Managing wounds in neonates is different than in children or adults and deserves special considerations. Neonatal skin is physiologically and developmentally different, and some skin characteristics are dependent on gestational age.1 For example, skin barrier function increases with gestational age; the epidermis is mature by 34 weeks’ gestation, but preterm infants take 2 to 3 weeks longer to reach this maturity.2 The skin of preterm infants has less functionality and thus a higher risk of injury.
Not only does skin development affect neonatal outcomes, but the wound causes are also unique. Pediatric specialists should consider several factors when called to assess a newborn with wounds. Evaluate if wounds are the result of skin fragility influenced by genetic disorders including epidermolysis bullosa or some types of ichthyosis. Consider facility-acquired pressure injury incidence and prevalence (as in this issue’s Open Access article on pressure injuries in the pediatric population by Delmore et al) and extrinsic factors such as medical devices.3,4 This evaluation may involve previous surgeries, immobility, sepsis, and other events. Finally, iatrogenic etiologies include chemical burns from antiseptics, access line extravasation injuries, or medical adhesive-related skin injury.5,6
Although institutional protocols for neonatal skin care vary, published guidelines address practices including bathing, moisturizing, umbilical cord handling, sterilization, and diapering7 and often include specific recommendations for preterm infants.8 However, there is limited guidance regarding the use of dressings. In this issue, Keswani et al provide a comprehensive review of wound care products for neonates. Both this CE/CME article and a recently published white paper3 provide important references for neonatal healthcare providers.
Because many products exist with varying costs and availability, learn about product categories, know their properties, and anticipate possible scenarios in which a product category might be indicated. Formularies may guide practice, but choosing among products remains an important skill in need of development. Be familiar with atraumatic dressings and tapes, adhesive remover products, and the correct way to remove tape to help prevent injuries.
Further, monitor neonates for possible complications including irritant or allergic contact dermatitis. Potential causes of irritant contact dermatitis include leakage of bodily fluids, as well as antiseptics, adhesives, occlusive topical ointments or creams, and some dressings.
Another important consideration is the systemic absorption of topical medications.3 Adverse effects include silver-related leukopenia or argyria with silver sulfadiazine cream, aminoglycoside-related ototoxicity from gentamicin or neomycin, and iodine-induced thyroid disorders.9 Prilocaine-related methemoglobinemia from EMLA cream (Astra USA, Inc, Westborough, Massachusetts) can often be prevented; avoid formulation in infants less than 37 weeks’ gestational age and in children younger than 1 year who are on drugs that can induce methemoglobinemia.10 The need for topical medications should be considered carefully; adhere to the minimum required frequency and duration, in addition to limiting the area and amount of product being applied. If significant absorption is suspected, confirm the plasma concentration of the drug and promptly discontinue the offending agent.
We hope you enjoy this focused issue supporting best practice care for your vulnerable neonatal and pediatric patients.
Irene Lara-Corrales, MD, MSc
Cathryn J. Sibbald, MD, MSc, FRCPC
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
Gary R. Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
1. Broom M, Dunk AM, E Mohamed AL. Predicting neonatal skin injury: the first step to reducing skin injuries in neonates. Health Serv Insights 2019;12:1178632919845630.
2. Fluhr JW, Darlenski R, Taieb A, et al. Functional skin adaptation in infancy—almost complete but not fully competent. Exp Dermatol 2010;19(6):483–92.
3. Delmore B, Deppisch M, Sylvia C, Luna-Anderson C, Nie AM. Pressure injuries in the pediatric population: a National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care 2019;32(9):394–408.
4. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Haesler Emily, ed. Prevention and Treatment of Pressure Injuries/Injuries: Clinical Practice Guideline. The International Guideline. EPUAP/NPIAP/PPPIA; 2019.
5. Vanzi V, Pitaro R. Skin injuries and chlorhexidine gluconate-based antisepsis in early premature infants: a case report and review of the literature. J Perinat Neonatal Nurs 2018;32(4):341–50.
6. Wang D, Xu H, Chen S, Lou X, Tan J, Xu Y. Medical adhesive-related skin injuries and associated risk factors in a pediatric intensive care unit. Adv Skin Wound Care 2019;32(4):176–82.
7. Blume-Peytavi U, Hauser M, Stamatas GN, Pathirana D, Garcia Bartels N. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol 2012;29(1):1–14.
8. Kusari A, Han AM, Virgen CA, et al. Evidence-based skin care in preterm infants. Pediatr Dermatol 2019;36(1):16–23.
9. Fox M, Helfrich Y, Kang S. Other topical medications. In: Bolognia JL, Shaffer JV, Cerroni L, eds. Dermatology. 4th ed. China: Elsevier; 2018.
10. The Aspen Group. Product Monograph: EMLA Cream. 2017. https://pdf.hres.ca/dpd_pm/00040608.PDF
. Last accessed April 22, 2020.