of this knowledge as a reflex in the decrease in mortality in the neonatal period.

Current use of medicinal plants for children's diseases among mothers in Southern Romania

There is a limited number of studies focusing on ethnomedical practices in children, particularly in Eastern Europe. Romania has a rich history of using medicinal plants in ethnopediatric care, and our objective was to identify the medicinal plants currently employed in treating childhood illnesses in the southern region of the country. Material and methods Our investigation used structured interviews, focusing on respondent demographics, local names of therapeutically employed herbs, the specific plant part(s) utilized, methods of preparation and administration, and local folk indications of taxa. A total of 326 mothers with children aged 0 to 18, hospitalized in the "Grigore Alexandrescu" Children Emergency Hospital Bucharest and residing in Southern Romania, were enrolled in the study. Use Value Citation Index (UVc), Informant Consensus Factor (Fic), and Fidelity Level (FL) were calculated. Results Twenty-five plants were identified for treating children's diseases in Southern Romania. The majority of informants resided in urban areas, and mothers primarily acquired knowledge from family members and healthcare professionals. The herbs most frequently employed were Mentha spp. (UV = 0.509) for diarrhea, Matricaria spp. (UV = 0.301) for skin infections (Fic = 0.99) and digestive diseases (Fic = 0.98), and Calendula officinalis L. (UV = 0.365) for skin diseases (Fic = 0.99). Less utilized were Raphanus raphanistrum subsp. sativus (L.) Domin in respiratory diseases, Prunus avium (L.) L. stalks in urinary tract ailments, Helianthus annuus L. in ear infections, Allium sativum L. in intestinal parasitosis, Viola tricolor L. in hives, Triticum aestivum L. in dermatitis and Allium ursinum L. as a tonic. In 184 cases herbal treatment was used in conjunction with conventional medications. Education level correlated with the number of employed plants and the variety of treated ailments, while residency (rural vs. urban) did not. Both residency and education influenced plant procurement methods: rural background and, surprisingly, higher education were linked to a preference for harvesting rather than purchasing plants. Conclusion Botanical remedies are still commonly used in the treatment of pediatric diseases in Southern Romania, although the variety of taxa seems reduced compared to the past. Further exploration is essential to unlock the maximum benefits of ethnopediatric practices.

Women Skin Microbiota Modifications during Pregnancy

Several studies have shown fluctuations in the maternal microbiota at various body sites (gut, oral cavity, and vagina). The skin microbiota plays an important role in our health, but studies on the changes during pregnancy are limited. Quantitative and qualitative variations in the skin microbiota in pregnant woman could indeed play important roles in modifying the immune and inflammatory responses of the host. These alterations could induce inflammatory disorders affecting the individual's dermal properties, and could potentially predict infant skin disorder in the unborn. The present study aimed to characterize skin microbiota modifications during pregnancy. For this purpose, skin samples were collected from 52 pregnant women in the first, second, and third trimester of non-complicated pregnancies and from 17 age- and sex-matched healthy controls. The skin microbiota composition was assessed by next generation sequencing (NGS) of the V3-V4 region of the bacterial rRNA 16S. Our results indicate that from the first to the third trimester of pregnancy, changes occur in the composition of the skin microbiota, microbial interactions, and various metabolic pathways. These changes could play a role in creating more advantageous conditions for fetal growth.

Iatrogenic skin injuries in infants admitted to neonatal intensive care units: An investigation in 22 Chinese units

OBJECTIVE

To investigate the incidence of iatrogenic skin injuries in neonates across 22 neonatal intensive care units (NICUs) in China.

DESIGN

Prospective study.

SETTING

22 NICUs in China.

PATIENTS

Infants admitted to NICU.

INTERVENTIONS

None.

MEASUREMENTS

The "Iatrogenic Skin Injuries Data Collection Form of infants" were used to collect the data during hospitalization.

MAIN RESULTS

A total of 8126 neonates who were hospitalized in 22 tertiary hospitals across 15 provinces, cities, and autonomous regions of China between December 1, 2019 and January 31, 2020 were analyzed. Five hundred and twenty-one infants had iatrogenic skin injuries, including 250 with diaper dermatitis (47.98%), 70 with physicochemical factor-related skin lesions (PCFRSIs) (13.44%), 81 with medical device-related pressure injuries (MDRPIs) (15.55%), and 69 with medical adhesive-related skin injuries (MARSIs) (13.24%), accounting for 91% of the total number of iatrogenic injuries. Among these, diaper dermatitis was closely related to the skin and feeding status. Furthermore, the risk was higher among neonates who had skin damage upon admission or were already fully fed orally. The influencing factors of MDRPIs and MARSIs were similar. They were negatively associated with gestational age and birth weight, and were closely related to the presence of various tubes.

CONCLUSIONS

Diaper dermatitis, PCFRSIs, MDRPIs, and MARSIs were the four common types of iatrogenic skin injuries in newborns. The various types of iatrogenic skin injuries were influenced by varying factors. Specialized nursing measurements can reduce the likelihood of these injuries.

The Effects of a New Wireless Non-Adhesive Cardiorespiratory Monitoring Device on the Skin Conditions of Preterm Infants

AIM

The aim of our study was to investigate skin conditions when wearing and removing a novel wireless non-adhesive cardiorespiratory monitoring device for neonates (Bambi-Belt) compared to standard adhesive electrodes.

STUDY DESIGN

This was a prospective study including preterm neonates requiring cardiorespiratory monitoring. Besides standard electrodes, the infants wore a Bambi Belt for 10 consecutive days. Their skin conditions were assessed using Trans Epidermal Water Loss (TEWL) and the Neonatal Skin Condition Score (NSCS) after daily belt and standard electrode removal. The ∆TEWL was calculated as the difference between the TEWL at the device's location (Bambi-Belt/standard electrode) and the adjacent control skin location, with a higher ∆TEWL indicating skin damage.

RESULTS

A total of 15 infants (gestational age (GA): 24.1-35.6 wk) were analyzed. The ΔTEWL significantly increased directly after electrode removal (10.95 ± 9.98 g/m2/h) compared to belt removal (5.18 ± 6.71 g/m2/h; F: 8.73, p = 0.004) and after the washout period (3.72 ± 5.46 g/m2/h vs. 1.86 ± 3.35 g/m2/h; F: 2.84, p = 0.09), although the latter did not reach statistical significance. The TEWL was not influenced by prolonged belt wearing. No significant differences in the NSCS score were found between the belt and electrode (OR: 0.69, 95% CI [0.17, 2.88], p = 0.6).

CONCLUSION

A new wireless non-adhesive device for neonatal cardiorespiratory monitoring was well tolerated in preterm infants and may be less damaging during prolonged wearing.

Microbiome: Role in Inflammatory Skin Diseases

As the body's largest organ, the skin harbors a highly diverse microbiota, playing a crucial role in resisting foreign pathogens, nurturing the immune system, and metabolizing natural products. The dysregulation of human skin microbiota is implicated in immune dysregulation and inflammatory responses. This review delineates the microbial alterations and immune dysregulation features in common Inflammatory Skin Diseases (ISDs) such as psoriasis, rosacea, atopic dermatitis(AD), seborrheic dermatitis(SD), diaper dermatitis(DD), and Malassezia folliculitis(MF).The skin microbiota, a complex and evolving community, undergoes changes in composition and function that can compromise the skin microbial barrier. These alterations induce water loss and abnormal lipid metabolism, contributing to the onset of ISDs. Additionally, microorganisms release toxins, like Staphylococcus aureus secreted α toxins and proteases, which may dissolve the stratum corneum, impairing skin barrier function and allowing entry into the bloodstream. Microbes entering the bloodstream activate molecular signals, leading to immune disorders and subsequent skin inflammatory responses. For instance, Malassezia stimulates dendritic cells(DCs) to release IL-12 and IL-23, differentiating into a Th17 cell population and producing proinflammatory mediators such as IL-17, IL-22, TNF-α, and IFN-α.This review offers new insights into the role of the human skin microbiota in ISDs, paving the way for future skin microbiome-specific targeted therapies.

Validity and reliability of the italian-Neonatal skin risk assessment scale (i-NSRAS)

BACKGROUND

The skin of infants has important anatomical and physiological differences from that of children and adults. Because of skin immaturity, reduced mobility, neurological changes, and the need for medical devices, infants are at high risk for pressure injuries. Specific, validated tools are needed to assess the risk of pressure injuries in this population.

OBJECTIVES

To assess the psychometric properties of the Italian version of Neonatal Skin Risk Assessment Scale (construct validity, internal consistency and reliability).

METHOD

A cross-sectional descriptive study was conducted in the neonatal units of the two Italian hospitals. 200 infants were examined 3 times by 54 nurses to assess the risk of pressure injuries. Exploratory and confirmatory factor analysis were performed jointly to assess construct validity. Internal consistency was analyzed using McDonalds omega coefficient and Cronbach's alpha, while intra and interobserver agreement using Intraclass Correlation Coefficients (ICC).

RESULTS

Exploratory factor analysis confirmed a 2-factor model; the factor "duration and intensity of pressure" explained four subscales (mental state, mobility, activity and nutrition), while "skin immaturity" explained the subscales (general physical condition and skin moisture). Confirmatory factor analysis results indicated good model fits (X2/df = 0.84, p = 0.002, RMSEA = 0, NNFI = 1.01, NFI = 0.98 y CFI = 1 (M1 with MI). The italian-Neonatal Skin Risk Assessment Scale showed a good internal consistency, McDonalds omega coefficient and Cronbach's alpha both 0.86. An excellent intra and inter observer reliability was also observed, ICC 0.99 and 0.98 respectively.

CONCLUSION

The psychometric characteristics indicate that the italian-Neonatal Skin Risk Assessment Scale is useful, valid and reliable for measuring risk of pressure injuries in the neonatal population.

IMPLICATIONS FOR CLINICAL PRACTICE

This is the first valid and reliable newborn-specific scale that assesses the presence of medical devices. Its use could enable efficient management of preventive resources, early classification of newborns at risk and assignment of preventive interventions, facilitate the development of risk assessment protocols.

Effects of Liquid and Bar Soaps on the Skin of Brazilian Newborns: A Randomized Controlled Trial

INTRODUCTION

Compared to adults, newborns' skin has a thinner epidermis and stratum corneum with decreased hydration levels, higher transepidermal water loss, and a pH variation between 5.5 and 7.5. These characteristics can predispose to the occurrence of dryness, infections, and dermatological conditions. Water and liquid soap with adequate formulation have shown to be beneficial and safe for newborns' skin. However, studies evaluating the effect of bar soap, products widely used in Brazil and Latin America, are unknown. Therefore, the objective of this study was to compare the effects of liquid and bar soaps on the term newborns' skin.

METHODS

This randomized controlled, parallel, single-blind clinical trial was conducted at a public university hospital in São Paulo, Brazil. 100 healthy term newborns with no congenital anomalies, acute diseases, or dermatological conditions were randomized to use liquid soap (experimental group) or bar soap (control group). Skin pH, transepidermal water loss, stratum corneum hydration, sebum content, and skin condition were assessed before and after the first bath, at 48 h, 14 days, and 28 days after birth. These evaluations were performed on the forearm, abdomen, buttocks, and thigh. In addition, the mother's perception of soap use was also evaluated.

RESULTS

Data of 100 newborns were analyzed by intention to treat. The rate of retention was 53%. Newborns exposed to the liquid soap presented significantly better skin acidification (p < 0.001) and significantly better stratum corneum hydration (p < 0.001) than the skin of newborns exposed to the bar soap, regardless of the area evaluated. There were no significant differences in transepidermal water loss, sebum content, dryness, erythema, or skin breakdown and the mother's perceptions of the use of the soaps.

CONCLUSION

Newborns in the experimental group presented better skin acidification and stratum corneum hydration when compared to newborns in the control group.

Psychometric Testing of the Newborn Skin Assessment Attitude Scale in Neonatal ICU Nurses

OBJECTIVE

To develop a Newborn Skin Assessment Attitude Scale (NSAAS) for neonatal ICU (NICU) RNs.

METHODS

The study was conducted with 326 nurses working in NICUs in three cities in Turkey. The researchers evaluated the content and construct validity and reliability of the scale with item-total score correlation analysis, the test-retest method, and calculating the Cronbach α reliability coefficient.

RESULTS

The content validity index of the scale ranged between 0.87 and 1.00. Prior to exploratory factor analysis and confirmatory factor analysis, the Kaiser-Meyer-Olkin coefficient of the NSAAS was 0.976, and the Bartlett test of sphericity result was χ2 = 15,337.052 (P < .001). The scale was constructed with 35 items with factor loads greater than 0.40 and three subdimensions. Confirmatory factor analysis showed that the fit indices of the NSAAS were χ2/df = 3.57, root mean square error of approximation = 0.08, normed fit index = 0.98, non-normed fit index = 0.98, comparative fit index = 0.98, and standardized root mean square residual = 0.05. The overall reliability coefficient of the NSAAS was α = .978. The test-retest coefficients of correlation were r = 0.558 for the overall scale and r = 0.615, r = 0.504, and r = 0.598 for the Awareness, Practice, and Avoidance subdimensions, respectively. In addition, no statistically significant difference was observed when comparing the test-retest mean scores for the total scale and the subdimensions (P > .05).

CONCLUSIONS

The NSAAS can be reliably used for measuring NICU nurses' attitudes toward newborn skin assessment.

Assessment of Skin Maturity by LED Light at Birth and Its Association With Lung Maturity: Clinical Trial Secondary Outcomes

BACKGROUND

Clinicians face barriers when assessing lung maturity at birth due to global inequalities. Still, strategies for testing based solely on gestational age to predict the likelihood of respiratory distress syndrome (RDS) do not offer a comprehensive approach to addressing the challenge of uncertain outcomes. We hypothesize that a noninvasive assessment of skin maturity may indicate lung maturity.

OBJECTIVE

This study aimed to assess the association between a newborn's skin maturity and RDS occurrence.

METHODS

We conducted a case-control nested in a prospective cohort study, a secondary endpoint of a multicenter clinical trial. The study was carried out in 5 Brazilian urban reference centers for highly complex perinatal care. Of 781 newborns from the cohort study, 640 were selected for the case-control analysis. Newborns with RDS formed the case group and newborns without RDS were the controls. All newborns with other diseases exhibiting respiratory manifestations were excluded. Skin maturity was assessed from the newborn's skin over the sole by an optical device that acquired a reflection signal through an LED sensor. The device, previously validated, measured and recorded skin reflectance. Clinical data related to respiratory outcomes were gathered from medical records during the 72-hour follow-up of the newborn, or until discharge or death, whichever occurred first. The main outcome measure was the association between skin reflectance and RDS using univariate and multivariate binary logistic regression. Additionally, we assessed the connection between skin reflectance and factors such as neonatal intensive care unit (NICU) admission and the need for ventilatory support.

RESULTS

Out of 604 newborns, 470 (73.4%) were from the RDS group and 170 (26.6%) were from the control group. According to comparisons between the groups, newborns with RDS had a younger gestational age (31.6 vs 39.1 weeks, P<.001) and birth weight (1491 vs 3121 grams, P<.001) than controls. Skin reflectance was associated with RDS (odds ratio [OR] 0.982, 95% CI 0.979-0.985, R2=0.632, P<.001). This relationship remained significant when adjusted by the cofactors antenatal corticosteroid and birth weight (OR 0.994, 95% CI 0.990-0.998, R2=0.843, P<.001). Secondary outcomes also showed differences in skin reflectance. The mean difference was 0.219 (95% CI 0.200-0.238) between newborns that required ventilatory support versus those that did not and 0.223 (95% CI 0.205-0.241) between newborns that required NICU admission versus those that did not. Skin reflectance was associated with ventilatory support (OR 0.996, 95% CI 0.992-0.999, R2=0.814, P=.01) and with NICU admission (OR 0.994, 95% CI 0.990-0.998, R2=0.867, P=.004).

CONCLUSIONS

Our findings present a potential marker of lung immaturity at birth using the indirect method of skin assessment. Using the RDS clinical condition and a medical device, this study demonstrated the synchrony between lung and skin maturity.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-3f5bm5; https://tinyurl.com/9fb7zrdb.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-027442.

Risk Factors for Dehiscence of Operative Incisions in Newborns after Laparotomy

BACKGROUND

 Surgical wound dehiscence (SWD) in neonates is a life-threatening complication. The aim was to define risk factors of postoperative incision dehiscence in this population.

METHODS

 Data of 144 patients from 2010 to 2020 were analyzed retrospectively. All full-term newborns or preterm newborns up to 42 weeks of amenorrhea (adjusted) who had a laparotomy within 30 days were included. Descriptive patient information and perioperative data were collected. SWD was defined as any separation of cutaneous edges of postoperative wounds.

RESULTS

 Overall, SWD occurred in 16/144 (11%) patients, with a significantly increased incidence in preterm newborns (13/59, 22%) compared with full-term newborns (3/85, 4%; p < 0.001). SWD was significantly associated with exposure to postnatal steroids (60% vs. 4%, p < 0.001) and nonsteroidal anti-inflammatory drugs (25% vs. 4%, p < 0.01), invasive ventilation duration before surgery (median at 10 vs. 0 days, p < 0.001), preoperative low hemoglobin concentration (115 vs. 147 g/L, p < 0.001) and platelet counts (127 vs. 295 G/L, p < 0.001), nonabsorbable suture material (43% vs. 8%, p < 0.001), the presence of ostomies (69% vs. 18%, p < 0.001), positive bacteriological wound cultures (50% vs. 6%, p < 0.001), and relaparotomy (25% vs. 3%, p < 0.01). Thirteen of 16 patients with SWD presented necrotizing enterocolitis/intestinal perforations (81%, p < 0.001).

CONCLUSION

 This study identified prematurity and a number of other factors linked to the child's general condition as risk factors for SWD. Some of these can help physicians recognize and respond to at-risk patients and provide better counseling for parents.

Recommendations for use of adhesives on hospitalized newborns: A systematic review of the literature

BACKGROUND

The skin is the largest organ in the human body. It provides multiple barrier functions, tactile or defensive, and acts as a mediator allowing for the attachment of vital monitoring devices with medical adhesives. Adhesives consist of several layers with varying compositions and properties. We aimed to provide recommendations for their use in the care of hospitalized neonates on the basis of a systematic literature review.

METHODS

We searched PubMed for English or French articles published before May 29, 2020, using the keywords "adhesive," "tape,", "skin," and "neonat*." Recommendations were developed after review by a multidisciplinary group including 15 professionals and parent representatives.

RESULTS

We identified 295 studies, and from 30 eligible studies we developed six recommendations according to four perspectives: assessment of the skin condition to improve the methods of application of the different adhesives and their removal; use of adhesives as a platform; and discouraging the regular use of semi-permeable dressings to compensate for the immaturity of the skin barrier.

CONCLUSION

Skin lesions are common for hospitalized neonates. Use of adhesives may increase the occurrence of such lesions. Adhesives should be subject to good clinical practice guidelines. Health professionals caring for newborns should know the tools for screening and preventing skin lesions.

Development and validation of the atopic dermatitis and infant skincare knowledge, attitude, and practice (ADISKAP 1.0) scale

Importance

Preserving skin health is crucial for atopic dermatitis control as well as for the thriving of children. However, a well-developed and validated tool that measures the knowledge, attitude, and practice of skin care is lacking.

Objective

To develop and validate the atopic dermatitis and infant skincare knowledge, attitude, and practice (ADISKAP 1.0) scale that measures parental health literacy on atopic dermatitis and skin care.

Methods

We conducted a review of the literature, a focus group (two dermatologists and 12 parents), and a panel discussion in order to generate the ADISKAP prototype. Two samples of parents with knowingly superior (dermatologists, n = 59) and inferior (general population, n = 395) knowledge traits participated in the validation of ADISKAP. Cronbach's alpha was reported as a measure of internal consistency, and the intraclass correlation coefficient (ICC) was calculated to assess the test-retest validity. The known-groups technique was used to evaluate construct validity.

Results

The ADISKAP scale contained 17 items after content and face validity validation. After removing items that displayed poor test-retest reliability (n = 4) and construct validity (n = 3), 12 items were retained in the ADISKAP 1.0.

Interpretation

ADISKAP 1.0 is a reliable and valid tool for assessing parental knowledge, attitude, and practice on infantile atopic dermatitis and skin care.

Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India

Purpose

Neonatal skin care practices guided by personal experience and preferences might be substantially different across different hospital settings. The aim of this consensus recommendation is to provide clinical practice guidance to healthcare practitioners on evidence-based neonatal skin care practices from delivery-to-discharge, in hospital settings.

Patients and Methods

A Scientific Advisory Board meeting on "Evidence-based Neonatal Skin Care Practices and Protocols" was held in December 2020 with an expert panel comprising neonatologists, pediatricians, obstetricians and gynecologists and pediatric dermatologist. Comprehensive literature search was performed up to 23 March 2021 using PubMed and Google Scholar to retrieve relevant evidence.

Results

Recommendations were developed on critical aspects of skin care in healthy full-term neonates including cleansing at birth, skin-to-skin care, cord care, diaper area care, initial and routine bathing, cleansers and emollients use, and criteria to choose appropriate skin care products. Recommendations include inclusion of skin assessment in routine neonatal care, first bath timing after cardio-respiratory and thermal stabilization, 6-24 hours after birth; bathing with water alone or adding a mild liquid cleanser could be considered appropriate as it does not impact the developing skin barrier; use of emollients is recommended for neonates with higher risk of development of eczema to maintain and enhance skin barrier function and integrity; and inclusion of skin care advice in neonatal discharge checklist. Importance of rigorous quality control, high-quality clinical trials for assessment of baby products, usage of products that are formulated appropriately for newborns, and full label transparency for baby products were highlighted. The panel identified gaps in literature and discussed the scope for future research.

Conclusion

These recommendations may help to standardize evidence-based skin care for healthy full-term neonates in Indian hospital settings to improve the quality of care that neonates receive in hospital and facilitate improvement in overall neonatal health outcomes.

Clinical Study of Continuous Non-Invasive Blood Pressure Monitoring in Neonates

The continuous monitoring of arterial blood pressure (BP) is vital for assessing and treating cardiovascular instability in a sick infant. Currently, invasive catheters are inserted into an artery to monitor critically-ill infants. Catheterization requires skill, is time consuming, prone to complications, and often painful. Herein, we report on the feasibility and accuracy of a non-invasive, wearable device that is easy to place and operate and continuously monitors BP without the need for external calibration. The device uses capacitive sensors to acquire pulse waveform measurements from the wrist and/or foot of preterm and term infants. Systolic, diastolic, and mean arterial pressures are inferred from the recorded pulse waveform data using algorithms trained using artificial neural network (ANN) techniques. The sensor-derived, continuous, non-invasive BP data were compared with corresponding invasive arterial line (IAL) data from 81 infants with a wide variety of pathologies to conclude that inferred BP values meet FDA-level accuracy requirements for these critically ill, yet normotensive term and preterm infants.

The dynamic balance of the skin microbiome across the lifespan

For decades research has centered on identifying the ideal balanced skin microbiome that prevents disease and on developing therapeutics to foster this balance. However, this single idealized balance may not exist. The skin microbiome changes across the lifespan. This is reflected in the dynamic shifts of the skin microbiome's diverse, inter-connected community of microorganisms with age. While there are core skin microbial taxa, the precise community composition for any individual person is determined by local skin physiology, genetics, microbe-host interactions, and microbe-microbe interactions. As a key interface with the environment, the skin surface and its appendages are also constantly exchanging microbes with close personal contacts and the environment. Hormone fluctuations and immune system maturation also drive age-dependent changes in skin physiology that support different microbial community structures over time. Here, we review recent insights into the factors that shape the skin microbiome throughout life. Collectively, the works summarized within this review highlight how, depending on where we are in lifespan, our skin supports robust microbial communities, while still maintaining microbial features unique to us. This review will also highlight how disruptions to this dynamic microbial balance can influence risk for dermatological diseases as well as impact lifelong health.

Microbiome Changes in Pregnancy Disorders

The human microbiota comprises all microorganisms, such as bacteria, fungi, and viruses, found within a specific environment that live on our bodies and inside us. The last few years have witnessed an explosion of information related to the role of microbiota changes in health and disease. Even though the gut microbiota is considered the most important in maintaining our health, other regions of the human body, such as the oral cavity, lungs, vagina, and skin, possess their own microbiota. Recent work suggests a correlation between the microbiota present during pregnancy and pregnancy complications. The aim of our literature review was to provide a broad overview of this growing and important topic. We focused on the most significant changes in the microbiota in the four more common obstetric diseases affecting women's health. Thus, our attention will be focused on hypertensive disorders, gestational diabetes mellitus, preterm birth, and recurrent miscarriage. Pregnancy is a unique period in a woman's life since the body undergoes different adaptations to provide an optimal environment for fetal growth. Such changes also involve all the microorganisms, which vary in composition and quantity during the three trimesters of gestation. In addition, special attention will be devoted to the potential and fundamental advances in developing clinical applications to prevent and treat those disorders by modulating the microbiota to develop personalized therapies for disease prevention and tailored treatments.

A neonate with multiple hand flexor tendon ruptures due to methicillin-susceptible Staphylococcus aureus sepsis: a case report

BACKGROUND

Neonatal pyogenic tenosynovitis is a highly emergent soft tissue infection. We report a case of a neonate with pyogenic tendinopathy and tendon rupture diagnosed by ultrasonography (US). He subsequently developed pyogenic arthritis and osteomyelitis during antimicrobial therapy.

CASE PRESENTATION

A 7-day-old boy was admitted to our hospital with redness and swelling of the right index finger. US on admission showed rupture of the flexor tendon of the right index finger with inactivity. The day after admission, he developed pyogenic arthritis of the right elbow and, subsequently, pyogenic osteomyelitis. Staphylococcus aureus was identified through bacterial culture, and the patient was treated with intravenous antibiotics for 6 weeks. However, after discharge from our hospital, rupture of the flexor tendon of the left thumb was confirmed. A two-stage flexor tendinoplasty was completed at the age of 2 years and 1 month for the flexor tendon rupture on his right index finger.

CONCLUSIONS

In addition to blood culture, ultrasonographic evaluation should be performed in neonates with erythematous and swollen joints to identify the focus of infection as soon as possible. Moreover, repeated regular US examination is important in the follow-up of bone and soft tissue infections.

Prediction values of a novel prognostic index hypoproteinemia combined with contaminated wounds for wound dehiscence after abdominal surgery in neonates.. [DOI: 10.21203/rs.3.rs-2517931/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background Abdominal Wound Dehiscence (AWD), occupying a large proportion of neonatal surgery is an essential complication of abdominal surgery, which can leads to severe consequences, including life-threatening. This study aims at exploring prediction value for AWD with potential joint factors of hypoproteinemia and incision type. Method The Cox proportional-hazards model (the Cox model) was applied to analyze clinical data came from 453 patients underwent neonatal laparotomy from June 2009 to June 2020. According to application of the random numbers, 453 cases were divided into two separate models randomly involving training set with 318 observations (70%) and validation set with 135 observations (30%), and then the models trained were validated based on the validation set. Investigation in the connection between hypoproteinemia, incision type, combined factors and AWD, were used for comparing those prediction values for AWD. Results With a median follow-up of 15 months, the incidence of neonatal AWD was 6.0% (27/453). Based on the univariate and multivariate Analysis using the Cox Regression Analysis, hypoproteinemia(HR = 7.005, P = 0.001) and joint factor༈HR = 6.901, P < 0.001༉were both the independent risk factors for neonatal AWD in training set. Meanwhile, hypoproteinemia and joint factor༈HR = 5.497, P = 0.045༉were both also the independent risk factors for neonatal AWD in validation models, which indicated that joint factor was the independent risk factor in both models. The summary ROC curve was estimated, and the area under the ROC curve (AUC) was calculated as a criterion for validating the models trained. The findings illustrated that AUC of joint prediction factor for AWD was higher than either that of hypoproteinemia༈0.759 vs. 0.638) or incision type factor ༈0.759 vs. 0.671༉singly. Conclusion The contribution of hypoproteinemia and incision type combined factor for predicting AWD is superior than that of them individually, resulting in a significant promotion in prediction efficiency and accuracy of predicting neonatal AWD.

Global variation in skin injures and skincare practices in extremely preterm infants

BACKGROUND

Globally, are skincare practices and skin injuries in extremely preterm infants comparable? This study describes skin injuries, variation in skincare practices and investigates any association between them.

METHODS

A web-based survey was conducted between February 2019 and August 2021. Quantifying skin injuries and describing skincare practices in extremely preterm infants were the main outcomes. The association between skin injuries and skincare practices was established using binary multivariable logistic regression adjusted for regions.

RESULTS

Responses from 848 neonatal intensive care units, representing all geographic regions and income status groups were received. Diaper dermatitis (331/840, 39%) and medical adhesive-related skin injuries (319/838, 38%) were the most common injuries. Following a local skincare guideline reduced skin injuries [medical adhesive-related injuries: adjusted odds ratios (aOR) = 0.63, 95% confidence interval (CI) = 0.45-0.88; perineal injuries: aOR = 0.66, 95% CI = 0.45-0.96; local skin infections: OR = 0.41, 95% CI = 0.26-0.65; chemical burns: OR = 0.46, 95% CI = 0.26-0.83; thermal burns: OR = 0.51, 95% CI = 0.27-0.96]. Performing skin assessments at least every four hours reduced skin injuries (abrasion: aOR = 0.48, 95% CI = 0.33-0.67; pressure: aOR = 0.51, 95% CI = 0.34-0.78; diaper dermatitis: aOR = 0.71, 95% CI = 0.51-0.99; perineal: aOR = 0.52, 95% CI = 0.36-0.75). Regional and resource settings-based variations in skin injuries and skincare practices were observed.

CONCLUSIONS

Skin injuries were common in extremely preterm infants. Consistency in practice and improved surveillance appears to reduce the occurrence of these injuries. Better evidence regarding optimal practices is needed to reduce skin injuries and minimize practice variations.

Antimicrobial skin peptides in premature infants: Comparison with term infants and impact of perinatal factors

Introduction

Preterm infants have an immature epidermis barrier function that may lead to an increased permeability to pathogens. On the surface of the human skin, antimicrobial peptides (AMPs) are important molecules of the innate immune system, have broad antimicrobial properties, and provide an essential role in integrity of the microbiome. Given the marked susceptibility of preterm infants to infection, we hypothesize a decreased expression of AMPs on the skin of preterm infants.

Materials and methods

In a prospective single-center study with 35 preterm and 20 term infants, we analyzed skin rinsing probes for the presence of the AMPs psoriasin (S100A7) and ribonuclease 7 (RNase 7) via enzyme-linked immunosorbent assay. Samples were taken from preterm infants < 34 0/7 weeks gestational age (mean ± SD gestational age, 28.8 ± 2.4 weeks) on days 0, 7, 14, and 28 after birth. Term infants (> 36 6/7 weeks) (controls) were washed on days 0 and 28.

Results

Psoriasin and RNase 7 were both expressed on skin of preterm and term infants and increased in concentration significantly over time. RNase 7 was more expressed in term infants on day 0 [preterm = 1.1 (0.7-2.9) vs. term = 2.0 (1.1-3.4) ng/ml, p = 0.017]. On day 28, premature infants showed higher values of psoriasin [preterm = 10.9 (5.6-14.2) vs. term = 6.3 (3.4-9.0) ng/ml, p < 0.001]. Notably, preterm infants with infectious or inflammatory context driven by histological proof of chorioamnionitis and early-onset or late-onset sepsis had higher concentrations of psoriasin as compared with non-affected preterm infants. After exclusion of infants with inflammatory hit, median concentrations of RNase 7 and psoriasin did not differ between preterm and full-term infants on days 0 and 28.

Discussion

Psoriasin and RNase 7 concentrations increase over time on the skin of newborn infants and seem to play a role in the first defense against infection. This is of particularly interest as the role of AMPs on a maturing skin microbiome and its possible new prevention strategies is unclear and needs to be determined.

Distribution of Vernix Caseosa and Associated Factors Among Newborns Delivered at Adama Comprehensive Specialized Hospital Medical College, Ethiopia, in 2022: Cross-Sectional Study

Background

Vernix caseosa is a complex proteolipid material synthesized partly by fetal sebaceous glands during the last trimester of pregnancy. Understanding the structure and function of newborn skin is crucial for determining optimal thermal support, infection control, and skin moisturization. So far, in Ethiopia, there is no research done related to the distribution of vernix caseosa and associated factors on newborn skin. Doing such research could give awareness about factors associated with the distribution of vernix caseosa on newborns' skin and to take necessary protective measures for those that may be affected.

Objective

The objective of this study is to assess the distribution of vernix caseosa and associated factors among newborns delivered at Adama Comprehensive Specialized Hospital Medical College from November to December 1, 2021.

Methodology

Hospital-based cross-sectional study design was conducted from November to December 1, 2021 at Adama Comprehensive Specialized Hospital Medical College (ACSHMC). Four hundred twenty-two eligible newborns were selected by a systematic sampling method. Data were collected by four data collectors by using a pretested questionnaire. The distribution of vernix caseosa on the different regions of the neonate was assessed, by exposing their whole body for a minute. Data entry was done by EPI data version 4.6 and analyzed by using SPSS version 25. A logistic regression of P-value of <0.25 during bivariate and P < 0.05 during multivariate analysis at a 95% confidence level was considered statistically significant.

Results

Out of 422 study participants 231 (54.7%) with 95% CI (49.8, 59.8) babies had vernix caseosa. Being primiparous with (AOR = 1.9, PV = 0.013, 95% CI: 1.141, 2.92), being multiparous with (AOR = 1.98, PV = 0.04, CI: 1.29, 3.225), being females with (AOR = 2.1, PV = 0.001, CI: 1.39, 3.18), being preterm with (AOR = 2.98, PV = 0.036, 95% CI: 1.08, 10.72), non-diseased newborns with (AOR = 1.6, PV = 0.046, 95% CI: 1.07, 2.7) were identified as associated factors for the distribution of vernix caseosa on the newborn skin.

Conclusion

This study showed that the distribution of vernix caseosa on the skin of the newborns was associated with parity, sex, gestational age, and absence of disease.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

Exploring Environmental Factors Contributing to Fluid Loss in Diapers Placed in Neonatal Incubators

PURPOSE

Assessing fluid output for infants in the neonatal intensive care unit is essential to understanding fluid and electrolyte balance. Wet diaper weights are used as standard practice to quantify fluid output; yet, diaper changes are intrusive and physiologically distressing. Less frequent diaper changes may have physiologic benefits but could alter diaper weights following extended intervals.

METHODS

This pilot study examined the impact of initial diaper fluid volume, incubator air temperature and humidity, and diaper brand on wet diaper weight over time. Baseline fluid volume was instilled, and then diapers were placed in a neonatal incubator. Wet diaper weight was assessed longitudinally to determine changes in fluid volume over time. A factorial design with repeated measures (baseline, 3 hours, and 6 hours) was used to explore the effects of diaper brand (brand 1 vs brand 2), baseline fluid volume (3 mL vs 5 mL), and incubator temperature (28°C vs 36°C) and humidity (40% vs 80%) on the trajectory of weight in 80 diapers.

RESULTS

Wet diaper weight was significantly reduced over 6 hours (P < .005). However, wet diaper weight increased in 80% humidity, but decreased in the 40% humidity over time (P < .0001). Baseline fluid volume, incubator temperature, and diaper brand did not influence wet diaper weight over time (all P > .05).

IMPLICATIONS

Understanding environmental factors that influence the trajectory of wet diaper weight may support clinicians in optimizing the interval for neonatal diaper changes to balance the impact of intrusive care with need to understand fluid volume loss.

Investigation of Healthcare Professionals' Knowledge of Evidence-Based Clinical Practices for Preterm Neonatal Skin Care-A Pilot Study

Neonatal skin care practices are considered crucial for a neonate's survival and are closely related to healthcare professionals' (HPs) knowledge and skills in delivering scientifically valid neonatal care interventions. In this descriptive cross-sectional pilot study, conducted in 2022, we aimed to assess HPs' basic theoretical knowledge of neonatal vernix caseosa, skin microbiota, and bathing as well as knowledge regarding evidence-based clinical practices (referred to as "clinical knowledge") for preterm neonatal skin care. Eligible participants were neonatologists, pediatricians, obstetricians, midwives and nurses working in the Greek setting. The research instrument was an online questionnaire designed by the research team. Finally, 123 HPs took part in the study. The theoretical, clinical and total knowledge scores were all significantly associated with age, healthcare profession and the sources used for education. Participants' theoretical and clinical knowledge scores were compared and found not to differ significantly (p = 0.566). A significant and positive correlation was found between theoretical and clinical knowledge scores. Thus, it is concluded that HPs should be updated with the latest evidence-based knowledge and clinical guidelines in order to provide neonatal skin care with high-quality standards.

Mesenchymal Stem Cells Profile in Adult Atopic Dermatitis and Effect of IL4-IL13 Inflammatory Pathway Inhibition In Vivo: Prospective Case-Control Study

Atopic dermatitis (AD) is an inflammatory disease that typically begins in childhood and may persist into adulthood, becoming a lifelong condition. The major inflammatory mediators of AD are known to be interleukin IL4 and IL13, so Dupilumab, which is able to inhibit both interleukins by blocking the shared IL4Rα subunit, has become an attractive option for treating AD. Mesenchymal stem cells (MSCs) are involved in the onset and development of AD by secreting specific interleukins. The aim of this study was to isolate MSCs from healthy controls (C-MSCs) and patients with AD before (AD-MSCs T0) and after 16 weeks of treatment with Dupilumab (AD-MSCs T16); to evaluate the expression mainly of IL4 and IL13 and of other inflammatory cytokines in C-MSCs, AD-MSCs at T0 and at T16; and to evaluate the efficacy of Dupilumab on MSCs immunobiology. C- and AD-MSCs (T0, T16) were isolated from skin specimens and characterized; the expression/secretion of IL4 and IL13 was evaluated using immuno-cytochemistry (ICC), indirect immune-fluorescence (IIF) and an ELISA test; secretion of IL2, IL4, IL5, IL6, IL10, IL12, IL13, IL17A, Interferon gamma (IFNγ), Tumor necrosis factor alpha (TNFα), Granulocyte Colony-Stimulating Factor (G-CSF), and Transforming Growth Factor beta1 (TGFβ1) were measured with ELISA. IL13 and IL6 were over-expressed, while IL4 was down-regulated in AD-MSCs at T0 compared to C-MSCs. IL6 and IL13 expression was restored after 16 weeks of Dupilumab treatment, while no significant effects on IL4 expression were noted. Finally, IL2, IL5, IL10, IL12, IL17A, INFγ, TNFα, G-CSF, and TGFβ1 were similarly secreted by C- and AD-MSCs. Although Dupilumab blocks the IL4Rα subunit shared by IL4 and IL13, it is evident that its real target is IL13, and its ability to target IL13 in MSCs reinforces the evidence, already known in differentiated cells, of the central role IL13 rather than IL4 in the development of AD. The inflammatory cascade in AD begins at the mesenchymal level, so an upstream therapeutic intervention, able to modify the immunobiology of atopic MSCs, could potentially change the natural history of the disease.

Evaluation of Biophysical Properties of Potential Materials for the Manufacture of Protective Garments for Preterm Infants

Preterm infants, due to immature and dysfunctional skin, have increased water loss through the skin and consequently a decreased body temperature. In order to develop protective garments for preterm infants, it is important to select materials that will protect the child against water and heat loss. The authors are currently involved in the development of protective garments for premature babies, which are similar to baby clothes and contain a membrane that is partially permeable for vapor in combination with textile materials. This article presents the study of materials intended for the production of protective garments for pre-term infants. Samples of materials were investigated to determine biophysical comfort (tests of heat resistance, vapor resistance according to PN-EN ISO 11092:2014-11 and air permeability according to PN-EN ISO 9237) and porosity, surface mass in accordance with PN-EN 12127, and thickness in accordance with PN-EN ISO 5084. In order to determine the porosity of materials and to visualize the structure, tests on computer microtomography were carried out. The mechanical properties of the tested materials and the evaluation of the total hand value were characterized; the samples were tested on the KES device. The aim of this study was to select the most suitable fabrics for protective garments for premature infants to prevent excessive heat and moisture loss from the body, which can lead to hypothermia. For laminates, the optimal results of vapor resistance and heat resistance were obtained for laminate (15 g·m⁻² PE foil + 15 g·m⁻² PP non-woven), with a level of thermal resistance of 0.0766 m²·K·W⁻¹ and vapor resistance of 188.729 m²·Pa·W⁻¹, and for laminate (15 g·m⁻² PE foil + 10 g·m⁻² PP non-woven), with a level of thermal resistance of 0.0683 m²·K·W⁻¹ and vapor resistance of 164.085 m²·Pa·W⁻¹. For knitted fabrics, knitwear single cotton 155 g·m⁻² showed the highest thermal resistance (0.0296 m²·K·W⁻¹), and knitwear interlock polyester 120 g·m⁻² showed the lowest thermal resistance (0.0179 m²·K·W⁻¹). Knitwear cotton 120 g·m⁻² had the highest water vapor resistance (8.402 m²·Pa·W⁻¹), while knitwear interlock polyester 130 g·m⁻² sample had the lowest resistance (6.356 m²·Pa·W⁻¹). Garments for premature babies should have moisture barrier properties and high thermal insulation. They should also be characterized by optimal air permeability properties. Sample two-layer laminate (15 g·m⁻² PE foil + 15 g·m⁻² PP non-woven) had the best vapor resistance and thermal insulation properties. Moreover, this sample was characterized by good air permeability and surface weight compared to the other laminate samples. During the design of garments for premature babies, it is important to reduce the surface weight to as low as possible. Among the knitted fabrics, a knitwear single cotton 120 g·m⁻² knitwear polyester interlock 120 g·m⁻² was selected for having the best THV or tactile comfort. In addition, these knits were chosen for their lower surface weight. Based on the conducted tests, two-layer laminate (15 g·m⁻² PE foil + 15 g·m⁻² PP non-woven), the knitwear single cotton 120 g·m^−2, and knitwear polyester interlock 120 g·m⁻² were selected for further research.

Newborn and elderly skin: two fragile skins at higher risk of pressure injury

Skin is a key organ maintaining internal homeostasis by performing many functions such as water loss prevention, body temperature regulation and protection from noxious substance absorption, microorganism intrusion and physical trauma. Skin ageing has been well studied and it is well known that physiological changes in the elderly result in higher skin fragility favouring the onset of skin diseases. For example, prolonged and/or high-intensity pressure may suppress local blood flow more easily, disturbing cell metabolism and inducing pressure injury (PI) formation. Pressure injuries (PIs) represent a significant problem worldwide and their prevalence remains too high. A higher PI prevalence is correlated with an elderly population. Newborn skin evolution has been less studied, but some data also report a higher PI prevalence in this population compared to older children, and several authors also consider this skin as physiologically fragile. In this review, we compare the characteristics of newborn and elderly skin in order to determine common features that may explain their fragility, especially regarding PI risk. We show that, despite differences in appearance, they share many common features leading to higher fragility to shear and pressure forces, not only at the structural level but also at the cellular and molecular level and in terms of physiology. Both newborn and elderly skin have: (i) a thinner epidermis; (ii) a thinner dermis containing a less-resistant collagen network, a higher collagen III:collagen I ratio and less elastin; (iii) a flatter dermal-epidermal junction (DEJ) with lower anchoring systems; and (iv) a thinner hypodermis, resulting in lower mechanical resistance to skin damage when pressure or shear forces are applied. At the molecular level, reduced expression of transforming growth factor β (TGFβ) and its receptor TGFβ receptor II (TβRII) is involved in the decreased production and/or increased degradation of various dermal extracellular matrix (ECM) components. Epidermal fragility also involves a higher skin pH which decreases the activity of key enzymes inducing ceramide deficiency and reduced barrier protection. This seems to be correlated with higher PI prevalence in some situations. Some data also suggest that stratum corneum (SC) dryness, which may disturb cell metabolism, also increases the risk of PI formation. Besides this structural fragility, several skin functions are also less efficient. Low applied pressures induce skin vessel vasodilation via a mechanism called pressure-induced vasodilation (PIV). Individuals lacking a normal PIV response show an early decrease in cutaneous blood flow in response to the application of very low pressures, reflecting vascular fragility of the skin that increases the risk of ulceration. Due to changes in endothelial function, skin PIV ability decreases during skin ageing, putting it at higher risk of PI formation. In newborns, some data lead us to hypothesize that the nitric oxide (NO) pathway is not fully functional at birth, which may partly explain the higher risk of PI formation in newborns. In the elderly, a lower PIV ability results from impaired functionality of skin innervation, in particular that of C-fibres which are involved in both touch and pain sensation and the PIV mechanism. In newborns, skin sensitivity differs from adults due to nerve system immaturity, but the role of this in PIV remains to be determined.

Association Between Neonatal Phototherapy Exposure and Childhood Neoplasm

OBJECTIVE

To study the association between phototherapy for the treatment of neonatal jaundice and the risk of childhood neoplasms.

STUDY DESIGN

This population-based retrospective cohort study included all infants born at ≥32 weeks of gestation at a single medical center between 1988 and 2018. The incidence of neoplastic diseases was compared between infants exposed to phototherapy and those unexposed. Kaplan-Meier curves and log-rank tests were used for cumulative incidence comparison, and multivariable Cox and Weibull survival analysis were used to adjust for confounding or clinically significant variables.

RESULTS

The study population included 342 172 infants, of whom 18 797 (5.5%) were exposed to phototherapy. The median duration of follow-up was 9.5 years (range, birth to 18 years). Phototherapy was associated with a significantly increased risk for childhood malignancies and benign tumors (preterm birth and maternal age-adjusted hazard ratio, 1.89 [95% CI, 1.35-2.67] for malignancies and 1.27 [95% CI, 1.02-1.57] for benign tumors) Specifically, phototherapy was associated with hematopoietic cancers and leukemia (hazard ratio, 2.29 [95% CI, 1.48-3.54; P < .01] for hematopoietic cancers and 2.51 [95% CI, 1.52-4.14; P < .001] for leukemia), but not with solid tumors and lymphoma.

CONCLUSIONS

Phototherapy may be associated with a slightly increased childhood risk of neoplasm. It is important to strictly follow phototherapy treatment guidelines to minimize unnecessary exposure.

Early life host-microbe interactions in skin

Our skin is the interface through which we mediate lifelong interactions with our surrounding environment. Initial development of the skin's epidermis, adnexal structures, and barrier function is necessary for normal cutaneous microbial colonization, immune development, and prevention of disease. Early life microbial exposures can have unique and long-lasting impacts on skin health. The identity of neonatal skin microbes and the context in which they are first encountered, i.e., through a compromised skin barrier or in conjunction with cutaneous inflammation, can have additional short- and long-term health consequences. Here, we discuss key attributes of infant skin and endogenous and exogenous factors that shape its relationship to the early life cutaneous microbiome, with a focus on their clinical implications.

2% aqueous vs alcohol-based chlorhexidine for skin antisepsis in VLBW neonates undergoing peripheral venipuncture: a non-inferiority trial

OBJECTIVE

To compare 2% aqueous chlorhexidine gluconate (AQC) vs. 2% chlorhexidine gluconate in 70% isopropyl alcohol (ALC) for pre-venipuncture skin antisepsis in very-low-birth-weight neonates (VLBW, birth-weight <1500 grams).

STUDY DESIGN

Double-blind, non-inferiority trial randomized 199 VLBW neonates, age 2-28 days, to receive pre-venipuncture skin preparation using single application of swabstick impregnated with AQC (n = 99) or ALC (n = 100). Skin clearance rate (percentage post-cleansing skin swabs with <15 bacterial colony forming units) with a 10% non-inferiority margin for AQC was primary outcome. Absolute and relative CFU reduction and adverse skin reactions were compared.

RESULTS

AQC's clearance was non-inferior to ALC (91% vs. 88%; 95% CI -6.6%, +12.4%). Median (interquartile range) absolute [61 (16, 110) vs. 63 (18, 100); p = 0.65] and relative [100% (97%, 100%) vs. 100% (99.7%, 100%); p = 0.20] CFU reductions were similar. Neither group experienced any adverse reactions.

CONCLUSION

AQC may provide non-inferior skin disinfection to ALC in VLBW neonates.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT01270776.

Neonatal Skin Structure: Pressure Injury Staging Challenges

GENERAL PURPOSE

To review neonatal pressure injuries (PIs), including clinical features and challenges in evaluation and staging related to the unique anatomic features of preterm neonatal skin as well as the common sites and mechanisms of injury.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Recognize the causes of PIs in preterm neonates.2. Choose the outcomes of PIs in preterm neonates.3. Distinguish the common characteristics of preterm neonates' skin.4. Summarize the challenges clinicians face when classifying the PIs of preterm neonates.

Risks of Infectious Diseases in Newborns Exposed to Alternative Perinatal Practices

The purpose of this report is to educate providers about the risk of infectious diseases associated with emerging alternative peripartum and neonatal practices. This report will provide information pediatricians may use to counsel families before birth and to appropriately evaluate and treat neonates who have been exposed to these practices.

Effects of emollient therapy with sunflower seed oil on neonatal growth and morbidity in Uttar Pradesh, India: a cluster-randomized, open-label, controlled trial

BACKGROUND

Newborn oil massage is a widespread practice. Vigorous massage with potentially harmful products and forced removal of vernix may disrupt skin barrier integrity. Hospitalized, very-preterm infants treated with sunflower seed oil (SSO) have demonstrated improved growth but community-based data on growth and health outcomes are lacking.

OBJECTIVES

We aimed to test whether SSO therapy enhances neonatal growth and reduces morbidity at the population level.

METHODS

We conducted an open-label, controlled trial in rural Uttar Pradesh, India, randomly allocating 276 village clusters equally to comparison (usual care) and intervention comprised of promotion of improved massage practices exclusively with SSO, using intention-to-treat and per-protocol mixed-effects regression analysis.

RESULTS

We enrolled 13,478 and 13,109 newborn infants in demographically similar intervention and comparison arms, respectively. Adherence to exclusive SSO increased from 22.6% of intervention infants enrolled in the first study quartile to 37.2% in the last quartile. Intervention infants gained significantly more weight, by 0.94 g · kg-1 · d-1 (95% CI: 0.07, 1.82 g · kg-1 · d-1, P = 0.03), than comparison infants by intention-to-treat analysis. Restricted cubic spline regression revealed the largest benefits in weight gain (2-4 g · kg-1 · d-1) occurred in infants weighing <2000 g at birth. Weight gain in intervention infants was higher by 1.31 g · kg-1 · d-1 (95% CI: 0.17, 2.46 g · kg-1 · d-1; P = 0.02) by per-protocol analysis. Morbidities were similar by intention-to-treat analysis but in per-protocol analysis rates of hospitalization and of any illness were reduced by 36% (OR: 0.64; 95% CI: 0.44, 0.94; P = 0.02) and 44% (OR: 0.56; 95% CI: 0.40, 0.77; P < 0.001), respectively, in treated infants.

CONCLUSIONS

SSO therapy improved neonatal growth, and reduced morbidities when applied exclusively, across the facility-community continuum of care at the population level. Further research is needed to improve demand for recommended therapy inside hospital as well as in community settings, and to confirm these results in other settings.This trial was registered at www.isrctn.com as ISRCTN38965585 and http://ctri.nic.in as CTRI/2014/12/005282.

An Adaptation of the Skin Safety Model to Guide Diaper Dermatitis Research in the NICU

Diaper dermatitis is an ever-present condition among infants. Little is known about the prevalence among infants in the NICU. This article presents an adaptation of the skin safety model (SSM) for the infant in the NICU. The concepts of the model were extracted, defined, and integrated into an adapted SSM model to provide a focus on the infant with diaper dermatitis in the intensive care setting. It is essential to include all factors of the infant's clinical characteristics and hospital experience in the modeling to accurately predict risk of skin vulnerability in this infant population.

An investigation on the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit

OBJECTIVES

To investigate the current status of the cognition of neonatal pain assessment and analgesia management among medical staff in the neonatal intensive care unit (NICU).

METHODS

A self-made scale was developed according to "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)" and was used to distribute questionnaires to the medical staff in the NICU from the member units of Jiangsu Province Medical Quality Control Centre of Neonatal Department to evaluate their levels of understanding the basic knowledge, assessment, and management of neonatal pain.

RESULTS

A total of 957 questionnaires (from 383 doctors and 574 nurses) were collected. Doctors and nurses had mean correct rates of 38% and 39% respectively in answering the questions on the basic knowledge of neonatal pain. They had median correct rates of 0% and 50% respectively in answering the questions on neonatal pain assessment, and mean correct rates of 73% and 68% respectively in answering on analgesia management. Compared with those who did not receive the training on neonatal pain, the medical staff who received such training had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment (P<0.05). The medical staff from tertiary hospitals had significantly higher correct rates in answering the questions on the basic knowledge of neonatal pain and neonatal pain assessment than those from secondary hospitals (P<0.05).

CONCLUSIONS

The medical staff in the NICU have insufficient cognition of neonatal pain, and thus it is necessary to carry out the special training on neonatal pain, focusing on the promotion and practical application of "Expert consensus on neonatal pain assessment and analgesia management (2020 edition)", in order to improve the level of neonatal pain assessment and analgesia management among medical staff in the NICU.

Risk factors and predictive model for abdominal wound dehiscence in neonates: a retrospective cohort study

BACKGROUND

Abdominal wound dehiscence (AWD) is a major complication of abdominal surgery, and neonates are a group with a high risk of AWD, which has serious consequences or can even result in death. The purpose of this study is to explore the risk factors for neonatal AWD and construct a predictive model.

METHODS

The clinical data of 453 cases that underwent neonatal laparotomy from June 2009 to June 2020 were retrospectively analyzed, among which 27 cases of AWD were identified. Nine factors, including gender, age at admission, weight at admission, preterm delivery, level of preoperative anaemia, hypoalbuminemia, operation time, incision length, and incision type, were analyzed to explore their correlation with neonatal AWD.

RESULTS

The incidence of neonatal AWD was 6.0% (27/453), among which partial wound dehiscence accounted for 4.9% (22/453) and complete wound dehiscence accounted for 1.1% (5/453). Hypoproteinemia and incision type were the independent risk factors for neonatal AWD, and weight at admission was a protective factor for AWD in the multivariate models. All these factors were incorporated to construct a nomogram, and a calibration curve was plotted. The result indicated that the actual risk was close to the predicted risk when the predicted risk rate was greater than about 35%.

CONCLUSIONS

Neonatal AWD is closely related to hypoproteinemia and incision contamination. Our predictive model showed the potential to provide an individualized risk estimate of AWD for neonatal patients undergoing abdominal surgery.Key messagesNeonatal abdominal wound dehiscence (AWD) has a serious consequence and the incidence of neonatal AWD was about 6.0% and the complete AWD morbidity is 1.1%.Hypoproteinemia and incision type were the independent risk factors for neonatal AWD.Our predictive model showed the potential to provide an individualized risk estimate of AWD for neonatal patients undergoing abdominal surgery.

Interrelationships between Skin Structure, Function, and Microbiome of Pregnant Females and Their Newborns: Study Protocol for a Prospective Cohort Study

Background

Pregnancy leads to several skin changes, but evidence about structural and functional skin changes is scarce. Findings on skin structure and function in children in their first year reveal rapid skin maturation, but evidence indicates that in particular, water holding and transport mechanisms are different from adults. Important questions include whether maternal cutaneous properties predict infant skin condition, and if so, how. This is especially relevant for the skin's microbiome because it closely interacts with the host and is assumed to play a role in many skin diseases. Therefore, the study objective is to explore characteristics of skin and hair of pregnant women and their newborns during pregnancy and in the first six months after delivery and their associations.

Methods

The study has an observational longitudinal design. We are recruiting pregnant females between 18 and 45 years using advertisement campaigns in waiting areas of gynecologists and hospital's outpatient services. A final sample size of n = 100 women is the target. We perform noninvasive, standardized skin, hair, and skin microbiome measurements. We establish the baseline visit during pregnancy until at the latest four weeks before delivery. We schedule follow-up visits four weeks and six months after birth for mothers and their newborns. We will calculate descriptive statistical methods using frequencies and associations over time depending on scale levels of the measurements. Discussion. The majority of previous studies that have investigated infants' skin microbiome and its associations used cross-sectional designs and focused on selected characteristics in small samples. In our longitudinal study, we will characterize a broad range of individual and environmental characteristics of mothers and their newborns to evaluate interrelationships with skin parameters and their changes over time. Considering the combination of these multiple variables and levels will allow for a deeper understanding of the complex interrelationship of the newborn's skin maturation. This trial is registered with ClinicalTrials.gov (Identifier: NCT04759924).

Newborn-oriented and environmental factors for newborns' skin barrier functions

AIM

This study aimed to examine newborn-oriented and environmental factors of newborn skin barrier functions.

METHODS

This was a retrospective secondary analysis of 227 newborns from a previous study. Newborn skin barrier functions were measured on the fourth day after birth via the following parameters: stratum corneum hydration, transepidermal water loss, skin pH, and sebum secretion. Skin barrier functions were measured at four body sites; their averaged values were used for the analysis. The associations among skin barrier functions, newborn-oriented factors, and environmental factors were evaluated. Multiple regression analysis was performed using a forced entry method, and independent variables for which p-values were <.05 in Student's t test, analysis of variance, and Pearson's correlation analysis were included.

RESULTS

A total of 211 participants were analyzed. The mean ± standard deviation values of stratum corneum hydration, transepidermal water loss, skin pH, and sebum secretion were 28.58 ± 8.40 and 7.28 ± 2.02 g/m² /h, 5.77 ± 0.53, and 23.59 ± 15.89 μg/cm² , respectively. Newborn-oriented factors (gestational days, weight, amount of vernix, and parity) and environmental factors (birth season) were significantly associated with one or more skin barrier functions.

CONCLUSIONS

Newborn-oriented (including labor- and delivery-related) and environmental factors were associated with the skin barrier functions. The newborn maturity level, newborn sex, environmental temperature, and humidity may affect skin barrier functions in newborns. Further studies should focus on the effects of these factors on newborn skin barrier assessments, and develop tailored skincare strategies based on their characteristics.

Skincare practices in extremely premature infants: A survey of tertiary neonatal intensive care units from Australia and New Zealand

AIM

To investigate skincare practices in the first 2 weeks of life in extremely premature infants across tertiary neonatal intensive care units (NICUs).

METHODS

A web-based secure survey invite was emailed to the medical directors of tertiary NICUs. The survey included questions on various aspects of skincare practices in the first 2 weeks of life in extremely premature infants (born before 28 weeks gestation). The person most familiar with local skincare practices was asked to complete the survey and only one response per unit was requested. We performed a descriptive analysis.

RESULTS

We received responses from 30 out of 32 NICUs (response rate 93%). Twenty-five NICUs (89%) reported offering resuscitation and intensive care to infants born at ≥23 weeks gestation. All NICUs reported occurrences of skin breakdown, including medical adhesive-related skin injury (30%), abrasion/friction-associated skin injury (46%), perineal skin breakdown (55%), pressure site injury (47%) and diaper dermatitis (60%). A high level of consensus (≥75%) was observed for certain practices, such as the use of polyethylene occlusive plastic wraps at birth and aqueous chlorhexidine solution for sterile procedures, but a low level of consensus (<25%) was observed for many other practices, including the skin risk assessment tool used.

CONCLUSIONS

Skin injuries in extremely premature infants are common and skincare practices vary considerably amongst NICUs. Clinical practice improvement projects and further clinical research will help improve consistency amongst NICUs. Further research is needed to assist the development of evidence-based guidelines and benchmarking for skincare practices in these vulnerable infants.

Age-dependent changes in protein incorporation into collagen-rich tissues of mice by in vivo pulsed SILAC labelling

Collagen-rich tissues have poor reparative capacity that predisposes to common age-related disorders such as osteoporosis and osteoarthritis. We used in vivo pulsed SILAC labelling to quantify new protein incorporation into cartilage, bone, and skin of mice across the healthy life course. We report dynamic turnover of the matrisome, the proteins of the extracellular matrix, in bone and cartilage during skeletal maturation, which was markedly reduced after skeletal maturity. Comparing young adult with older adult mice, new protein incorporation was reduced in all tissues. STRING clustering revealed changes in epigenetic modulators across all tissues, a decline in chondroprotective growth factors such as FGF2 and TGFβ in cartilage, and clusters indicating mitochondrial dysregulation and reduced collagen synthesis in bone. Several pathways were implicated in age-related disease. Fewer changes were observed for skin. This methodology provides dynamic protein data at a tissue level, uncovering age-related molecular changes that may predispose to disease.

Neonatal burns: a 10-year review of community- and hospital-acquired neonatal burns in Western Australia

BACKGROUND

There are very few studies in the literature focusing on neonatal burns, and to our knowledge this is the largest study on this topic.

METHODS

A retrospective review was conducted over a 10-year period from 2010 to 2020 to investigate the incidence, mechanisms involved and outcomes for burn injuries in neonates in Western Australia. This study included children aged 4 weeks or younger who sustained a burns injury requiring admission to hospital or during their hospital admission. Premature infants who sustained burns during a hospital admission in the neonatal intensive care unit and were under 4 weeks corrected age were also included. Short-term outcomes of burn injuries included infection and need for surgery, and the long-term outcomes included scarring and requirement for laser therapy.

RESULTS

Over the 10-year period, 30 burn injuries were sustained by 27 neonates. Thirteen (43.3%) of these burns occurred at home or in the community, and 17 (56.7%) occurred in hospital. Scalds (n = 4) and sunburn (n = 4) were the most common mechanism in the community, while chemical (n = 12) burns including extravasation injuries were the most common sustained in hospital. No neonates required theatre for skin grafting or laser therapy for scarring. There were no infected burns in the cohort. Time to healing ranged from 2 to 62 days with a mean of 12.1 days.

CONCLUSION

Outcomes for burns sustained in the neonatal period in Western Australia are generally positive, and have not been associated with infection and have low rates of scarring.

Effect of sunflower seed oil emollient therapy on newborn infant survival in Uttar Pradesh, India: A community-based, cluster randomized, open-label controlled trial

BACKGROUND

Hospitalized preterm infants with compromised skin barrier function treated topically with sunflower seed oil (SSO) have shown reductions in sepsis and neonatal mortality rate (NMR). Mustard oil and products commonly used in high-mortality settings may possibly harm skin barrier integrity and enhance risk of infection and mortality in newborn infants. We hypothesized that SSO therapy may reduce NMR in such settings.

METHODS AND FINDINGS

This was a population-based, cluster randomized, controlled trial in 276 clusters in rural Uttar Pradesh, India. All newborn infants identified through population-based surveillance in the study clusters within 7 days of delivery were enrolled from November 2014 to October 2016. Exclusive, 3 times daily, gentle applications of 10 ml of SSO to newborn infants by families throughout the neonatal period were recommended in intervention clusters (n = 138 clusters); infants in comparison clusters (n = 138 clusters) received usual care, such as massage practice typically with mustard oil. Primary analysis was by intention-to-treat with NMR and post-24-hour NMR as the primary outcomes. Secondary analysis included per-protocol analysis and subgroup analyses for NMR. Regression analysis was adjusted for caste, first-visit weight, delivery attendant, gravidity, maternal age, maternal education, sex of the infant, and multiple births. We enrolled 13,478 (52.2% male, mean weight: 2,575.0 grams ± standard deviation [SD] 521.0) and 13,109 (52.0% male, mean weight: 2,607.0 grams ± SD 509.0) newborn infants in the intervention and comparison clusters, respectively. We found no overall difference in NMR in the intervention versus the comparison clusters [adjusted odds ratio (aOR) 0.96, 95% confidence interval (CI) 0.84 to 1.11, p = 0.61]. Acceptance of SSO in the intervention arm was high at 89.3%, but adherence to exclusive applications of SSO was 30.4%. Per-protocol analysis showed a significant 58% (95% CI 42% to 69%, p < 0.01) reduction in mortality among infants in the intervention group who were treated exclusively with SSO as intended versus infants in the comparison group who received exclusive applications of mustard oil. A significant 52% (95% CI 12% to 74%, p = 0.02) reduction in NMR was observed in the subgroup of infants weighing ≤1,500 g (n = 589); there were no statistically significant differences in other prespecified subgroup comparisons by low birth weight (LBW), birthplace, and wealth. No severe adverse events (SAEs) were attributable to the intervention. The study was limited by inability to mask allocation to study workers or participants and by measurement of emollient use based on caregiver responses and not actual observation.

CONCLUSIONS

In this trial, we observed that promotion of SSO therapy universally for all newborn infants was not effective in reducing NMR. However, this result may not necessarily establish equivalence between SSO and mustard oil massage in light of our secondary findings. Mortality reduction in the subgroup of infants ≤1,500 g was consistent with previous hospital-based efficacy studies, potentially extending the applicability of emollient therapy in very low-birth-weight (VLBW) infants along the facility-community continuum. Further research is recommended to develop and evaluate therapeutic regimens and continuum of care delivery strategies for emollient therapy for newborn infants at highest risk of compromised skin barrier function.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN38965585 and Clinical Trials Registry-India (CTRI/2014/12/005282) with WHO UTN # U1111-1158-4665.

Variation in Newborn Skincare Policies Across United States Maternity Hospitals

OBJECTIVE

Newborn skincare influences levels of beneficial factors from vernix and vaginal secretions but also the emergence of potential skin pathogens. However, evidence-based national guidelines for newborn skincare do not exist, and actual hospital practices for newborn skincare have not been described. In this study, we test the hypothesis that US maternity hospitals follow differing policies with regard to newborn skincare.

METHODS

A 16-question survey querying skin care practices was distributed to nursery medical directors at the 109 US hospital members of the Better Outcomes through Research for Newborns network. Data from free text responses were coded by 2 study personnel. Survey responses were analyzed by using descriptive statistics and compared by region of the United States.

RESULTS

Delaying the first newborn bath by at least 6 hours is a practice followed by 87% of US hospitals surveyed. Discharging newborns without a bath was reported in 10% of hospitals and was more common for newborns born in nonacademic centers and on the West Coast. Procedures and products used for newborn skincare varied significantly. Parental education on tub immersion and soap use was also inconsistent and potentially contradictory between providers. Evidence cited by hospitals in forming their policies is scant.

CONCLUSION

In this study, we identify similar and strikingly different newborn skincare policies across a national network of US maternity hospitals. Research is needed to identify effects of differing skincare routines on skin integrity, infection rates, and childhood health outcomes to improve the evidence base for the care of newborn skin.

Three-dimensional bioprinting of a full-thickness functional skin model using acellular dermal matrix and gelatin methacrylamide bioink

Treatment of full-thickness skin defects still presents a significant challenge in clinical practice. Three-dimensional (3D) bioprinting technique offers a promising approach for fabricating skin substitutes. However, it is necessary to identify bioinks that have both sufficient mechanical properties and desirable biocompatibilities. In this study, we successfully fabricated acellular dermal matrix (ADM) and gelatin methacrylamide (GelMA) bioinks. The results demonstrated that ADM preserved the main extracellular matrix (ECM) components of the skin and GelMA had tunable mechanical properties. Both bioinks with shear-thinning properties were suitable for 3D bioprinting and GelMA bioink exhibited high printability. Additionally, the results revealed that 20% GelMA with sufficient mechanical properties was suitable to engineer epidermis, 1.5% ADM and 10% GelMA displayed relatively good cytocompatibilities. Here, we proposed a new 3D structure to simulate natural full-thickness skin, which included 20% GelMA with HaCaTs as an epidermal layer, 1.5% ADM with fibroblasts as the dermis, and 10% GelMA mesh with human umbilical vein endothelial cells (HUVECs) as the vascular network and framework. We demonstrated that this 3D bioprinting functional skin model (FSM) could not only promote cell viability and proliferation, but also support epidermis reconstruction in vitro. When transplanted in vivo, the FSM could maintain cell viability for at least 1 week. Furthermore, the FSM promoted wound healing and re-epithelization, stimulated dermal ECM secretion and angiogenesis, and improved wound healing quality. The FSM may provide viable functional skin substitutes for future clinical applications. STATEMENT OF SIGNIFICANCE: We propose a new 3D structure to simulate natural full-thickness skin, which included 20% GelMA with HaCaTs as an epidermal layer, 1.5% ADM with fibroblasts as the dermis, and 10% GelMA mesh with HUVECs as the vascular network. It could not only maintain a moist microenvironment and barrier function, but also recreate the natural skin microenvironment to promote cell viability and proliferation. This may provide viable functional skin substitutes for future clinical applications.

Towards Optimal pH of the Skin and Topical Formulations: From the Current State of the Art to Tailored Products

Acidic pH of the skin surface has been recognized as a regulating factor for the maintenance of the stratum corneum homeostasis and barrier permeability. The most important functions of acidic pH seem to be related to the keratinocyte differentiation process, the formation and function of epidermal lipids and the corneocyte lipid envelope, the maintenance of the skin microbiome and, consequently, skin disturbances and diseases. As acknowledged extrinsic factors that affect skin pH, topically applied products could contribute to skin health maintenance via skin pH value control. The obtained knowledge on skins’ pH could be used in the formulation of more effective topical products, which would add to the development of the so-called products ‘for skin health maintenance’. There is a high level of agreement that topical products should be acidified and possess pH in the range of 4 to 6. However, formulators, dermatologists and consumers would benefit from some more precise guidance concerning favorable products pH values and the selection of cosmetic ingredients which could be responsible for acidification, together with a more extensive understanding of the mechanisms underlaying the process of skin acidification by topical products.