Skin Care in the premature Baby

The skin is a functional organ of the human body that plays many roles.

These include:

• Protecting from injury and infection.

• Regulatory fluid and electrolytes balance

• Sense organ

• Thermoregulatory functions

Introduction

• Premature infant have underdeveloped organs, including the skin.

• It is important to recognize the role that skin plays and How to protect the infant during the maturation of the skin.

Skin Structure

• The skin structure of the human contains multiple layers, the skin of the infant even at term is thinner than the adult.

• First, it is important to understand the structure of the skin in the premature infant and particularly How it differs from the adult.

Layers of the skin include:

• Epidermis: top most layer of the skin; protects

against potential intrusions. The more premature the infant, the poorer the function of this layer.

• Dermis: composed of collagen and elastin fibers, provide good mechanical strength and elasticity. Helps maintain thermoregulation. This layer is thinner in the infant according to G.A.• Subcutaneous tissue: loose bundles of connective tissue and lipocytes. Provide cushion and protection from heat and cold. Even though infants born at 26 to 29 week will have some subcutaneous tissue.

Skin of premature • Premie skin is not fully developed –skin is not

a barrier for infection.

• Underdevoloped stratum corneum - full term infant & adult has 10-20 layers - 28 weeker has 2 -3 layers, takes 2 weeks to

mature - 23 weeker has no layers takes 6-8 weeks to

mature • Diminished cohesion at dermo-epidermal

border

• Decreased collagen stability

Skin Function

• Protecting of underlying structures

• The primary function of the skin to protect the underlying structures from injury.

• In the preterm infant the epidermal/dermal junction is weak, for this reason, adhesives removal often leads to injury.

Skin function

• The skin also serves against foreign substances and organisms.

• The skin in the premature infant is thin, it is poorly equipped to provide this protection.

• The impact of poor function in this area includes increased water loss, as well as increased permeability to toxins and bacteria, topical cleansers, ointment, lotions and other itmes can be readily transferred into the blood stream due to permeability of the infant skin.

• Barrier against foreign substances and organisms

Skin function • Sense organ

•Skin also is a sense organ. With repeated or sever injury, sensation is lost, this prevents recognition of heat/cold and other important indicators of the world.

• Temperature regulation / Metabolic organ• Another important function of the skin is to regulate temperature.

• Even relively small areas of skin can lead to significant heat and fluid loss in the infant.

• Water and electrolytes can excreted through the skin as needed, this is important in maintaining thermoregulatory balance in the active adult through sweating.

• Infant do not have the ability to sweat until several days of age, depending on gestational age and therefore are unable to regulate temperature.

Rational for early non-use of baby Bathing product

• Baby’s are born with an alkine skin surface with an average pH of 6.84, However within days the pH has fallen to about 4.95 (Acid), This also occurs in the premature infant; but can take weeks rather than days to complete. This is known as “acid manthle” and is the skin protector.

• The development of this acid manthle takes between 2-8 weeks depending on G.A. So it is even more important to avoid damage to the premature infants skin in the early weeks of life.

• So introduction of Baby Bathing products, wipes, creams, etc could disrupt this delicate protective barrier and lead to problems, including eczema or allergic reaction.

Bathing

• First Bath

• The first bath should be provided once the neonates’ temperature has been stabilized and has remained 2-5 hours.

• Universal precaution including wearing gloves should be maintained until after first bath.

• Excessive vernix may be removed but removal of all vrenix is not necessary for hygiene purposes.

• Napkins Changes:

• Napkins should be changed frequently, at least at each nursing and feeding time, it should be carefully washed in warm water then rinsed off and dried thoroughly.

• The diaper area is specifically vulnerable because it is a closed environment suitable for microorganism and with frequent wetting, it is more often moist and dry; hence the skin becomes prone to maceration and increases its permeability to other irritants.

• The skin here is constantly in contact with strong alkalinizing agents, e.g. urine and feces and the pH here is prone to high alkalinity that damages the skin integrity

• In such cases using partially occlusive agent like mineral oil on the buttocks can help to form a physiological barrier that minimize this interface.

• Warm water and soft cotton wool should be used to wipe the nappy area, feces have a tendency to stick and scrubbing only worsens the status of the delicate skin.

• Here the use of an emulsion like baby lotion can ease the removal by reducing the surface tension and cleansing the debris.

• Skin should then be thoroughly dried each time the diaper is changed by exposing it for a few minutes.

• The buttock should be wiped from front to back to avoid fecal matter from reaching the genitals.

• Soap is too drying for skin and it is not necessary.

• Antimicrobial soap is not recommended for use in infant due to the harshness of the soap as well as the effect it will have on skin colonization.

Preventive measures for minimizing epidermal striping and preserve skin integrity

• Maintenance of skin integrity and prevention of Iatrogenic injury must be paramount in nursing care in the NICU.

• The risk of damage to a baby’s skin is directly proportional to the degree of prematurity.

• The potential for trauma is highest at < 32 week gestation.

• The most vulnerable time for skin damage to occur in the first 2-3 weeks of life during the process of keratinisation (thickening and maturation of preterm skin resulting from exposure to the atmosphere.

Adhesives• Adhesives application

and removal occurs many times per day in the NICU, this carries the greatest risk of skin breakdown.

• Therefore minimal use of tape and adhesives in the premature infants skin may be damaged from repeated attachment and removal of adhesive tapes to secure electrodes, I.V cannula, drains, etc.

• Adhesive should be used on small area of skin and removed gently with warm water, soaked gauze and diluted soap, but not alcohol which may be irritant for baby’s skin.

• Before any adhesive is used, one should evaluate if it is indeed necessary and if there might be another method to secure the device.

Skin Cleansing• Skin cleansing prior to invasive

procedures is a common occurrence in the NICU. The most common products used are alcohol,povidone-iodine (PI) and chlorohexidine gluconate (CHG).

• All cleansing agents should be evaluated for toxicity that may occur with absorption as the skin does not provide a good barrier in the preterm infant.

• In addition, they should be evaluated for efficacy in reducing infection and potential for damage to the stratum corneum.

• Both CHG and PI have the potential to damage tissue.

• Alcohol has shown to be less effective at decreasing bacteria at the site and more drying to the skin.

Lubrication• The purpose of lubrication is to decrease

transepidermal water loss and prevent skin breakdown.

• If skin breakdown has already occurred, lubrication will facilitate healing.

• Infant products should be carefully examined before use as many contains dyes, perfumes and alcohol that can further irritating to the skin and may even create contact dermatitis later in life.

• An important point to remember when using lubricants in the NICU is that it does not require a lot of lubricant to be effective.

• The lubricants in never applied to the face. It can be sparingly to the rest of the body and can be removed if something needs to be secured later, with soap and water.

Incubator

• Frequent change of infant position in the incubator reduces the risk of skin erosion and impeding bed sore, fingers and toes must be kept visible, catheters or needles should be secured with a transparent tape to allow easy detection of fluid extravasation.

Transcutaneous Oxygen Monitors

TCM should not be left in place for more than one hour without surveillance, erythema can develop by keeping such electrodes for prolonged period.

Placement by electrodes on the limbs, especially in very low birth weights infants can eliminate the need to frequently remove these pads to facilitate auscultation or other assessment of the chest well.

• Thank you