Physiological skin conditions of preterm and term neonates

Severe cellulitis from methicillin-resistant Staphylococcus aureus (MRSA) in a couple of preterm twins: a case report

BACKGROUND

Preterms are at risk of systemic infections as the barrier function of their immature skin is insufficient. The long period of hospitalization and the huge number of invasive procedures represent a risk factor for complications. Among the nosocomial infections of the skin, methicillin-resistant Staphylococcus aureus (MRSA) is associated with significant morbidity and mortality. We report a clinical case of cellulitis and abscess in two preterm twins caused by MRSA in a tertiary level Neonatal Intensive Care Unit (NICU).

CASE PRESENTATION

Two preterm female babies developed cellulitis from MRSA within the first month of extrauterine life. The first one (BW 990 g) showed signs of clinical instability 4 days before the detection of a hyperaemic and painful mass on the thorax. The second one (BW 1240 g) showed signs of clinical instability contextually to the detection of an erythematous, oedematous and painful area in the right submandibular space. In both cases the diagnosis of cellulitis was confirmed by ultrasound. A broad spectrum, multidrug antimicrobial therapy was administered till complete resolution.

CONCLUSIONS

Due to the characteristic antibiotic resistance of MRSA and the potential complications of those infections in such delicate patients, basic prevention measures still represent the key to avoid the spreading of neonatal MRSA infections in NICUs, which include hand hygiene and strict precautions, as well as screening of patients for MRSA on admission and during hospital stay, routine prophylactic topical antibiotic of patients, enhanced environmental cleaning, cohorting and isolation of positive patients, barrier precautions, avoidance of ward crowding, and, in some units, surveillance, education and decolonization of healthcare workers and visiting parents.

Multi-wavelength multi-distance diffuse correlation spectroscopy system for assessment of premature infants' cerebral hemodynamics

Infants born at an extremely low gestational age (ELGA, < 29 weeks) are at an increased risk of intraventricular hemorrhage (IVH), and there is a need for standalone, safe, easy-to-use tools for monitoring cerebral hemodynamics. We have built a multi-wavelength multi-distance diffuse correlation spectroscopy device (MW-MD-DCS), which utilizes time-multiplexed, long-coherence lasers at 785, 808, and 853 nm, to simultaneously quantify the index of cerebral blood flow (CBFi) and the hemoglobin oxygen saturation (SO2). We show characterization data on liquid phantoms and demonstrate the system performance on the forearm of healthy adults, as well as clinical data obtained on two preterm infants.

Physiologically Based Pharmacokinetic Modeling in Neonates: Current Status and Future Perspectives

Rational drug use in special populations is a clinical problem that doctors and pharma-cists must consider seriously. Neonates are the most physiologically immature and vulnerable to drug dosing. There is a pronounced difference in the anatomical and physiological profiles be-tween neonates and older people, affecting the absorption, distribution, metabolism, and excretion of drugs in vivo, ultimately leading to changes in drug concentration. Thus, dose adjustments in neonates are necessary to achieve adequate therapeutic concentrations and avoid drug toxicity. Over the past few decades, modeling and simulation techniques, especially physiologically based pharmacokinetic (PBPK) modeling, have been increasingly used in pediatric drug development and clinical therapy. This rigorously designed and verified model can effectively compensate for the deficiencies of clinical trials in neonates, provide a valuable reference for clinical research design, and even replace some clinical trials to predict drug plasma concentrations in newborns. This review introduces previous findings regarding age-dependent physiological changes and pathological factors affecting neonatal pharmacokinetics, along with their research means. The application of PBPK modeling in neonatal pharmacokinetic studies of various medications is also reviewed. Based on this, we propose future perspectives on neonatal PBPK modeling and hope for its broader application.

Sterile water moisturizer of the skin of extremely low birth weight infants

OBJECTIVE

To assess the feasibility of sterile water application to the skin of the extremely low birth weight (ELBW) newborns in the first week of life and examine its effects on their skin integrity and outcomes.

DESIGN

Pilot randomized controlled trial.

SETTING

Open-bay, 18 bed Level III NICU in the Eastern United States.

PARTICIPANTS

Twenty-eight ELBW neonates. Two newborns expired, sixteen newborns remained in the intervention group and twelve newborns in the control group.

METHODS

ELBW neonates were either assigned to receive frequent sterile water wash to skin or not during care for the first week of life. Using the Neonatal Skin Condition Scale (NSCS), assessments were performed twice a day during the first week. Fluid intake, serum electrolytes, culture proven sepsis and other morbidities, and length of stay (LOS) were compared while controlling for confounding variables using multiple regression analysis.

RESULTS

There was no difference in the demographic or clinical characteristics between both groups. Sterile water wash application to skin was not associated with differences in skin health indices or fluid intake. However, it was associated with higher median sodium level and with early regression of bilirubin level when compared to controls.

CONCLUSION

Frequent skin washes with sterile water are feasible and safe. However, they may not be associated with improved skin integrity or fluid intake.

[Guidelines for neonatal skin management in the neonatal intensive care unit (2021)]

Neonates are easily suffering from local or systematic infections due to their vulnerable skin barrier function, which leads to the increasing risk of death. Therefore, it is important to protect neonatal skin integrity and prevent neonatal skin injury in the neonatal intensive care unit (NICU). Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and current evidence, the guidelines for neonatal skin management in the NICU were developed to provide recommendations on routine skin care and prevention and treatment of iatrogenic skin injury of neonates for health care providers.

Neonatal skin assessments and injuries: Nomenclature, workplace culture and clinical opinions-Method triangulation a qualitative study

AIM AND OBJECTIVE

To explore and establish the language, clinical opinions and workplace culture around neonatal skin injury nomenclature. Specifically, what nomenclature is used to describe, define, identity and communicate neonatal skin injuries including (a) terms, (b) locations, (c) associated risks and (d) mechanical forces.

BACKGROUND

Skin injuries are affirmed or denied based on visual assessment with findings reported by language rather than measurements. However, if language or nomenclature is ambiguous, assessments could be misinterpreted effecting healthcare delivery.

DESIGN

Qualitative enquiry including applied discourse analysis and between-method triangulation, within a larger exploratory mixed-methods study.

METHODS

Data were collected over two years from four sources: literature, documents, interviews/focus groups and free text injury assessments. Data analysis included content analysis, selective coding and thematic analysis. The collective data were further explored using discourse analysis and triangulation to achieve collective conclusions about opinions, emotions, feelings, perceptions and workplace cultures. The COREQ checklist provided structure for the reporting of study methods, analysis and findings.

RESULTS

A total of 427 data points were collected from literature, documentation and two clinical data sources. Data convergence revealed that neonatal skin injuries are described by numerous terms with preferences for "injury," "trauma" or "redness." Injuries occur in over 20 anatomical locations and risks for injuries included hospitalisation, specific treatments and prematurity. Essential medical devices, clinical condition, lack of clinician experience and overactive neonates were uniquely associated risks. There was incongruency between sources. The literature and documents empathise pressure as the primary force related to skin injury, while varied forces were identified within interviews, focus groups and free text injury assessments.

CONCLUSIONS

The variety of unique terms, locations and risks for injury indicate the need for updated neonatal skin injury frameworks. If frameworks and policies continue to be created without the empirical knowledge of neonatal clinicians, misrepresentation of neonatal skin injury locations and risk will continue to dominate the literature.

RELEVANCE TO CLINICAL PRACTICE

The recognition and management of neonatal skin injuries are related to language used to describe assessments in the absence of diagnostic confirmation, which has implications for both the neonate and the healthcare team.

Development of a Nursing Guideline for Improving Skin Integrity in High-Risk Infants

BACKGROUND

High-risk infants are highly susceptible to skin impairment caused by invasive procedures, radiant warmers, and phototherapy, in addition to their intrinsic vulnerability. This leads to a vicious cycle that aggravates the risk of skin infections. Concerns have been raised that neonatal nurses may lack knowledge regarding feasible guidelines to improve skin integrity of high-risk newborns.

METHOD

A clinical guideline was developed for neonatal skin care practices based on skin physiology, and its educational effects on the knowledge and confidence of neonatal nurses was evaluated. A booklet was developed on skin care practice guidelines divided into topics determined through a nationwide survey.

RESULTS

Using a quasi-experimental design with 46 neonatal nurses, education with this booklet improved nurses' knowledge of skin care practices but not their confidence.

CONCLUSION

These findings highlight the importance of implementing a tailored systematic program rather than a single educational session on skin care in high-risk infants for neonatal nurses. [J Contin Educ Nurs. 2020;51(5):238-244.].

The effect of tub bathing and sponge bathing on neonatal comfort and physiological parameters in late preterm infants: A randomized controlled trial

BACKGROUND

Increasing comfort and physiological stabilization in preterm infants during neonatal care improves their neurophysiological development. Bathing procedures that support this development and will not expose the newborn to stress should be preferred.

OBJECTIVES

Our study aimed to examine the effectiveness of tub bathing and sponge bathing methods on the physiological parameters (i.e., heart rate, respiration rate, oxygen saturation, body temperature) and comfort of late preterm infants.

DESIGN

Randomized controlled trial. Study is registered at ClinicalTrials.gov NCT03796312.

SETTINGS

The trial was conducted in a neonatal intensive care unit of a university hospital in Antalya, Turkey.

METHODS

Late preterm infants (gestational age between 34 0/7 weeks and 36 6/7 weeks) were randomly assigned by a computer program to either intervention (tub bath) or control group (sponge bath). The physiological parameters and comfort of preterm infants in both groups were evaluated at 10 min before the bath. Infant comfort was reevaluated 10 min after the procedure, while physiological parameters were reevaluated after 15 and 30 min. Preterm infant heart rate, oxygen saturation, respiratory rate, body temperature and comfort behaviors were assessed by two independent evaluators who were blinded to the purpose of the study at different phases across the two bathing protocols. Written consent was obtained from the university and hospital ethics committee where the research was performed, and from the families of the infants participating in the study. SPSS 20.0 and SAS 9.3 were used for data analysis. Data was analyzed by percentage distribution, mean, repeated analysis, variance analysis, Bonferroni analysis as a further analysis and t-test in dependent groups.

RESULTS

Approximately 120 preterm infants completed the protocol (60 in each group). The two groups did not differ in gestational age, sex, weight or other demographic variables (p > 0.05). Tub bathing was more effective in reducing preterm infants' comfort scores (9.47 ± 2.55 vs. 14.85 ± 4.77, p < 0.001) and heart rate than sponge bathing (132.88 ± 12.00 vs. 144.00 ± 17.74, p < 0.05). Preterm infants in the tub bathing group maintained their body temperature better than those in the sponge bathing group (36.75 ± 0.26 vs. 36.59 ± 0.25, p < 0.05). There was no difference in oxygen saturation (98.35 ± 0.88 vs. 97.85 ± 1.36, p = 0.291) or respiratory rate (45.57 ± 5.39 vs. 47.20 ± 5.41, p = 0.472) between the tub and sponge bathing groups.

CONCLUSIONS

Tub bathing is a safer, more pleasurable/comfortable bathing option and is the recommended method for bathing healthy, late preterm infants.

Prevalence of neonate adhesive skin injuries in a Jordanian intensive care unit

AIM

To determine the prevalence of adhesive skin injuries in neonates in a Jordanian neonatal intensive care unit (NICU) and to examine the characteristics of neonates with these injuries.

METHOD

A cross-sectional period-prevalence study was conducted in a NICU in Irbid National University Hospital in Jordan. A total of 169 neonates were examined for skin injuries caused by adhesive equipment.

RESULTS

The prevalence of skin injuries in this population was 26.6%. The injuries were located mostly on the face, arms, hands and chest, and were caused by endotracheal tubes, intravenous cannulae, fixation of nasogastric tubes and electrodes. Neonates with skin injuries were more likely to be preterm and underweight, to have respiratory problems and to have been connected to a mechanical ventilator.

CONCLUSION

Adhesive skin injuries were found in more than one quarter of the neonates in this NICU and healthcare service providers should endeavour to minimise the occurrence of these injuries.

Assessment of health risks resulting from early-life exposures: Are current chemical toxicity testing protocols and risk assessment methods adequate?

Abstract Over the last couple of decades, the awareness of the potential health impacts associated with early-life exposures has increased. Global regulatory approaches to chemical risk assessment are intended to be protective for the diverse human population including all life stages. However, questions persist as to whether the current testing approaches and risk assessment methodologies are adequately protective for infants and children. Here, we review physiological and developmental differences that may result in differential sensitivity associated with early-life exposures. It is clear that sensitivity to chemical exposures during early-life can be similar, higher, or lower than that of adults, and can change quickly within a short developmental timeframe. Moreover, age-related exposure differences provide an important consideration for overall susceptibility. Differential sensitivity associated with a life stage can reflect the toxicokinetic handling of a xenobiotic exposure, the toxicodynamic response, or both. Each of these is illustrated with chemical-specific examples. The adequacy of current testing protocols, proposed new tools, and risk assessment methods for systemic noncancer endpoints are reviewed in light of the potential for differential risk to infants and young children.

[Treatment of skin lesions in newborn children: meeting the needs of nursing staff]

OBJECTIVE

To understand, together with nursing staff, the care needed to treat skin lesions in newborn children hospitalized in a neonatal unit.

METHOD

Qualitative research, of the convergent care type. The data was collected through semi-structured interviews, which were conducted from November to December 2012, in the neonatal unit of a hospital in southern Brazil. The participants were four auxiliary nurses, six nursing technicians and four nurses.

RESULTS

The following three categories were designated: questions about what can be used in relation to newborn children; hospitalization can cause lesions on the skin of newborn children; and knowledge about care promotes professional autonomy.

CONCLUSION

There is an urgent need for staff to know more about the treatment of skin lesions, which would provide safer care for newborn children and would also support the autonomy of professional nurses in providing that care.


Effective use of transdermal drug delivery in children

Transdermal administration offers a non-invasive and convenient method for paediatric drug delivery. The competent skin barrier function in term infants and older children limits both water loss and the percutaneous entry of chemicals including drugs; but the smaller doses required by children eases the attainment of therapeutic concentrations. Transdermal patches used in paediatrics include fentanyl, buprenorphine, clonidine, scopolamine, methylphenidate, oestrogens, nicotine and tulobuterol. Some patches have paediatric labelling supported by clinical trials whereas others are used unlicensed. Innovative drug delivery methods, such as microneedles and sonophoresis are being tested for their safety and efficacy; needleless injectors are primarily used to administer growth hormone; and two iontophoretic devices were approved for paediatrics. In contrast, the immature and rapidly evolving skin barrier function in premature neonates represents a significant formulation challenge. Unfortunately, this population group suffers from an absence of approved transdermal formulations, a shortcoming exacerbated by the significant risk of excessive drug exposure via the incompletely formed skin barrier.

Health-related quality of life for infants in the neonatal intensive care unit

When discussing the benefits and burdens of medical interventions for critically ill infants, clinicians and families are challenged to weigh the uncertainties of treatment success with infant pain and suffering. Concrete measures of infant suffering or quality of life, which could inform infant care and decision-making are lacking. Although consistent and reliable health-related quality of life (HRQOL) definitions and measures have been extensively developed for adults and older children, they have not been relevant to neonates or infants. Advancing HRQOL research methodology is an objective of Healthy People 2020. This paper will review the evidence and practices relevant to HRQOL with a focus on intensive care and pediatric settings. We will highlight existing HRQOL measures, which could be adapted for neonates and existing neonatal intensive care unit measures and practices, which could inform new measures of HRQOL.

Children and newborn skin care and prevention

Neonatal skin suffers a progressive adaptation to the extrauterine environment and special care is needed during this period. This skin is very sensitive, thin and fragile. Immaturity of the epidermal barrier reduces the defense against the excessive proliferation of microbes and makes the skin more vulnerable to trauma and percutaneous drug toxicity. Because of the peculiar characteristics of newborn, infant and children's skin, the use of cosmetic products designed for hygiene and protection requires caution. In order to preserve the integrity of neonatal and child's skin, this article reviewed basic preventive care practices in relation to hygiene, bathing, cleansing agents, topical products and their percutaneous toxicity.

Skin care practices for newborns and infants: review of the clinical evidence for best practices

In recent years, there have been continuing efforts to understand the effects of baby skin care routines and products on the healthy development of baby skin. Such efforts aim ultimately to determine the best infant skin care practices. The pediatric and dermatologic communities have not reached consensus on what constitutes an appropriate cleansing practice. In the United States, guidelines for neonatal skin care have been developed, propagated, and implemented. The accumulated knowledge has promoted evidence-based clinical practices and, therefore, may help to improve clinical outcomes, although these guidelines primarily cover the care of preterm newborns and the treatment of those with other health problems. High-level, long-term clinical evidence of the effective and safe cleansing of healthy, full-term newborns and infants is scarce. This review presents a comprehensive analysis of the scientific literature on baby skin development, cleansing practices, and related products (for healthy newborns and babies) since 1970. The evidence drawn from the reviewed literature can be summarized as follows: Bathing immersed in water seems generally superior to washing alone. Bathing or washing with synthetic detergents (syndets) or mild liquid baby cleansers seems comparable with or even superior to water alone. Nevertheless, larger randomized clinical trials with age-defined cohorts of babies as well as more-defined parameters are required to identify optimal practices and products for skin cleansing of healthy infants. These parameters may include standardized skin function parameters such as transepidermal water loss, stratum corneum hydration, skin surface pH, and sebum production. Clinical skin scores such as the Neonatal Skin Condition Score may be employed as outcome measures.