Preterm Infant Skin Structure Is Qualitatively and Quantitatively Different From That of Term Newborns

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.

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.

A Unique Case of Intrauterine Pressure Injury

ABSTRACT

The authors present a review of the literature regarding pressure injuries (PIs) in neonates and a case of a newborn who developed a PI following a prolonged labor process and fetal malposition. A girl born at 35 weeks' gestation to a 34-year-old gravida 7 para 6 mother with a medical history of untreated gestational diabetes, preeclampsia, and COVID-19 was delivered via cesarean section after failure to progress through labor. The premature infant was found to have a 3.2 × 2.3-cm PI at the nape of the posterior neck. Premature infants have a histologically proven, age-dependent decreased thickness of their stratum corneum, epidermis, and dermis, which places them at increased risk of developing PIs that can be painful and lead to infection. In the present case, the neonate's congenital PI was successfully treated with medical-grade honey for approximately a month.

Analysis of the prevalence and risk factors of pressure injuries in the hospitalized pediatric population: A retrospective study

BACKGROUND

Pressure injury (PI) is an essential indicator of the quality of nursing care and affects hospitalized newborns and children. However, studies on the prevalence of PI and associated risk factors in children are limited.

AIMS

This study aimed to analyze the prevalence of PI and risk factors affecting the development of PI in the hospitalized pediatric population.

METHODS

This was a descriptive, retrospective study. Data were obtained via electronic medical records of 6350 pediatric patients admitted to a university hospital between January 2019 and April 2022. Ethics committee approval was obtained. Patient medical records and data associated with PI and medical treatment were collected through the 'Information Form,' 'Braden Scale,' 'Braden Q Scale,' 'Pressure Ulcer Staging Form,' and 'Pediatric Nutrition Risk Score (PNRS).' Data were analyzed using descriptive statistics, correlation analysis, Mann-Whitney U test, Kruskal Wallis test, and Multilinear Regression analysis.

RESULTS

More patients (66.2%) were males, and 49.2% of the children were 0-12 months old. 2368 out of 6350 pediatric patients were treated in the PICU. It was determined that a total of 143 PI occurred in 59 patients from PICU. The PI prevalence was 2.25% for all patients and 6.04% for PICU patients. Twenty-one percent of the patients had medical device-related PI (MDRPIs), 35.7% of PI occurred in the occiput, 13.3% in the coccyx/sacrum, and 67.1% of PI was Deep Tissue Injury. In the multiple regression model, children's albumin level, hemoglobin level, PNRS scores, Body Mass Index, and length of hospital stay significantly affected BRADEN scores. They were explained 30.3% of their scores of Braden.

CONCLUSION

Despite the limitations of the retrospective study, the prevalence of PI in the pediatric population in this study was lower than that reported in previous studies, but the prevalence of MDRPIs was higher. Based on the study results, it is recommended to implement preventive interventions for MDRPIs and plan prospective studies.

Rete ridges: Morphogenesis, function, regulation, and reconstruction

Rete ridges (RRs) are distinct undulating microstructures at the junction of the dermis and epidermis in the skin of humans and certain animals. This structure is essential for enhancing the mechanical characteristics of skin and preserving homeostasis. With the development of tissue engineering and regenerative medicine, artificial skin grafts have made great progress in the field of skin healing. However, the restoration of RRs has been often disregarded or absent in artificial skin grafts, which potentially compromise the efficacy of tissue repair and regeneration. Therefore, this review collates recent research advances in understanding the structural features, function, morphogenesis, influencing factors, and reconstruction strategies pertaining to RRs. In addition, the preparation methods and limitations of tissue-engineered skin with RRs are discussed. STATEMENT OF SIGNIFICANCE: The technology for the development of tissue-engineered skin (TES) is widely studied and reported; however, the preparation of TES containing rete ridges (RRs) is often ignored, with no literature reviews on the structural reconstruction of RRs. This review focuses on the progress pertaining to RRs and focuses on the reconstruction methods for RRs. In addition, it discusses the limitations of existing reconstruction methods. Therefore, this review could be a valuable reference for transferring TES with RR structure from the laboratory to clinical applications in skin repair.

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.

Nursing care of infants born extremely preterm

With improving survival at the lowest gestations an increasing number of tiny and vulnerable infants are being cared for, and optimal outcomes require an approach to care that takes their specific characteristics into account. These include immature organ function and a risk for iatrogenic injury, and parental/familial strain due to the high degree of uncertainty, infant-mother separation, and long hospital stay. While the challenges in providing nursing care to these infants are obvious it is also clear that this field has tremendous potential to influence both short and long-term outcomes of this population. This mini-review discusses aspects of the nursing care provided to infants born at the very lowest gestations and their families, with focus on doing less harm by establishing an adequate care environment, actively promoting parental closeness and care-giving, and conservative skin care.

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.

Incubator humidity and temperature control in infants born at 22-23 weeks' gestation

BACKGROUND

Preterm infants, especially those born at ≤23 gestational weeks (GW), present with extremes in insensible water loss (IWL) and changes in water balance.

AIMS

To prevent water loss from the skin and achieve skin maturation without infection, we investigated transepidermal water loss (TEWL), IWL from the skin (IWL-s), and electrolyte balance with differences in high incubator humidity and temperature control from birth to postnatal 1 month in 22-23 GW and 24-25 GW infants.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

Extremely preterm infants born at 22-23 GW (n = 11) and 24-25 GW (n = 11), admitted to the neonatal intensive care unit between September 2018 and October 2019.

OUTCOME MEASURES

Total fluid intake (TFI), fluid output volume, TEWL, IWL-s, and electrolyte balance were compared between the two groups with controlled incubator humidity and temperature, gradually decreasing the humidity and ambient temperature from 95% to 50% and from 37.0 to 34.0 °C, respectively, while maintaining the central body temperature at 36.5-37.5 °C.

RESULTS

TEWL and IWL-s between the 22-23 and 24-25 GW was not significantly different for infants at postnatal age. No significant difference in electrolyte imbalance was noted between the two groups, within the first 7 days. Differences in TEWL and IWL-s were eliminated with corresponding humidity and temperature adjustments.

CONCLUSIONS

Incubator humidity and temperature control should aid management of 22-23 GW infants to reduce IWL, facilitate skin maturation, and prevent infection.

Malnutrition and Pressure Injury Risk in Vulnerable Populations: Application of the 2019 International Clinical Practice Guideline

ABSTRACT

Nutrition plays a vital role in promoting skin integrity and supporting tissue repair in the presence of chronic wounds such as pressure injuries (PIs). Individuals who are malnourished are at greater risk of polymorbid conditions, adverse clinical outcomes, longer hospital lengths of stay, PI development, and mortality, and incur increased healthcare costs compared with patients who are adequately nourished. In addition, some patient populations tend to be more vulnerable to PI formation, such as neonates, patients with obesity, older adults, and individuals who are critically ill. Accordingly, this article aims to review the latest nutrition care recommendations for the prevention and treatment of PIs, including those recommendations tailored to special populations. A secondary objective is to translate nutrition recommendations into actionable steps for the healthcare professional to implement as part of a patient plan of care.Implementing an evidence-based plan of care built around individualized nutrition interventions is an essential step supporting skin integrity for these populations. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG) affirms that meeting nutrient requirements is essential for growth, development, maintenance, and repair of body tissues. Many macronutrients and micronutrients work synergistically to heal PIs. Registered dietitian nutritionists play an important role in helping patients identify the most nutrient dense foods, protein supplements, and oral nutrition supplements to meet their unique requirements.

Incidence and prevalence of pressure injuries in children patients: A systematic review and meta-analysis

BACKGROUND

Pressure injuries presently has been a serious healthcare problem all over the world. Children were recognized as the high-risk population of pressure injuries in the latest prevention and treatment of pressure injuries clinical practice guideline. However, the estimates of incidence, and prevalence of pressure injuries in hospitalized children patients vary considerable in relevant published studies.

OBJECTIVE

To systematically quantify the incidence and prevalence of pressure injuries (PIs) in hospitalized children and the most affected PIs sites.

METHODS

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Electronic databases searches of the Cochrane Library, Pubmed, Web of Science, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, China Knowledge Resource Integrated Database (CNKI), Wanfang Database, Chinese Biomedical Database (CBM), and Weipu Database (VIP), and hand-search through references were conducted to find relevant articles. Studies were evaluated independently by two researchers and audited by a third researcher. The data were extracted and presented in tables. The risk of bias was assessed using Hoy's tool. The I² statistic and random-effects model were used to assess the heterogeneity. Meta-regression analysis and subgroup analysis were conducted to examine between-study heterogeneity.

RESULTS

A total of 6, 672 articles were screened, and 30 studies with 251, 501 participants were ultimately included in this review. The pooled incidence of PIs for 3, 205 children was 13.5% (95% CI: 10.5-16.5); and the pooled prevalence of PIs for 4, 639 children was 12.2% (95% CI: 8.0-16.3). The most affected body sites were occiput, ears, and nose. Meta-regression and subgroup analysis showed that the inpatient ward, and region were the sources of heterogeneity.

CONCLUSIONS

The incidence and prevalence of PIs was significantly higher than the adults. Our discoveries recommended that healthcare givers ought to pay more consideration to diminish the happens of PIs. Additionally, more research may be needed to improve our understanding of the characteristics of PIs among children and to identify PIs risk factors to prevent and treat it in children effectively.

Potential Benefits of Bovine Colostrum in Pediatric Nutrition and Health

Bovine colostrum (BC), the first milk produced from cows after parturition, is increasingly used as a nutritional supplement to promote gut function and health in other species, including humans. The high levels of whey and casein proteins, immunoglobulins (Igs), and other milk bioactives in BC are adapted to meet the needs of newborn calves. However, BC supplementation may improve health outcomes across other species, especially when immune and gut functions are immature in early life. We provide a review of BC composition and its effects in infants and children in health and selected diseases (diarrhea, infection, growth-failure, preterm birth, necrotizing enterocolitis (NEC), short-bowel syndrome, and mucositis). Human trials and animal studies (mainly in piglets) are reviewed to assess the scientific evidence of whether BC is a safe and effective antimicrobial and immunomodulatory nutritional supplement that reduces clinical complications related to preterm birth, infections, and gut disorders. Studies in infants and animals suggest that BC should be supplemented at an optimal age, time, and level to be both safe and effective. Exclusive BC feeding is not recommended for infants because of nutritional imbalances relative to human milk. On the other hand, adverse effects, including allergies and intolerance, appear unlikely when BC is provided as a supplement within normal nutrition guidelines for infants and children. Larger clinical trials in infant populations are needed to provide more evidence of health benefits when patients are supplemented with BC in addition to human milk or formula. Igs and other bioactive factors in BC may work in synergy, making it critical to preserve bioactivity with gentle processing and pasteurization methods. BC has the potential to become a safe and effective nutritional supplement for several pediatric subpopulations.