Neonatal skin care: the scientific basis for practice

Simulation-based development: shaping clinical procedures for extra-uterine life support technology

BACKGROUND

Research into Artificial Placenta and Artificial Womb (APAW) technology for extremely premature infants (born < 28 weeks of gestation) is currently being conducted in animal studies and shows promising results. Because of the unprecedented nature of a potential treatment and the high-risk and low incidence of occurrence, translation to the human condition is a complex task. Consequently, the obstetric procedure, the act of transferring the infant from the pregnant woman to the APAW system, has not yet been established for human patients. The use of simulation-based user-centered development allows for a safe environment in which protocols and devices can be conceptualized and tested. Our aim is to use participatory design principles in a simulation context, to gain and integrate the user perspectives in the early design phase of a protocol for this novel procedure.

METHODS

Simulation protocols and prototypes were developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from participants with clinical expertise from a range of disciplines. The procedure made use of fetal and maternal manikins and included animations and protocol task cards.

RESULTS

Physical simulation with the active participation of clinicians led to the diffusion of tacit knowledge and an iteratively formed shared understanding of the requirements and values that needed to be implemented in the procedure. At each sequel, participant input was translated into simulation protocols and design adjustments.

CONCLUSION

This work demonstrates that simulation-based participatory design can aid in shaping the future of clinical procedure and product development and rehearsing future implementation with healthcare professionals.

Effectiveness of different bathing methods on physiological indexes and behavioral status of preterm infants: a systematic review and meta-analysis

BACKGROUND

Bath is an external stimulus for preterm infants. Currently, three methods are used for preterm infants to bath. It is important to choose the best way for them. The objective of this meta-analysis is to evaluate the effectiveness of different bath methods on physiological indexes and behavioral status of preterm infants.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines and was registered in PROSPERO(CRD42022377657). PubMed, Embase, Cochrane Library, Web of Science, CINAHL, Sino Med, China National Knowledge Internet (CNKI) and Wan-Fang database were systematically searched for randomized controlled trials on the effects of different bath methods for preterm infants. The retrieval time was from the establishment of the database to February 2023. According to the inclusion and exclusion criteria, the literature was screened, quality evaluated and the data was extracted. Reman Version 5.4 was used for meta-analysis and Stata 16.0 software for publication bias Egger's test.

RESULTS

A total of 11 RCTs with 828 preterm infants were included. The results of meta-analysis showed that the body temperature and oxygen saturation of preterm infants in the sponge bath group were lower than those in conventional tub bath group (SMD = -0.34; 95%CI -0.56 to -0.12; I2 = 0; p < 0.01), (MD = -0.39; 95%CI -0.76 to -0.02; I2 = 39%; p = 0.04), while the heart rates were higher than those in conventional tub bath group(MD = 5.90; 95%CI 0.44 to 11.35; I2 = 61%; p = 0.03). Preterm infant's body temperature and blood oxygen saturation of in swaddle bath group were higher than those in conventional tub bath group (MD = 0.18; 95%CI 0.05 to 0.30; I2 = 88%; p < 0.01), (MD = 1.11; 95%CI 0.07 to 2.16; I2 = 86%; p = 0.04), respiratory rates were more stable compared with infants in conventional tub bath group (MD = -2.73; 95%CI -3.43 to -2.03; I2 = 0; p < 0.01). The crying duration, stress and pain scores of preterm infants in swaddle bath group were lower than those in conventional tub bath group (SMD = -1.64; 95CI -2.47 to -0.82; I2 = 91%; p < 0.01), (SMD = -2.34; 95%CI -2.78 to -1.91; I2 = 0; p < 0.01), (SMD = -1.01; 95%CI -1.40 to -0.62; I2 = 49%; p < 0.01). Egger's test showed no publication bias in body temperature, respiratory rate, oxygen saturation, and crying duration.

CONCLUSIONS

Swaddle bath is the best bathing method than conventional tub bath and sponge bath in maintaining the stability of preterm infant's body temperature, blood oxygen saturation and respiratory rate. In addition, swaddle bath also plays a role in reducing cry duration, stress scores, and pain levels of preterm infant compared with conventional tub bath and sponge bath. However, due to the important heterogeneity in some outcomes, future studies with larger sample size and more appropriately design are needed to conduct before recommendation.

TRIAL REGISTRATION

Prospero CRD42022377657.

Comparison of the Effects of Bathing and the Dry Technique on the Skin Condition of Early Neonates: A Prospective Observational Study

BACKGROUND

In Japan, neonates have typically been bathed in a bathtub immediately after birth because bathing is a custom for cleansing impurities. However, dry technique has been introduced into many institutions since 2000. There is little scientific evidence on the benefit or harmfulness of either method to neonatal skin, and consequently, opinion remains split on which method is superior.

OBJECTIVE

The purpose of the present study was to determine whether bathing or the dry technique of cleaning is better in maintaining skin health in the early neonatal period.

METHODS

Transepidermal water loss (TEWL) and skin pH, considered an index of skin barrier function, were measured in each group. Tumor necrosis factor (TNF)-alpha and interleukin (IL)-6, which are inflammatory cytokines released by keratinocytes, were measured by skin blotting.

RESULTS

TEWL and skin pH of neonates were lower with the dry technique than with bathing. The expression level of IL-6 and TNF-α in chest skin of neonates was higher with bathing than with the dry technique.

CONCLUSION

These results suggest that the dry technique may maintain skin health better than bathing in the early neonatal period.

Perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda: a qualitative study

BACKGROUND

The skin is a major route of infection in the neonatal period, especially in low birthweight (LBW) infants. Appropriate and safe neonatal skin care practices are required to reduce this risk. The perceptions and beliefs of mothers and other caregivers towards various neonatal skin care practices in our setting have been documented. Data from Asia suggests that the application of emollient to the skin of LBW infants can promote growth, reduce serious neonatal infections, and potentially reduce mortality. This is the first study to explore the acceptability of emollients and massage as part of neonatal skin care in a low-resource setting in sub-Saharan Africa (SSA) that is representative of the majority of government health facilities in Uganda and many in SSA.

OBJECTIVE

To explore perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda.

METHODS

We conducted a qualitative study consisting of three focus group discussions (30 participants), eight in-depth interviews with mothers/caregivers of preterm and term neonates and 12 key informant interviews with midwives, doctors and community health workers involved in neonatal care, to explore the perceptions and practices surrounding neonatal skin care and emollient use. Data collected were transcribed and analyzed using thematic content analysis.

RESULTS

Mothers perceived that skin care began in utero. Skincare practices depended on the place of delivery; for deliveries in a health facility the skincare practices were mainly based on the health worker's advice. Vernix caseosa was often washed off due to its perceived undesirability and was attributed to sexual intercourse in the last trimester. Despite their deleterious attributes found in previous studies, petrolatum-based oils, petrolatum-based jellies and talcum baby powders were the most commonly reported items used in neonatal skin care. In our population, there was high acceptability of emollient therapy use; however, neonatal massage was treated with scepticism as mothers feared damaging the vulnerable neonate. Mothers suggested massage and emollient application be undertaken by health workers, if it becomes an intervention.

CONCLUSIONS

In eastern Uganda, the perceptions and beliefs of mothers/caregivers toward neonatal skincare influenced their practices of which some could potentially be beneficial, and others harmful. Emollient use would be easily accepted if adequate sensitisation is conducted and using the gatekeepers such as health workers.

Skin barrier immunology from early life to adulthood

Our skin has a unique barrier function, which is imperative for the body's protection against external pathogens and environmental insults. Although interacting closely and sharing many similarities with key mucosal barrier sites, such as the gut and the lung, the skin also provides protection for internal tissues and organs and has a distinct lipid and chemical composition. Skin immunity develops over time and is influenced by a multiplicity of different factors, including lifestyle, genetics, and environmental exposures. Alterations in early life skin immune and structural development may have long-term consequences for skin health. In this review, we summarize the current knowledge on cutaneous barrier and immune development from early life to adulthood, with an overview of skin physiology and immune responses. We specifically highlight the influence of the skin microenvironment and other host intrinsic, host extrinsic (e.g. skin microbiome), and environmental factors on early life cutaneous immunity.

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.

Medical adhesive-related skin injuries in the neonatology department of a teaching hospital

BACKGROUND

Medical adhesives are used to affix components to the skin. They are part of procedures performed by medical specialties because of their participation as constituents of different products, such as tapes, dressings, and electrodes.

AIM

This study aims to assess the prevalence of, and factors associated with, the development of medical adhesive-related skin injuries (MARSIs) in patients treated with medical tapes in the neonatology department of a large teaching hospital in Brazil.

STUDY DESIGN

Cohort study.

METHODS

All premature newborns (gestational age from 28 to <37 weeks) admitted in the neonatal intensive care unit of a teaching hospital, from March to August 2019, were followed up. Neonate skin condition was assessed based on the Neonatal Skin Condition Scale (NSCS). Data analyses were conducted in R software.

RESULTS

In total, 46 premature newborns were included in the study; 552 evaluations were performed-mean of 11.7 per patient. Most neonates (n = 41; 89.1%) used adhesive tapes, either paper tape (n = 37; 80.4%) or transparent film dressing (n = 34; 73.9%). Newborns' face and head were the most affected body regions (n = 125; 50.2%). Eight patients had MARSIs (19.5% of patients who used tape). NSCS scores (P value <.001) and the adopted warming system (P value = .01302) were associated with the occurrence of MARSIs. Incubators seem to be a protective factor for MARSI (OR = 0.048; IC95% = 0.0008-0.75; P value = .013).

CONCLUSION

Adhesive tapes in premature newborns should be considered a risk factor for injuries. Although NSCS showed mild-to-moderate impairment and lesion severity was low, this event is relatively frequent in neonatal units.

RELEVANCE TO CLINICAL PRACTICE

Awareness of the risk associated with adhesive tape application and removal in newborns allow health services to better address the problem by enforcing good practices, elaborating better protocols, qualifying the health care professionals, and potentially selecting softer tapes for neonates.

Pressure Injury Prevention and Treatment in Critically Ill Children

Pressure injury prevention in critically ill pediatric patients can be challenging. The current article discusses pressure injury prevention and treatment with attention to unique aspects of pediatric physiology that influence risk for pressure injury. Medical device-related pressure injuries are particularly problematic in pediatric patients; therefore, this article presents best practice in preventing pediatric medical device-related pressure injuries. Treatment of pressure injuries is also discussed, with special attention to products that should be used with caution or avoided.

Effects of Formulation Excipients on Skin Barrier Function in Creams Used in Pediatric Care

Semisolid dosage forms are recommended for the dermal care of babies and children. If we look at the ingredients of these preparations, there are still many cases in which there are substances (occlusive agents, preservatives) that no longer meet certain requirements of the modern age, so it is timely to replace them with other substances. The aim of this work was to formulate a science-based formulation with new components that keep or improve its moisturizing properties, rheological parameters, and microbiological stability. Occlusive oils, like white petrolatum and liquid paraffin and the preservative parabens are traditional ingredients in oil in water creams, were replaced with white beeswax, sunflower oil, and phenoxyethanol, respectively. Cocoa butter, urea, and glycerol were added to improve long-lasting hydration and support the barrier function of the reformulated creams. The rheological properties of the formulations were determined. The effects of the preparations on skin hydration and on the barrier function of the skin were tested. Furthermore, microbiological stability was investigated. The result of the reformulation was an o/w cream that provided a good longer-lasting hydration effect; supported the barrier function of the baby skin without occlusion; and had adequate consistency, easy spreading, a pleasant skin feeling, proper pH, and good microbiological stability.

BATHING, MAKE-UP, AND SUNSCREEN: WHICH PRODUCTS DO CHILDREN USE?

Objective:

To evaluate the hygiene practices and frequency of use of personal hygiene products, cosmetics, and sunscreen among children and adolescents.

Methods:

Cross-sectional study with interviews about skincare conducted with caregivers through closed-ended questions. We included patients up to 14 years of age waiting for consultation in pediatric outpatient clinics of a tertiary hospital. We performed a descriptive statistical analysis and applied the Kruskal-Wallis test and Fisher’s exact test to compare the practices according to maternal schooling.

Results:

We conducted 276 interviews. The median age of the participants was age four, and 150 (54.3%) were males. A total of 143 (51.8%) participants bathed once a day and 128 (46.3%) bathed two or more times a day, lasting up to ten minutes in 132 (47.8%) cases. Adult soap was used by 103 (37.3%) children and bar soap by 220 (79.7%). Fifty-three (19.2%) participants used sunscreen daily. Perfume was used by 182 (65.9%) children, hair gel by 98 (35.5%), nail polish by 62 (22.4%), and some type of make-up by 71 (25.7%) - eyeshadow by 30 (10.8%), lipstick by 52 (18.8%), face powder and mascara by 13 (4.7%). Make-up use started at a median age of 4 years. Henna tattoo was done in eight children.

Conclusions:

The children studied used unsuitable products for their skin, such as those intended for adults, used sunscreen inadequately, and started wearing make-up early, evidencing the need for medical orientation.

Multiple Aplasia Cutis Congenita Lesions of the Scalp: A Case Study

Aplasia cutis congenita (ACC) is a rare condition that presents at birth as an absence of skin that does not usually involve underlying structures. Occurring in 3/10,000 live births, ACC is evenly distributed between males and females; the risk of ACC increases to 7 percent in consanguineous marriages. Up to 86 percent of lesions are found on the scalp in the midline vertex position. Lesions can also be found on the trunk and limbs, as with Adams-Oliver syndrome or accompanying epidermolysis bullosa. ACC is associated with chromosomal abnormalities and 35-50 percent of the time with trisomy 13 (Patau syndrome). This case study presents an infant with multiple ACC lesions of the scalp. The pathophysiology, treatment, potential long-term complications, and nursing considerations are discussed.

Infant skin care: updates and recommendations

PURPOSE OF REVIEW

Neonatal skin acclimates rapidly to dry, aerobic conditions at birth and skin function gradually matures throughout infancy. Gentle skin care practices support the ongoing development and function of newborn skin. This article reviews research updates and current skin care recommendations for full-term infants, premature infants, and infants born with severe cutaneous manifestations of genetic skin disorders.

RECENT FINDINGS

Although safe early bathing of full-term infants with environmental controls is possible, delaying the first newborn bath for 12-24 h of life offers benefits of increased parental bonding and breastfeeding success. Swaddled bathing every 4 days is an effective bathing strategy for premature neonates. Among infants with a family history of atopic dermatitis, regular application of bland skin moisturizers reduces their risk of developing the disease. For newborns with erosive or blistering genetic skin conditions, use of specialized wound dressings and emollients promotes wound healing and helps limit skin damage. Environmental control with humidified incubators helps prevent life-threatening hypernatremic dehydration among babies born with collodion membranes; however, affected infants can tolerate breaks outside of the humidifier to promote parent-infant bonding.

SUMMARY

This article reviews infant skin care recommendations relevant to pediatric practice. Research to further optimize newborn skin care is ongoing, particularly, for the special populations of premature neonates and infants born with severe skin disease.

Quality improvement measures for early detection of severe intravenous infiltration in infants

Intravenous infiltration is one of the most commonly seen morbidity in infants admitted to the neonatal intensive care unit (NICU). The risk of intravenous infiltration in preterm infants is probably due to prolonged peripheral intravenous access requirement for nutritional support and usage of other intravenous medications to support their growth. Infants are more likely to develop intravenous infiltrations due to the increased fragility of their blood vessels, deficient subcutaneous tissue and inability to express pain. As a result, the intravenous infiltrates in infants can rapidly progress to severe stage 3 and stage 4 infiltrates with necrosis if timely intervention is not provided. Also, factors obscuring to identify stage 1 and stage 2 infiltrates, may lead their progression to severe infiltration. Root cause analysis was performed following two severe intravenous infiltrates that required plastic surgery intervention in our level III NICU. Quality improvement measures were implemented. We developed a unique intravenous securing method, conducted educational programmes for NICU staff, increased intravenous site surveillance and ascertained to maintain the intravenous pump pressures in the reference range. The hospital NICU intravenous care policy was updated with quality improvement measures. Data were collected preintervention and postintervention. The incidence of intravenous infiltration in preterm infants varies widely in different places. This may be due to under-reporting of these relatively rare adverse events, but may also be due to the fact that the preterm infants represent a small portion of the patient population. The present study has shown that severe infiltration was associated with an increase in intravenous days. Following the quality improvement measures, there were no reported cases of severe intravenous infiltration. In conclusion, the awareness of the problem with evidence-based quality improvement measures may help in early detection of intravenous infiltrates and decrease the severe intravenous infiltration in infants.

Pressure ulcers' incidence, preventive measures, and risk factors in neonatal intensive care and intermediate care units

Epidemiological studies on pressure ulcers (PUs) in hospitalised infants are scarce. Spain lacks comprehensive research studies providing data on the prevalence or incidence in this population. This work was developed to determine the incidence of PUs in hospitalised infants admitted to intensive and intermediate care units, along with relevant risk factors and preventive measures. A prospective study appraising the incidence of PUs in infants was performed. The risk factors and preventive measures were evaluated using a multivariate logistic regression model. A sample of 268 infants was included. The cumulative incidence of PUs was 12.70% (95% confidence interval, CI_95% = [8.95%-17.28%]). The cumulative incidence in the intermediate care units was 1.90% (CI_95% = [0.39%-5.45%]), while it was 28.18% (CI_95% = [20.02%-37.56%]) in the intensive care units. The PUs were categorised as stage I, 57.10%; stage II, 31.70%; and stage III, 11.10%. The multivariate analysis found the following to be risk factors: low scores in the Spanish version of the Neonatal Skin Risk Assessment Scale (e-NSRAS) (Relative Risk (RR) 0.80; CI_95% = [0.66-0.97]), the use of non-invasive mechanical ventilation (RR 12.24; CI_95% = [4.02-37.32]), and the length of stay (RR 1.08; CI_95% = [1.02-1.15]), suggesting a direct impact of these factors on PU development in infants. Kangaroo care influenced the prevention of PUs (RR 0.26; CI_95% = [0.09-0.71]). The infants admitted in intermediate care units suffered PUs. In the case of intensive care units, the incidence is even higher. The risk increases with the length of stay, while the presence of medical devices, particularly non-invasive mechanical ventilation, is the main causal relationship. Kangaroo care has been shown to be an important preventive measure.

Critical assessment of the pH of children's soap

OBJECTIVE

To evaluate the pH value of children's antibacterial soaps and syndets used in children's baths and verify whether there is information regarding pH on the product label.

METHODS

Quantitative, cross-sectional, analytical observational study that included ninety soap samples, both in bar and liquid presentations, as follows: 67 children's soap (group 1), 17 antibacterial soaps (group 2), and 6 syndets (group 3). Each sample had its pH measured after 1% dilution. In addition to descriptive statistics, the Pearson-Yates chi-squared test and Student's t-tests were applied, considering the minimal significance level of 5%. The Wilcoxon-Mann-Whitney test, Fisher's exact test, and the Kruskal-Wallis test were used for inferential statistics.

RESULTS

The pH levels varied considerably between liquid and bar presentations, with lower levels (4.4-7.9) found for the liquids (p<0.05). Syndets showed pH levels close to the ideal (slightly acid) and the antibacterial soaps showed the highest pH levels (up to 11.34) (p<0.05). Only two of the soaps included in the study had information about their pH levels on the product packaging.

CONCLUSIONS

Knowledge of the pH of children's soap by doctors and users is important, considering the great pH variability found in this study. Moreover, liquid soaps, and especially syndets, are the most recommended for the sensitive skin of neonates and infants, in order to guarantee skin barrier efficacy.

Improving Detection of IV Infiltrates in Neonates

Neonates and infants in the neonatal intensive care unit suffer significant morbidity when intravenous (IV) catheters infiltrate. The underreporting of adverse events through hospital voluntary reporting systems, such as ours, can complicate the monitoring of low incidence events, like IV infiltrates. Based on severe cases of IV infiltrates observed in our neonatal intensive care unit, we attempted to improve the detection of all infiltrates and reduce the incidence of Stage 4 infiltrates. We developed, and initiated the use of, an evidence-based guideline for the improved surveillance, prevention, and management of IV infiltrates, with corresponding educational interventions for faculty and staff. We instituted the use of a checklist for compliance with guidelines, and as a mechanism of surveillance. The baseline incidence rate of IV infiltrates, determined by the voluntary reporting system, was 5 per 1000 line days. Following initiation of the guidelines and checklist, the IV infiltrate rate increased to 9 per 1000 line days. In most months, the detection of IV infiltrates was improved by use of the checklist. During the post-intervention period the rate of Stage 4 infiltrates, as measured by usage of nitroglycerin ointment, was significantly reduced. In conclusion, the detection of IV infiltrates was improved following our quality improvement interventions. Further, use of an evidence-based guideline for managing infiltrates may reduce the most severe infiltrate injuries.

Skin Physiology of the Neonate and Infant: Clinical Implications

Significance: The skin is a complex and dynamic organ that performs several vital functions. The maturation process of the skin starts at birth with the adaption of the skin to the comparatively dry environment compared to the in utero milieu. This adaptive flexibility results in the unique properties of infant skin. To deliver appropriate care to infant skin, it is necessary to understand that it is evolving with unique characteristics. Recent Advances: The role of biophysical noninvasive techniques in the assessment of skin development underlines the importance of an objective evaluation of skin physiology parameters. Skin hydration, transepidermal water loss, and pH values are measurable with specific instruments that give us an accurate and reproducible assessment during infant skin maturation. The recording of these values, following standard measurement procedures, allows us to evaluate the integrity of the skin barrier and to monitor the functionality of the maturing skin over time. Critical Issues: During the barrier development, impaired skin function makes the skin vulnerable to chemical damage, microbial infections, and skin diseases, possibly compromising the general health of the infant. Preterm newborns, during the first weeks of life, have an even less developed skin barrier and, therefore, are even more at risk. Thus, it is extremely important to evaluate the risk of infection, skin breakdown, topical agent absorption, and the risk of thermoregulation failure. Future Directions: Detailed and objective evaluations of infant skin maturation are necessary to improve infant skin care. The results of these evaluations should be formed into general protocols that will allow doctors and caregivers to give more personalized care to full-term newborns, preterm newborns, and infants.

Postnatal changes in skin water content in preterm infants

BACKGROUND

Preterm infants have immature skin, which contributes to skin problems. Very little is known about postnatal changes in the skin, despite the clinical importance of this issue.

AIM

To assess temporal changes in skin water content in preterm infants.

STUDY DESIGN

A prospective observational study.

SUBJECTS

Infants admitted to the neonatal intensive care unit were included in this study.

OUTCOME MEASURES

Skin water content was measured at five different skin regions using dielectric methods at a depth of 1.5mm. Skin water content was measured on postnatal day 1 in 101 infants, and the correlation between skin water content and gestational week was analyzed. Measurements were also made on postnatal days 2, 3, and 7, and every 7days thereafter until the corrected age of 37weeks in 87 of the 101 infants. Temporal changes were statistically analyzed after dividing participants into seven groups by gestational age.

RESULTS

On postnatal day 1, skin water content correlated inversely with gestational age at all skin regions. Skin water content decreased significantly over time, converging to the level of term infants by the corrected age of 32-35weeks.

CONCLUSIONS

Skin water content at a depth of 1.5mm was related to corrected age and reached the level of term infants by the corrected age of approximately 32-35weeks.

Topical Nystatin for the Prevention of Catheter-Associated Candidiasis in ELBW Infants

BACKGROUND

Catheter-associated Candida bloodstream infections are a common and serious problem in the neonatal intensive care unit (NICU). Several prophylactic regimens have been developed including oral administration of nonabsorbable antifungals and intravenous infusions. No reports to date have employed a topical regimen.

PURPOSE

To evaluate the effectiveness of topical nystatin cream in preventing catheter-associated Candida sepsis.

METHODS

A retrospective descriptive design was used to determine the incidence of Candida sepsis in extremely low-birth weight (ELBW, <1000 g at birth) infants who were treated with topical nystatin cream for Candida bloodstream infection prophylaxis between January 1, 2000, and December 31, 2010. The electronic medical records of study infants were reviewed to establish the incidence of Candida sepsis.

RESULTS

A total of 464 ELBW infants were admitted to the NICU during the study period. Three infants (0.65%) developed Candida sepsis.

IMPLICATIONS FOR PRACTICE

These data demonstrate that a topical nystatin cream protocol is associated with a very low rate of Candida sepsis in ELBW infants with central catheters. The use of this protocol may contribute to a decrease in the morbidity and mortality rate associated with catheter-associated Candida infections in ELBW infants.

IMPLICATIONS FOR RESEARCH

Before generalizations can be made as to the safety and efficacy of this protocol as compared to enteral and parenteral prophylactic treatments and in other institutions, large multicenter randomized controlled trials are required.

Cue-based feeding in the NICU: using the infant's communication as a guide

Although studies have shown cue-based feeding can lead to earlier achievement of full oral feeding, the successful implementation of cue-based feeding has been constrained by the volume-driven culture, which has existed for many years in the NIC U. This culture was built on the notion that a "better" nurse is one who could "get more in," and infants who are "poor feeders" are ones who "can't take enough." The infant who feeds faster is often viewed as more skilled in this task-oriented approach. The feeding relationship and the infant's communication about the experience of feeding may not be nurtured. This article will explain the central role of the preterm infant's communication in successful cue-based feeding. When the infant is perceived as having meaningful behavior (i.e., communicative intent), the focus changes from a volume-driven to a co-regulated approach, through which the infant guides the caregiver. This is cue-based feeding.

A national survey of neonatal peripherally inserted central catheter (PICC) practices

PURPOSE

The purpose of this study was to assess and describe the practices involved in the insertion and maintenance of peripherally inserted central catheters (PICCs) in neonates in level III neonatal intensive care units (NICUs) in the United States and to compare the findings with current recommendations and evidence.

SUBJECTS

The study included responses from 187 nurses, nurse practitioners, and neonatologists who place PICCs in NICUs representing 43 states.

METHODS

A 90-question, multiple-choice survey of a variety of PICC practices was sent to NICU directors and nursing staff responsible for PICC insertion. The explorative survey was sent by electronic and standard mail services. A descriptive analysis of the responses was performed.

MAIN OUTCOME MEASURES

Main outcome measures included the response rate to the survey and the summarized responses of multiple categories of PICC practices.

PRINCIPAL RESULTS

Of the 460 level III NICUs contacted, 187 returned surveys meeting criteria for analysis, yielding a 42% response rate. Responses showed wide variation of PICC practices in multiple aspects of PICC insertion and maintenance. The greatest level of conformity was seen with the following practices: use of 2 nurses to perform a dressing change, trimming the PICC, using a kit or cart containing insertion supplies, use of maximal sterile barrier precautions during insertion, catheter tip residing in the superior vena cava for upper body insertions, and not heparin locking, infusing blood products, performing catheter repair, or inserting using Modified Seldinger Technique. Some identified practices, such as infusion tubing change and catheter entry techniques, were contrary to current evidence and demonstrated a lack of correct information, and some represented safety concerns for the neonates having PICCs.

CONCLUSION

This extensive national survey of NICU PICC practices showed wide variation in multiple aspects of PICC insertion and maintenance. A gap between the evidence and current practice was evident in many facets of training, insertion techniques, and maintenance processes. The data suggest a need for an increase in awareness of clinicians of current practice guidelines and standards and the need for further research to develop an evidence basis for many aspects of PICC care where lacking.

Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age

Nappy dermatitis is a broad term used to describe an acute inflammatory reaction of the skin in the nappy area because of irritation from urine, faeces, moisture or friction. The prevalence is estimated to be between 7% and 35% in infants. Regular application of a barrier preparation at every nappy change may be a valuable component of nappy dermatitis prevention and/or treatment.

The infant skin barrier: can we preserve, protect, and enhance the barrier?

Infant skin is different from adult in structure, function, and composition. Despite these differences, the skin barrier is competent at birth in healthy, full-term neonates. The primary focus of this paper is on the developing skin barrier in healthy, full-term neonates and infants. Additionally, a brief discussion of the properties of the skin barrier in premature neonates and infants with abnormal skin conditions (i.e., atopic dermatitis and eczema) is included. As infant skin continues to mature through the first years of life, it is important that skin care products (e.g., cleansers and emollients) are formulated appropriately. Ideally, products that are used on infants should not interfere with skin surface pH or perturb the skin barrier. For cleansers, this can be achieved by choosing the right type of surfactant, by blending surfactants, or by blending hydrophobically-modified polymers (HMPs) with surfactants to increase product mildness. Similarly, choosing the right type of oil for emollients is important. Unlike some vegetable oils, mineral oil is more stable and is not subject to oxidation and hydrolysis. Although emollients can improve the skin barrier, more studies are needed to determine the potential long-term benefits of using emollients on healthy, full-term neonates and infants.

Oral feeding readiness in the neonatal intensive care unit

Oral feeding is a complex sensorimotor process that is influenced by many variables, making the introduction and management of oral feeding a challenge for many health care providers. Feeding practice guided by tradition or a trial-and-error approach may be inconsistent and has the potential to delay the progression of oral feeding skills. Oral feeding initiation and management should be based on careful, individualized assessment of the NICU infant and requires an understanding of neonatal physiology and neurodevelopment. The purpose of this article is to help the health care provider with this complex process by (a) defining oral feeding readiness, (b) describing the importance of oral feeding in the NICU and the physiology of feeding, and (c) providing a review of the literature regarding the transition from gavage to oral feeding in the NICU.

Wound care in the neonatal intensive care unit

The skin is a vital organ with key protective functions. Infants in the NICU are at risk for skin injury because of developmental immaturity and intensive care treatments. When skin injury occurs, the neonatal nurse is challenged to provide wound care to optimize functional and cosmetic healing. Optimal wound care requires basic knowledge of the mechanisms of injury, physiology of wound healing, host factors affecting wound healing, and wound assessment. This knowledge provides the basis for determining appropriate wound treatment, including dressing selection. Attention to pain issues associated with wound care is difficult because of the infant's developmental stage, but is essential because of the potentially negative life-long impact of pain. The premature infant's propensity for skin stripping limits the selection of appropriate dressing, as does the paucity of research examining wound care products in this population.

Effect of baby swimming and baby lotion on the skin barrier of infants aged 3-6 months

BACKGROUND

Skin care is important especially in infancy as the skin barrier matures during the first year of life. We studied the effects of baby swimming and baby lotion on the skin barrier function of infants.

SUBJECTS AND METHODS

44 infants aged 3-6 months were included in this mono-center prospective study. The healthy infants swam four times and were randomized to group(L) : baby lotion was applied after swimming all over the body and to group(WL) : no lotion was used. Transepidermal water loss, stratum corneum hydration, skin-pH and sebum were measured on four body regions using non-invasive methods.

RESULTS

In group(L), sebum and pH remained stable. In group(WL), significant decrease in sebum was noted on forehead and thigh, and for pH on thigh and buttock. Group(L) had fewer infants with at least one adverse event compared to group(WL). Location-dependent gender differences in skin barrier function were observed.

CONCLUSIONS

Reaction of skin barrier function to baby swimming and skin care regimens showed typical regional variability between body areas. Influence of baby lotion on skin barrier and gender differences in skin functional parameters were demonstrated for the first time in healthy infants participating in baby swimming.

Unraveling the mystery of vernix caseosa

Vernix caseosa is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy. Vernix coating on the neonatal skin protects the newborn skin and facilitates extra-uterine adaptation of skin in the first postnatal week if not washed away after birth. It consists of water-containing corneocytes embedded in a lipid matrix. The strategic location of the vernix on the fetal skin surface suggests participation in multiple overlapping functions required at birth, such as barrier to water loss, temperature regulation, and innate immunity. Vernix seems to perform various integral roles during transition of the fetus from intra-uterine to extra-uterine life. It has also found various interesting diagnostic and prognostic implications in this arena. Thus, it continues to be an intriguing topic of interest among the medical fraternity to understand its detailed biology and function in the fetus and also to put its naturally endowed characteristics to use in the adult population.

Effect of standardized skin care regimens on neonatal skin barrier function in different body areas

The effect of topical skin care products on neonatal skin barrier during first 8 weeks of life has not been scientifically evaluated. In a prospective, randomized clinical study, we compared the influence of three skin care regimens to bathing with water on skin barrier function in newborns at four anatomic sites. A total of 64 healthy, full-term neonates (32 boys and 32 girls) aged <48 hours were randomly assigned to four groups receiving twice-weekly: WG, bathing with wash gel (n = 16); C, bathing and cream (n = 16); WG + C, bathing with wash gel plus cream (n = 16); and B, bathing with water (n = 16). Transepidermal water loss, stratum corneum hydration, skin pH, sebum were measured on day 2, week 2, 4, 8 of life on front, abdomen, upper leg, and buttock. Skin condition was scored and microbiologic colonization was documented. After 8 weeks, group WG + C showed significantly lower transepidermal water loss on front, abdomen, and upper leg as well as higher stratum corneum hydration on front and abdomen compared with group B. Similarly, group C showed lower transepidermal water loss and higher stratum corneum hydration on these body regions. Group WG revealed significantly lower pH on all sites compared with group B at week 8. No differences in sebum level, microbiologic colonization and skin condition score were found. Skin care regimens did not harm physiologic neonatal skin barrier adaptation within the first 8 weeks of life. However, significant influence of skin care on barrier function was found in a regional specific fashion.

Securing PICC lines

Ms. Shirland raises a valid concern regarding safe securement of the neonatal PICC catheter and its role in preventing catheter fracture and catheter embolism. Ms. Paulson and Ms. Miller’s response is appreciated [see the author’s response in Neonatal Network, November/December 2008, p. 427]. In Dislodgement Rates and Impact of Securement Methods for Peripherally Inserted Central Catheters (PICCs) in Children, Frey and Schears report methods of PICC securement include transparent dressings, skin closure strips, sutures, and catheter-specific securement devices.1 However, a specific procedure for the appropriate placement of the skin closure strips is not delineated. In PICC Complications in Neonates and Children, Frey describes catheter fracture, where the damage was caused by a “sterile-tape thread” in a skin closure strip.2 Given the extended dwell time expected with PICC catheters, placement of skin closure strips including sterile tape fibers directly overlying the catheter would, in combination with infant mobility, support the possibility of external forces (fibers, adhesive agent, activity) causing severance of the catheter over time, which cannot be discounted. In cases of catheter embolism, catheter fragments required cardiac catheterization for retrieval.2

Tiny patients, tiny dressings: a guide to the neonatal PICC dressing change

Advances in neonatology now support the survival of the tiniest of infants. The peripherally inserted central catheter (PICC) has now become an integral part of routine practice in neonatal intensive care units around the world. Keen attention to safe maintenance of these devices is essential. A properly applied and maintained PICC dressing is the first line of defense to minimize the risk of complications such as dislodgement, migration, and infection. This article describes a neonatal PICC dressing change and discusses the frequently encountered quandaries surrounding this important procedure, including dressing materials, frequency, site preparation, barrier precautions, and other relevant concerns.

Interface pressure comparison of healthy premature infants with various neonatal bed surfaces

PURPOSE

The aim of this study was to determine interface pressure between the occiput of healthy premature infants and 5 different bed surfaces used in special care nurseries.

SUBJECTS

Thirteen healthy premature infants comprised the convenience sample enrolled 1 to 3 weeks prior to discharge.

DESIGN

A quasi-experimental design was used with the dependent variable being the interface pressures obtained under the occiput and the independent variables as the bed surfaces.

METHODS

Order of bed surfaces was randomized and standardization of the infant positioning and measuring procedure maintained. Measurements were made between the infant's occiput and the bed surface and interface pressures recorded in millimeters of mercury. The 5 bed surfaces were standard crib mattress with or without foam, gel donut, gel mattress, and water pillow.

MEASURES

Interface pressure measurements were obtained using the Mini-Texas Interface Pressure Evaluator (Mini-TIPE, Tee-Kay Applied Technology, Inc, Stafford, Texas).

RESULTS

A 1-way blocked analysis of variance was conducted to evaluate the relationship between the mattress surfaces and the interface pressure measurements. A significant difference in the mean of the interface pressures among the 5 mattress bed surfaces was determined, F(4,46) = 33.267, P < .001, with the lowest being the foam overlay. The standard crib mattress had the highest interface pressure that exceeded 100 mm Hg. Post hoc comparisons showed a significant difference between the standard crib mattress with and without foam and the other surfaces.

CONCLUSIONS

Interface pressure is an important consideration when choosing a support surface for premature infants susceptible to tissue compromise and head molding. Variations in interface pressures between neonatal bed surfaces are apparent. Comparison studies of interface pressures using these and other neonatal bed surfaces will be valuable in determining appropriate products for both premature and neonatal populations with lengthy intensive care stays.

Nursing Care Guidelines for prevention of nasal breakdown in neonates receiving nasal CPAP

Use of nasal continuous positive airway pressure (CPAP) is increasing as a means of respiratory support for respiratory distress syndrome in many premature neonates across the United States. Nasal CPAP is less invasive and may be as effective as mechanical ventilation in premature infants, and has been shown to cause less lung damage in premature neonates. Because of the increased use of nasal CPAP in neonates, especially younger and more fragile neonates, the presence of nare and nasal septum breakdown may be seen as a complication. Currently, all nasal CPAP systems use a hat and prong or mask type of delivery system. This appears to be effective for many neonates, but for some, it is difficult to appropriately fit the hat and prongs. The result of an inappropriately fitted device can be mild to severe nare and nasal septum damage. This article will discuss the need for nasal CPAP and the mechanics of nasal CPAP, but more importantly, serve to guide caregivers in the appropriate physical assessment and care of a neonate on nasal CPAP with the goal of preventing skin breakdown and nasal damage.

Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age

Nappy dermatitis is a broad term used to describe an acute inflammatory reaction of the skin in the nappy area because of irritation from urine, faeces, moisture or friction. The prevalence is estimated to be between 7% and 35% in infants. Regular application of a barrier preparation at every nappy change may be a valuable component of nappy dermatitis prevention and/or treatment.

A retrospective chart review of risk factors for extravasation among neonates receiving peripheral intravascular fluids

PURPOSE

To identify variables associated with extravasation and resulting tissue damage in neonates with peripheral intravascular therapy.

DESIGN

A retrospective chart review was completed.

SETTING AND SUBJECTS

Randomly selected medical records of 25 neonates admitted to a neonatal intensive care unit from January 2003 through April 2004 and who experienced peripheral intravascular infiltration were examined.

INSTRUMENTS

The Neonatal Tissue Extravasation Tool was created to reflect common descriptive variables of the neonatal population and infused solutions used in their care. Tissue damage was classified with the scale from the Task Force of Pediatric Nursing Research Committee, 1994.

RESULTS

Charts of 15 female and 10 male infants 24 to 39.6 weeks old were reviewed. Extravasation was not significantly related to age, weight, or sex. The most common intravenous medications were total parenteral nutrition (n = 19) and calcium (n = 18). Peripheral intravenous sites were secured with tape. The sites of the infiltrate were the arm (n = 16), foot/leg (n = 5), and scalp (n = 3) (one not recorded). Stages 0 (absence of redness, pain, swelling; flushes with ease) (n = 11) and 4 (severe swelling; blanching, pain, skin breakdown, etc.) (n = 6) were the most common stages. The site of the infiltrate was measured and care described in only 9 neonates.

CONCLUSIONS

The intravascular solutions causing the most extensive damage from extravasation were similar to those reported in other studies. No other potential risk factors were identified, but poor documentation about the extravasation site and management of skin damage hampered data collection via retrospective chart review.

Burns caused by fan heater used for managing post-operative hypothermia in a premature neonate

Generally fan forced area heaters are considered to be incapable of causing burn injury. A case is presented where such a heater was used to prevent post-operative hypothermia after cut-back anoplasty to correct low anorectal malformation (imperforate anus) in a premature neonate. The neonate sustained dermo-epidermal (second degree) burns to the abdominal wall and right forearm which were swaddled with cloth and deep (third degree) burns to the fingers of left hand that were exposed as intravenous line was inserted at dorsum of the hand.

Prevention and treatment of nosocomial sepsis in the NICU

Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. It is associated with an increase in mortality, morbidity, and prolonged length of hospital stay. Thus, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to describe simple changes in process, which when implemented, can reduce nosocomial infection rates in neonates and improve outcomes.

Nosocomial infection in the NICU: a medical complication or unavoidable problem?

Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. As it is associated with increases in mortality, morbidity, and prolonged length of hospital stay, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to review the topic of nosocomial infections in neonates.

Determination of positional skin-surface pressures in premature infants

PURPOSE

To describe the skin-surface pressure distributions and points of maximal pressure that are generated by healthy premature infants in the supine, prone, and right side-lying positions.

DESIGN

A descriptive, repeated-measures design.

SAMPLE

Four medically stable premature infants of 34 weeks postconceptional age. The mean weight was 2,180 gm, and the mean age was 24.5 days.

RESULTS

Similar regions of increased skin-surface pressures were identified for the four infants. Within areas of peak pressure, some sensor cells reached 28-32 millimeters of mercury, which is considered to be the critical compressive pressure for obstruction of nutritive flow to the underlying body tissues. These descriptive results may be a starting point for development of research studies to determine positioning strategies to optimize the skin integrity of premature infants while minimizing unnecessary handling.

Permeability barrier dysfunction in transgenic mice overexpressing claudin 6

A defective epidermal permeability barrier (EPB) in premature birth remains a leading cause of neonatal death as a result of its associated complications, which include poor temperature stability, infection by micro-organisms through the skin, and the outflow of water. Despite its importance in survival, the mechanisms involved in the formation and maintenance of the EPB are not well understood. To address the possibility that claudins, a new superfamily of tight junctional molecules, are involved, we engineered transgenic mice with claudin 6 (Cldn6) overexpressed via the involucrin (Inv) promoter. Interestingly, the Inv-Cldn6 transgenic animals die within 2 days of birth, apparently due to the lack of an intact EPB as evidenced by increased water loss and the penetration of X-gal through the skin. Barrier dysfunction was manifested biochemically by the aberrant expression of late epidermal differentiation markers, including K1, filaggrin, loricrin, transglutaminase 3, involucrin, repetin, members of the SPRR family and the transcriptional regulator Klf4. The overall claudin profile of the epidermis was also modified. Our data suggest that repetin and SPRR1A and 2A are downregulated in response to the downregulation of Klf4 in the transgenic animals, which would contribute to decreased protein crossbridging leading to fragile, defective cornified envelopes. These results provide new insights into the role of claudin 6 in epithelial differentiation and EPB formation. In addition, the epidermal phenotype of these transgenic mice, which is very reminiscent of that in pre-term infant skin, suggest that they will be an important and novel model for studies on human premature EPB-related morbidity.

Does bathing newborns remove potentially harmful pathogens from the skin?

BACKGROUND

Newborn infants are routinely bathed after birth partly to reduce the possibility of transmitting potential pathogens to others. The extent to which a mild soap reduces the quantity and type of microbes found on the skin through normal colonization has not been reported. The objective of the study was to compare colonization rates between infants bathed in soap and water and infants bathed in plain water.

METHOD

One hundred and forty infants were randomly assigned to one group bathed in a mild pH neutral soap and water or to another group bathed in water alone. Microbiology swabs were taken on three occasions (before the first bath, 1 hour after the bath, and 24 hours after birth) from two sites (anterior fontanelle and umbilical area).

RESULTS

No difference occurred between groups on type or quantity of organisms found at each time period. Skin colonization is a function of time, and the quantity of organisms identified increased over time (Friedman A 2 = 111.379, df = 5, p < 0.001).

CONCLUSIONS

Bathing with mild soap as opposed to bathing in water alone has minimal effect on skin bacterial colonization. Skin colonization increased over time. The findings did not support the efficacy of bathing with soap and water to reduce skin colonization of bacterial pathogens. Although the incidence of potential pathogens colonizing the skin during the first day of life is low and unlikely to pose a risk to healthy newborns, health care professionals may wish to wear gloves until the infant has been bathed.

The thyroid gland: physiology and pathophysiology

The thyroid gland contains many follicular cells that store the thyroid hormones within the thyroglobulin molecule until they are needed by the body. The thyroid hormones, often referred to as the major metabolic hormones, affect virtually every cell in the body. Synthesis and secretion of the thyroid hormones depend on the presence of iodine and tyrosine as well as maturation of the hypothalamic-pituitary-thyroid system. Interruption of this development, as occurs with premature delivery, results in inadequate production of thyroid-stimulating hormone and thyroxine, leading to a variety of physiologic conditions. Pathologic conditions occur in the presence of insufficient thyroid production or a defect in the thyroid gland. Laboratory tests are important in diagnosing conditions of the thyroid gland. A thorough history in combination with clinical manifestations and radiologic findings are also useful in diagnosing specific thyroid conditions. Nurses play an important role in identifying and managing thyroid disorders and in providing supportive care to infants and their families.

Adhesives and emollients in the preterm infant

This chapter focuses on recent advances in preterm infant skin care related to skin adhesion and skin emolliency. Different types of adhesives and hydrating agents are reviewed. Clinical applications are best guided by understanding the biology of epidermal barrier development. The role of xeric stress in accelerating formation of the stratum corneum is discussed along with the effects of occlusive agents and emollients on wound healing and epidermal barrier repair. The principles of skin moisturization are introduced. The concept is advanced that programmatic changes in skin adhesion and water handling occur during the normal ontogeny of superficial biofilms (sebum, sweat, acid mantle).