Percutaneous alcohol absorption and skin necrosis in a preterm infant

In vitro assessment of isopropanol leakage from antiseptic barrier caps into commonly used needleless connectors

BACKGROUND

Needleless connectors (NCs) can be disinfected using antiseptic barrier caps (ABCs) to reduce the risk of catheter-related bloodstream infections. However, recent evidence suggests that isopropanol can leak from the ABC into the NC, posing concern about their safe use. We sought to determine in vitro which ABC and NC parameters influence the leakage of isopropanol through the infusion circuit.

METHODS

We assessed 13 NCs and 4 ABCs available in the European market. In vitro circuits consisting of an isopropanol cap, a NC, and an 11-cm catheter line were created. The circuits were left in place for 1 to 7 days at room temperature to assess the kinetics of isopropanol leakage. Isopropanol content in ABC and in circuit flushing solutions (5 mL NaCl 0.9%) after exposure to the cap were measured using gas chromatography with a flame ionization detector.

RESULTS

The leakage of isopropanol from the cap to the NC was dependent on the NC, but not the cap. The NC mechanism did not predict the leakage of isopropanol. The Q-Syte NC exhibited the most isopropanol leakage (7.01±1.03 mg and 28.32±2.62 mg at 24 hours and 7 days, respectively), whereas the Caresite NC had the lowest isopropanol leakage at 7 days (1.69±0.01 mg).

CONCLUSION

The use of isopropanol ABCs can cause isopropanol leakage into the catheter circuit according to NC parameters. Caution should be exercised when using these devices, especially in the pediatric and neonatal population.

Skin Barrier Function in Infants: Update and Outlook

A good understanding of infant skin should provide a rationale for optimum management of the health of this integument. In this review, we discuss the skin barrier function of infants, particularly with reference to the use of diapers and baby wipes. The skin barrier of newborns continues to develop with age. Two years after birth, the barrier properties of infant skin closely resemble those of adult skin. However, several risk factors may contribute to impaired skin barrier and altered skin permeability in infants. Problems may arise from the use of diapers and baby wipes. The skin covered by a diaper is effectively an occluded environment, and thus is vulnerable to over-hydration. To date there has been no published information regarding dermal absorption of ingredients contained in baby wipes. Similarly, dermal absorption of topical ingredients in infants with underlying skin conditions has not been widely explored. Clearly, there are serious ethical concerns related to conducting skin permeation studies on infant skin. However, the increasing availability of non-invasive methods for in vivo studies is encouraging and offers new directions for studying this important patient group.

Bottom-up cubosome synthesis without organic solvents

HYPOTHESIS

Bottom-up synthesis of cubosomes is more energetically favourable than top-down approaches. However, bottom-up methods often rely on organic solvents such as ethanol as diluents, and lead to concurrent formation of liposomes. We propose using non-toxic diluents such as honey, glycerol and lactic acid for bottom-up cubosome synthesis.

EXPERIMENTS

Cubosomes were prepared using solutions of phytantriol in a range of diluents including choline chloride-glycerol, honey, lactic acid, glycerol, and ethanol. These solutions were added dropwise to water containing the stabiliser, poloxamer 407, following an established method of cubosome synthesis. The resulting structures were characterised using small-angle X-ray scattering, DLS and cryo-TEM.

FINDINGS

Cubosomes were successfully formed using a range of non-toxic diluents. This demonstrates that harmful organic solvents like ethanol are not required, and that the diluents need not be hydrotropes. Furthermore, unlike ethanol, these other diluents allowed formation of cubosomes without concurrent formation of liposomes. Given the huge potential for cubosomes in drug delivery, this new method offers a potentially useful low-cost, low-toxicity synthesis option.

COVID-19 and frequent use of hand sanitizers; human health and environmental hazards by exposure pathways

Till date no medication or vaccine is available to cope with the COVID-19 infection and infection rate is increasing drastically across the globe. Only preventive measures and healthy life style with efficient immune system have been suggested by WHO to fight and stay safe from COVID-19. WHO recommended alcohol based hand sanitizers for frequent hand hygiene, which are mainly made up from ethanol, isopropyl alcohols, hydrogen peroxides in different combinations. These preparations may become toxic to human health and environment when misused. These chemicals have known toxic and hazardous impact on environment when released by evaporation. In early five months of 2020, American Association of Poison Control Center reported 9504 alcoholic hand sanitizer exposure cases in children under the age of 12 years and recognized that even a small amount of alcohol can cause alcohol poisoning in children that is responsible for confusion, vomiting and drowsiness, and in severe cases, respiratory arrest and death. Furthermore, frequent usage of said hand sanitizers has reported increased chance of antimicrobial resistance and chance of other viral diseases. Current review is designed with main objective to highlight the toxic and serious health risks to human health and environment by frequent using hand hygiene products with alcohols based formulations.

Common parenting misconceptions regarding infant care: setting the record straight for parents (and some pediatricians)

PURPOSE OF REVIEW

First-time parents often turn to friends and family for advice regarding feeding, sleeping, bathing, diapering and toilet training, and childhood illnesses. Unfortunately, parents may at times be given incorrect and potentially dangerous advice as several widely embraced parenting practices are no longer deemed appropriate. In addition, young children are cared for by family and friends - many of whom are older and may still subscribe to outdated parenting practices.Parents and grandparents are not the only ones who subscribe to child care myths and misconceptions. Pediatricians also believe in the effectiveness of some outdated child care practices. Although some of these parenting myths are relatively benign, others may indeed pose a significant health risk or safety hazard to a young child. The purpose of this article is to review 10 commonly held myths or misconceptions regarding infant care.

RECENT FINDINGS

In this review article, we not only highlight many of the studies that document which outdated health beliefs are still endorsed by parents and/or pediatricians, but also review the specific health risks associated with these parenting myths or misconceptions.

SUMMARY

It is important that pediatricians educate parents and other primary caregivers about the potential risks of following outdated parenting practices.

Liposomes with an Ethanol Fraction as an Application for Drug Delivery

Liposomes containing a certain amount of ethanol are often referred to in the literature as ethosomes. Liposomes vary in size from 25 nm to 25,000 nm. Ethosomes are defined as lipids composed of phospholipids, ethanol, or isopropyl alcohol in quite high concentrations, and water. They enable active substances to reach the deep skin layers or even the general circulation. The structure of ethosomes allows for an increased penetration of the drug through two effects: the ethanolic effect and the ethosomal effect. Ethosomes can be obtained using three methods: the hot method, the cold method, and the classic method of mechanical dispersion. The literature describes many of the therapeutic groups of drugs that can be enclosed in ethosomal formulations. These include anti-viral drugs, antineoplastic drugs, antifungal drugs, hypnotic drugs, hormones, and many others. Ethosomes show important practical advantages compared to classic liposomes. It is necessary to conduct research with regard to real pharmaceutical systems using advanced physicochemical techniques.

Chlorhexidine-Induced Chemical Burns in Very Low Birth Weight Infants

Skin disinfection with chlorhexidine gluconate has not been standardized in preterm infants. We present 5 cases of chemical burns that occurred within the first 2 days of life in very low birth weight neonates after skin disinfection with aqueous and alcohol-based chlorhexidine solutions.

Poisoning Through Pediatric Skin: Cases from the Literature

Poisoning through pediatric skin leading to acute systemic symptoms is a relatively uncommonly reported phenomenon. Systemic toxicity through the skin typically occurs by direct contact between therapeutic or non-therapeutic topical agents and the skin. Though uncommon, poisoning through pediatric skin can have significant consequences and must be recognized so the offending agent may be discontinued and appropriate treatment initiated. We performed a literature search for all article types between 1950 and April 2016 to provide a single source of detectable cases of acute toxicity in pediatric patients due to percutaneous exposure. This literature review discusses relevant pediatric skin physiology along with reports of poisoning events that resulted in systemic signs and symptoms and even death to provide a comprehensive report on causes of pediatric poisoning through the skin.

Recent Advances in Neonatal Pharmacotherapy

Objective:

To provide commentary and reviews and brief discussions in controversial or innovative recent advances in neonatal pharmacotherapy. To discuss cutting edge drug delivery systems that may become useful in neonatal drug delivery in the future.

Data Sources:

Articles were identified through searches of MEDLINE (1990–October 2005), key articles in the authors' files, and in some cases, through data generated and/or published by the author of a particular topic.

Data Selection:

Article selection and relevance to the topics under discussion was determined by individual authors.

Data Synthesis:

Therapeutic strategies addressed in this review include the use of hematopoietic growth factors including a simulated amniotic fluid preparation containing these growth factors for neonates with selected gastrointestinal problems, erythropoietin for neuroprotection following perinatal asphyxia, drug therapy advances in treatment of patent ductus arteriosus (PDA), evaluation of advances in transdermal drug delivery, and its potential application to neonates and advances in the treatment of persistent pulmonary hypertension (PPHN) of the newborn.

Conclusions:

Despite being over 30 years old, the practice of neonatology is as much of an art as a science. Advances in the basic science research have improved our understanding of use of pharmacologic agents in the premature and full-term neonate including drug disposition pathways. Expanding our knowledge on issues such as physiology of hematopoietic factors, the pharmacologic responses of conditions such as PDA and PPHN, and newer technologies for drug administration, as well as other pharmacologic reponses in the neonate are vital in the development of safe and efficacious treatments for neonates. Many questions remain unanswered, and every clinician must make an effort to contribute to the knowledge and understanding of pharmacotherapy in this patient population.

Iatrogenic Skin Disorders and Related Factors in Newborn Infants

BACKGROUND/OBJECTIVES

Recent technological advances and diagnostic and therapeutic innovations have resulted in an impressive improvement in the survival of newborn infants requiring intensive care. Consequently, with the use of modern invasive diagnostic and therapeutic procedures, the incidence of iatrogenic events has also increased. The aim of this study was to assess various iatrogenic complications in neonates requiring intensive care and determine possible contributing factors to the injuries.

METHODS

Our prospective cross-sectional cohort survey was conducted in a central regional level III neonatal intensive care unit (NICU). Correlations between intensive therapeutic interventions, complications, factors influencing attendance and prognosis, and the prevalence of iatrogenic skin injuries (ISIs) were investigated over a 2-year study period.

RESULTS

Between January 31, 2012, and January 31, 2014, 460 neonates were admitted to the NICU, 83 of whom exhibited some kind of ISI. The major risk factors for ISIs were low birthweight, young gestational age, long NICU stay, use of the intubation-surfactant-extubation (INSURE) technique, surfactant use, mechanical ventilation, insertion of an umbilical arterial catheter, circulatory and cardiac support with dopamine or dobutamine, pulmonary hemorrhage, intracranial hemorrhage, patent ductus arteriosus, bronchopulmonary dysplasia, and positive microbiology culture results.

CONCLUSION

To prevent ISIs, careful consideration of risk factors and the creation of protocols ensuring efficient treatment of injuries are needed.

Antiseptic use in the neonatal intensive care unit - a dilemma in clinical practice: An evidence based review

Infants in the neonatal intensive care unit are highly susceptible to healthcare associated infections (HAI), with a substantial impact on mortality, morbidity and healthcare costs. Effective skin disinfection with topical antiseptic agents is an important intervention in the prevention or reduction of HAI. A wide array of antiseptic preparations in varying concentrations and combinations has been used in neonatal units worldwide. In this article we have reviewed the current evidence of a preferred antiseptic of choice over other agents for topical skin disinfection in neonates. Chlorhexidine (CHG) appears to be a promising antiseptic agent; however there exists a significant concern regarding the safety of all agents used including CHG especially in preterm and very low birth weight infants. There is substantial evidence to support the use of CHG for umbilical cord cleansing and some evidence to support the use of topical emollients in reducing the mortality in infants born in developing countries. Well-designed large multicentre randomized clinical trials are urgently needed to guide us on the most appropriate and safe antiseptic to use in neonates undergoing intensive care, especially preterm infants.

Skin antisepsis in the neonate: what should we use?

PURPOSE OF REVIEW

Neonates in intensive care are more susceptible to sepsis. Infection is commonly acquired via the transcutaneous portal. It is necessary to identify the most effective yet safest topical antiseptics for use in neonates to reduce nosocomial sepsis.

RECENT FINDINGS

Recent national surveys indicate that a wide range of topical antiseptic preparations are used in the neonatal nursery. There are very few comparative studies in neonates and no robust evidence in favour of any particular antiseptic. There are significant safety and potential toxicity issues for neonates with all the commonly used antiseptics, particularly in very small immature babies. There are no convincing roles for routine application of emollient creams on the skin, topical antiseptics on the umbilical stump, or maternal vaginal washes with chlorhexidine for the prevention of neonatal infection.

SUMMARY

Large multicentre trials are needed to determine the optimal antiseptic to use for neonates undergoing intensive care, especially for extremely preterm infants.

Chlorhexidine gluconate-impregnated central-line dressings and necrosis in complicated skin disorder patients

Although chlorhexidine gluconate (CHG) disks have been shown to help reduce the incidence of central line-associated blood stream infections, their use can result in local skin necrosis. The effects of CHG disks on patients with complex skin pathology have not been studied. We report 6 cases of dermal necrosis associated with Biopatch (Ethicon Inc, Somerville, NJ) CHG disks in adults with complex skin pathology including those with Stevens-Johnson syndrome, toxic epidermal necrolysis syndrome, graft-versus-host disease, burns, and anasarca. All patients had a CHG disk placed at a central venous catheter insertion site. Age range was from 21 to 84 years. Discovery of the reaction ranged from 4 to 14 days after disk placement. Resultant skin erosions required 2 to 10 weeks to reepithelialize. Complicated skin disorder patients represent a rare subset of the critically ill who appear prone to CHG disk necrosis. Continuous contact of CHG under occlusive dressings is speculated to predispose Stevens-Johnson syndrome, toxic epidermal necrolysis syndrome, graft-versus-host disease, and burn patients to local chemical injury secondary to loss of the epithelial tissue barrier, decreased cohesion of the epidermal-dermal junction, and increased tissue permeability. In these patients, the risk of placing the CHG disk may present more risk than using alternative antimicrobial dressings.

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.

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.

Exploring the olfactory environment of premature newborns: a French survey of health care and cleaning products used in neonatal units

AIM

To assess the main determinants of the newborn's nosocomial olfactory environment.

METHODS

An electronic questionnaire was sent to 99 neonatal units in France. Senior nurses and/or physicians described the nature and use of skin care products (e.g. umbilical cord and skin disinfectants, adhesive removers), lubrications used for tubes positioning, disinfectants used to clean materials, hand hygiene products (e.g. alcohol-based hand rubs, soaps) and newborns' bath.

RESULTS

Nine groups of products and 76 distinct commercial preparations were identified. Depending on their level of respiratory support, preterm newborns were estimated to be exposed to nosocomial odours (NO) an average of 1320-1800 times during their first month of life. During their whole hospital stay, newborns of 28 and 32 weeks of gestational age could be exposed to NOs products an average of 3448 and 2024 times, respectively. The use of these products varied among medical centres. Newborns were most frequently exposed to the odour of aqueous alcoholic solutions.

CONCLUSIONS

Vulnerable preterm infants are daily exposed to multiple NOs most of them be considered as irritant for the nose. Minimizing infants' exposure to them would be beneficial. Future studies should describe the exact olfactory properties of the products considered essential for infant care and should assess their effects on the infant's well-being and development.

Skin care for preterm and term neonates

Neonatal skin experiences a progressive adaptation to the extrauterine environment during which special care is needed. The immaturity of the epidermal barrier in the neonatal period may cause dry skin, vulnerability to trauma, rapid onset of microbial colonization and percutaneous drug toxicity. This article reviews the practical implications for hygiene, bathing practices, skin integrity, emollient use, infection control and exposure to percutaneous toxic agents in preterm and term infants.

Safety of alcohol hand gel use among children and personnel at a child day care center

BACKGROUND

Alcohol hand gels (AHG) have been used by children in child day care centers (CDCCs) to prevent the transmission of microbes. Because parents and personnel have been concerned about the safety of AHGs, we conducted a trial to assess this.

METHODS

A total of 82 children age 3.5 to 7.2 years (mean, 5.7 years) at 2 CDCCs rubbed their hands with AHG. Alcohol concentrations in expiratory air were measured using an official police alcometer after 15 and 60 minutes. We also conducted a questionnaire survey asking how commonly AHGs were used in CDCCs, obtaining 128 answers from 68 CDCCs (with more than 1 person responding in 6 CDCCs).

RESULTS

All of the alcometer readings were < 0.01 per thousand, although up to 30 contacts with the mucous membranes (mean, 2.4) occurred during the first 15 minutes. An AHG was used in all 68 CDCCs, but only by adults at 11 of them. The most common occasions for using an AHG were before serving food and after cleaning secretions. One case of fire occurred when a worker lit a fire while his hands were covered with AHG. Personnel were most concerned about situations in which children put their fingers into their mouth or eyes after using an AHG.

CONCLUSION

The use of an AHG in CDCCs is safe. Even though children tend to put their hands into their mouth after disinfection, no significant amount of alcohol is absorbed.

Safety evaluation of topical applications of ethanol on the skin and inside the oral cavity

Ethanol is widely used in all kinds of products with direct exposure to the human skin (e.g. medicinal products like hand disinfectants in occupational settings, cosmetics like hairsprays or mouthwashes, pharmaceutical preparations, and many household products). Contradictory evidence about the safety of such topical applications of the alcohol can be found in the scientific literature, yet an up-to-date risk assessment of ethanol application on the skin and inside the oral cavity is currently lacking.The first and foremost concerns of topical ethanol applications for public health are its carcinogenic effects, as there is unambiguous evidence for the carcinogenicity of ethanol orally consumed in the form of alcoholic beverages. So far there is a lack of evidence to associate topical ethanol use with an increased risk of skin cancer. Limited and conflicting epidemiological evidence is available on the link between the use of ethanol in the oral cavity in the form of mouthwashes or mouthrinses and oral cancer. Some studies pointed to an increased risk of oral cancer due to locally produced acetaldehyde, operating via a similar mechanism to that found after alcoholic beverage ingestion.In addition, topically applied ethanol acts as a skin penetration enhancer and may facilitate the transdermal absorption of xenobiotics (e.g. carcinogenic contaminants in cosmetic formulations). Ethanol use is associated with skin irritation or contact dermatitis, especially in humans with an aldehyde dehydrogenase (ALDH) deficiency.After regular application of ethanol on the skin (e.g. in the form of hand disinfectants) relatively low but measurable blood concentrations of ethanol and its metabolite acetaldehyde may occur, which are, however, below acute toxic levels. Only in children, especially through lacerated skin, can percutaneous toxicity occur.As there might be industry bias in many studies about the safety of topical ethanol applications, as well as a general lack of scientific research on the long-term effects, there is a requirement for independent studies on this topic. The research focus should be set on the chronic toxic effects of ethanol and acetaldehyde at the point of impact, with special regard to children and individuals with genetic deficiencies in ethanol metabolism.

A protocol for the use of amorphous hydrogel to support wound healing in neonatal patients: an adjunct to nursing skin care

The care registered nurses offer makes a critical difference in the quality and cost-effectiveness of patient outcomes. The prevention and treatment of alterations in skin integrity remain primary nurse-sensitive quality indicators. Although wound prevention is a primary goal for nurses, iatrogenic wounds do occur. Neonatal patients are at greater risk for alterations in skin integrity because of the fragile nature of their skin. When skin breakdown occurs, nurses must have knowledge of effective treatment alternatives. The purpose of this article is to describe the use of a collaborative practice protocol to introduce and document patient outcomes with the use of amorphous hydrogel as a treatment modality for iatrogenic neonatal wounds. All hospitals collect data on the quality of patient care, and it has been known for some time that registered nurses can make a critical difference in the quality of patient care and the effectiveness of patient outcomes. The American Nurses Association has identified ten specific quality measures that are impacted by nursing care. Referred to as nurse-sensitive quality indicators, these measures include the maintenance of skin integrity.

Development of an in vitro model for premature neonatal skin: Biophysical characterization using transepidermal water loss

The objective was to develop an in vitro model for the developing skin of the premature neonate. Barriers of different levels of efficiency were produced by differentially tape-stripping the stratum corneum (SC) from the skin of excised porcine ears, and were characterized by measurements of transepidermal water loss (TEWL). In this way, it was possible to express the recorded TEWL as a function of percentage SC thickness (F) generating the following relationship: TEWL = 2.7 + 41.exp [- 0.028.F]. These data were then compared to previously published in vivo measurements of TEWL obtained from a population of premature neonates at various post-conceptional ages (PCA). The latter conformed to a remarkably parallel relationship to that found in vitro with the porcine skin model, namely TEWL = 3.3 + 41.exp [-0.026.(PCA-160)]. It can be suggested, therefore, that the empirically adjusted PCA (i.e., PCA-160) correlates closely with the developing thickness of the neonate's SC. The corollary is that porcine skin, in vitro, tape-stripped to a particular level, can provide a barrier corresponding to a specific degree of neonate maturation and can serve, hence, as a useful tool with which to explore whether transdermal drug delivery in this unique patient population may be beneficial.

Acute methanol ingestion

Methanol poisoning is an insidious event that can culminate in severe metabolic disturbances, permanent neurologic dysfunction, blindness, and death. Although numerous adult cases have been extensively reviewed, there is a paucity of reports about pediatric ingestions. We present a case of acute methanol intoxication in a 6-year-old male patient who presented with headache, nausea, altered mental status, and drowsiness. His blood methanol level was 350 mg/dL (109.4 mmol/L), despite the absence of any history or identifiable source of methanol. Treatment with ethanol, alkalinization, and hemodialysis resulted in full recovery without residua. Unusual facets of this case are the child's relatively older age, the extremely high methanol blood level, and, most remarkably, the complete lack of visual disturbances on routine ophthalmologic evaluation.

Neonatal skin care

The relative importance of neonatal health and neonatal skin care has been highlighted in recent years as infant mortality rates have decreased while death rates during the neonatal period remain unacceptably high in many areas of the world. During the neonatal period, many newborns develop preventable, clinically apparent skin problems, and many more, especially preterm neonates, experience morbidity caused by compromised skin barrier integrity. Several strategies are available for protecting the integrity and promoting the hygiene of the skin and augmenting its function as a barrier to TEWL and heat loss and the entrance of infectious or toxic agents. Research defining optimal applications of many of these strategies, however, and the development of new approaches in skin care is one of the greatest challenges in pediatric dermatology and holds promise for improving neonatal outcome in the future. The ability to modulate epidermal barrier function and integrity relies largely on the topical use of protective materials and substances and manipulation of the external environment. As understanding of epidermal barrier development advances, perhaps pharmacologic manipulation of barrier development, as now practiced for augmentation of neonatal lung maturity, will become a reality. In the meantime, greater awareness among neonatal health care practitioners of state-of-the-art strategies for optimizing skin integrity in neonates is an important step toward improving neonatal health.

Characterization of vernix caseosa as a natural biofilm: comparison to standard oil-based ointments

The application of occlusive films and oil-in-oil ointments has been reported to improve epidermal barrier function in very low birthweight, preterm infants. Such infants have a structurally immature stratum corneum and lack a surface coating of vernix caseosa. In this study we examined the short-term effects of topical application of vernix caseosa to human skin and contrasted these effects with commonly used ointments and water-in-oil emulsions. Specifically, vernix, Eucerin(R), Aquaphor(R), and petrolatum were applied to the volar skin surface of adult volunteers. Surface electrical capacitance (SEC) and transepidermal water loss (TEWL) were measured as indices of surface hydration. Sorption-desorption profiles were performed to determine skin surface hydrophobicity. Particular attention was given to monitoring the acute (0-120 minutes) changes following vernix treatment in order to compare these effects with earlier reports on the rate of skin surface drying in newborn infants following birth. Immediately after vernix application there was an increase in the rate of water loss from the skin surface. Relative to control skin and skin treated with the ointments and water-in-oil emulsions, the application of vernix to freshly bathed human skin resulted in a unique profile of temporal change in baseline surface hydration, moisture accumulation, and water-holding capacity. These results demonstrate major differences between human vernix and standard oil-based topical ointments. The results provide a framework for discussing the various properties of topical barriers applied to the very low birthweight infant.

Neonatal skin care: the scientific basis for practice

OBJECTIVE

To review the literature addressing the care of neonatal skin.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review.

DATA EXTRACTION

Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown.

DATA SYNTHESIS

Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity.

CONCLUSIONS

This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

Neonatal skin care: the scientific basis for practice

OBJECTIVE

To review the literature addressing the care of neonatal skin.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review.

DATA EXTRACTION

Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown.

DATA SYNTHESIS

Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity.

CONCLUSIONS

This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

A survey of skin care practices for premature low birth weight infants

PURPOSE

To provide baseline information about current skin care practices in premature low birth weight infants (< 1,000 gm birth weight) in typical NICUs within the U.S.

DESIGN

Descriptive survey.

SAMPLE

104 hospitals with at least 2,500 deliveries per year and at least 20 Level III NICU beds.

MAIN OUTCOME VARIABLES

Environmental conditions, bathing practices and products, adhesive products used to secure IVs and endotracheal tubes, skin protectants used with diaper rash, treatment systems for fragile preterm skin, and treatment systems for denuded skin.

RESULTS

Most units surveyed based their premature low birth weight skin care protocols on a combination of gestational age and birth weight criteria. One-quarter of the units had no skin care protocols at all. Among the units, there was considerable practice variation with respect to common nursing procedures such as bathing, adhesive application, and wound care.

Adverse drug reactions from birth to early childhood

Neonates and older infants are a diverse group of children, quite different from their older counterparts. Adverse drug reactions may have profound immediate, delayed, and long-term implications for their neurologic and somatic development. The intrauterine, neonatal, and infancy periods are the only stages in life in which one is exposed to and affected by drugs administered to another person, the mother. In addition, because of the fragility of the neonate and the complexity of their illnesses, their pharmacotherapy is frequently complicated with misadventure and adverse drug reactions that are unavoidable or difficult to assess. Because of their differences in morphology and disease process and treatments, infants and children experience a different range of adverse drug reactions. These reactions are not necessarily predictable from the adult experience. Despite the advances made in the field of pediatric adverse drug reactions and the lessons learned through the misfortunes involving children, children continue to suffer. Sixty years after the Elixir of Sulfanilamide-Massengill disaster, children continue to be given medications with diethylene glycol in developing countries. Pediatricians, pharmacologists, and others must continue to be vigilant and active in preventing, monitoring, and treating adverse drug reactions in children. Learning from mistakes of the past will improve the health of children by preventing mistakes in the future.

Effect of age and sex on the elicitation of irritant contact dermatitis

Irritant contact dermatitis causes significant disability to numerous consumers and individuals in industry. Knowledge of the prevalence of this disease remains inadequate. Irritant contact dermatitis occurs in workers engaged in occupations where the subjects are exposed to different types and doses of irritants. The intensity of the reaction depends on the quality and the quantity of exposure. Irritant thresholds and dose responses depend on many different factors. This article reviews the clinical and physiological parameters that affect the age and sex related differences in irritant contact dermatitis.

Inhalational and percutaneous methanol toxicity in two firefighters

We present two cases of adult inhalational and percutaneous methanol toxicity resulting from transient exposure to vaporized methanol. Both patients complained only of a mild headache at the time of the emergency department evaluation and had normal physical examinations, normal anion gaps, and peak methanol levels of 23 and 16 mg/dL, respectively. Emergency physicians should recognize the potential for toxic transcutaneous absorption of methanol. Because of the varying relationship between clinical symptoms, physical examination findings, and anion gap values to potentially toxic methanol exposures, acquisition of empiric serum methanol levels appears warranted in appropriate situations.

Percutaneous absorption and age. Implications for therapy

Human skin changes dramatically with increasing age. Morphological, physiological, and biochemical changes within the tissue have been investigated and documented. Considerable interest in transdermal drug delivery to produce systemic effect has occurred in recent years. However, it is not known whether the penetration barrier of aged skin changes. Morphological and physiological changes in aged skin may affect the percutaneous absorption of compounds and thus their potential for localised, as well as systemic, efficacy. This article reviews the published literature on skin aging changes from adulthood to old age, collates these changes with clinical implications pertinent to the practising dermatologist, reviews the existing data supporting a change in the barrier function of human skin with increasing age, and comments on the relevance of conclusions previous investigators have drawn from their studies.

Transdermal delivery of theophylline to premature infants using a hydrogel disc system

1. Preterm infants show incompletely developed skin with reduced barrier function. The possibility of transdermal delivery of theophylline from hydrogel discs swollen with choline theophyllinate has been investigated. 2. Drug loaded hydrogel discs 2 cm2 in area were applied to the abdomen and occluded. Serum theophylline concentrations were measured in twenty-one infants of less than 31 weeks gestation. 3. Therapeutic concentrations were achieved in 18 individuals, and maintained for up to 15 days after repeated application of discs. A correlation between maximum serum drug concentration and transepidermal water loss, gestation and birthweight was demonstrated.

Percutaneous carbon dioxide excretion in the newborn infant

Percutaneous carbon dioxide excretion was studied in 42 newborn infants between 25 and 39 weeks gestation, using a closed skin cell attached to the abdomen. The rate of excretion during the first few days of life was inversely related to gestation, increasing from a mean of 31 ml/m2/h at term to 198 ml/m2/h below 30 weeks gestation. Postnatally there was a rapid fall in the rate of excretion in very preterm infants to values about twice those found at term. The rate of excretion was linearly related to the CO2 diffusion gradient, and zero diffusion would be expected when there was no diffusion gradient. It is estimated that up to 15% of resting CO2 excretion occurs through the skin of very preterm infants, and more if the tissue PCO2 is elevated.

Percutaneous absorption in preterm infants

The skin of preterm infants varies considerably in its level of maturity. To understand skin absorption in premature infants better, we report a technique for the assessment of percutaneous absorption at various gestational and postnatal ages using stable, isotope-labeled (13C6) benzoic acid. Our results indicate that in the preterm infant, this method detects enhanced skin absorption in the first postnatal days, which declines over three weeks to that expected of a full-term infant. This approach also indicates an inverse relationship between gestational age and skin absorption, as well as postnatal age and skin absorption. The reported technique is a safe and noninvasive method using a model skin penetrant for the study of percutaneous absorption in preterm infants from which basic data may be derived to add to our understanding of skin barrier function.