A newborn born between ___ and ___ weeks of gestation is described as term.
Preservation of skin integrity, reduction of risk factors and neonate skin care education for parents are key nursing priorities in the care of the term and preterm neonate. Show
The skin contains three separate layers. The uppermost layer is the stratum corneum. This provides the barrier function of the skin and has 10-20 layers in adults and term neonates. It protects against toxins, irritants, allergens and pathogens, retains heat and water as well as maintaining a normal microbiome. During the first year of life the stratum corneum is not fully mature and is approximately 30% thinner than that of adult skin. Directly under the stratum corneum is the basal layer of the epidermis and then the dermis which are also thinner and underdeveloped in neonates compared to adults. In preterm neonates the stratum corneum has only 2-3 layers. This deficiency and immaturity of the stratum corneum results in increased fluid and heat loss leading to electrolyte imbalance, reduced thermoregulation and increased infection risk. Understanding the physiological and anatomical skin differences of preterm and term neonate skin is important in aiding thorough assessment and appropriate management of the skin. Please see key differences in neonate skin for further information on the structure and function of neonate skin. This guideline provides recommendations for the skin care of neonates (birth to 28 days of age) of all gestational ages. Additional considerations for preterm neonates and product suggestions are identified in the boxes below each section. AimTo maintain skin integrity and minimise heat loss in the neonate requiring hospitialisation. This is achieved by understanding the key differences of preterm and term neonate skin enabling appropriate assessment and management of our neonatal population using evidence based practice. Definition of Terms
AssessmentAssessment of neonate skin should be undertaken daily, or more frequently as clinically indicated. Neonates at increased risk of systemic infection and longer hospital stays will be identified promptly. The Neonatal Skin Condition Score (NSCS) may be used to measure skin condition objectively. NSCS CriteriaDryness: Erythema: Breakdown: The relevant medical team must be notified if a neonate scores a single score of 3 in one area or a combined score of 6 and above. A dermatology referral may also be appropriate. ManagementNappy CareThe perineal environment is prone to changes in the skin barrier causing skin irritation. Increased moisture, prolonged contact with irritants, and an alkaline skin surface may contribute to skin breakdown.
Nappy care for the preterm infant is as above and assessed on an individual basis PRODUCT EXAMPLE Cleansing: Rediwipes, cotton wool, pH neutral cleanser (as below in bathing section) Barrier Creams: SudoCream™, Kenkay Zinc and Castor Oil cream™, Desitin™, Bepanthan™ Eye & Oral Care
Eye Care
Oral Care
BathingGeneral Bathing PrinciplesImplement safety principles when bathing neonates
Swaddled-Immersion
Sponge bathing
First Bath (applies to all neonates, additional considerations for preterm neonates given below)
Routine Bathing
Preterm Infant Considerations - Consider weight, gestational age and severity of illness when bathing preterm neonates - For neonates less than 32 weeks gestation, consider the use or warm water only bathing during the first week of life due to skin irritation and risk with cleansers. Avoid rubbing. - For neonates more than 32 week’s gestation, pH neutral or slightly acidic cleansers may be utilised. Neonates may be bathed every 2-3 days - Use warm sterile water when areas of skin breakdown are evident - If skin is dry, flaking or cracked after the bath, an emollient may be applied to the skin Product Suggestions Cleansing: QV Wash™, QV Gentle Cleanser™, Hamilton Skin Therapy Gentle ash™, Cetaphil Gentle Cleanser™, Avene Trixera Cleansing Gel™, Kenkay Body Wash™, Mustela Stelatopia Cream Cleanser™, CeraVe Hydrating Wash™, Dermeze Soap Free Wash™, Laroache Posay Lipikar Syndet™ Emollients: As per Emollient box below AdhesivesA number of measures can be undertaken to ensure a reduced incidence of skin trauma with the use of adhesives in NICU
ETT/NPT Strapping
ECG Dots
Transcutaneous Monitoring (TCM)
Taping (Venous and Arterial Access)Current best practice exists for the taping of venous and arterial lines, however the following are general considerations.
Intraoperative Eye Taping
Preterm Neonate Considerations Product Examples: DisinfectantsVery little data is available on what disinfectants are best suited to the neonate skin, in particular preterm neonate skin.
Preterm Neonate Considerations Product Example Umbilical Cord Care
EmollientsEmollients restore lipid levels, improve hydration, preserve natural moisturising factors and offer significant buffering capacity to normalise skin pH and maintain skin microbiome.
Preterm Neonate Considerations Product Example Common newborn rashesErythema Toxicum NeonatorumA common condition affecting as many as half of all full term neonate neonates. Most prominent on day 2, although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs. Palms and soles are not usually affected. Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual for an individual lesion to persist for more than a day. Figure 1. Erythema Toxicum Neonatorum ( http://www.huidziekten.nl/afbeeldingen/erythema-toxicum-neonatorum-2.jpg) Neonatal MiliaAffects 40-50% of newborn babies. Few to numerous lesions. Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk. Figure 2. Neonatal Milia ( http://www.forestlanepediatrics.com/wp-content/uploads/2014/04/Milia.jpg) Miliaria (Heat Rash)Arises from occlusion of the sweat ducts. In neonates, lesions commonly appear on the neck, groins and armpits, but also on the face. Clinical features: 1-3mm papules (vesicular or papular). Figure 3 & 4 Miliaria ( http://www.leememorial.org/HealthInformation/graphics/images/en/2892.jpg) Pityrosoprum FolliculitisNeonatalacne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the neonates' sebaceous glands cause inflammation and folliculitis. Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops, commonly affecting the cheeks, nose and forehead. This rash is not itchy. Figure 5 & 6 Pityrosoprum Folliculitus (Images courtesy of of Dr David Orchard, Dermatologist RCH) LinksEvidence TableEvidence table for the Neonatal and Infant Skincare guideline can be viewed here. References
Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Robyn Kennedy, Nurse Practitioner, Dermatology and Alanah-Rae Crowle, Associate Nurse Unit Manager/CNS, Neonatal Intensive Care and and approved by the Nursing Clinical Effectiveness Committee. Updated May 2020. Which of the following indicates an immediate need for chest compressions in a newborn?Chest compressions are indicated for a heart rate that is < 60 bpm despite adequate ventilation with supplementary oxygen for 30 seconds.
Which of the following factors is associated with the highest risk of newborn hypoglycemia?Maternal hypertension (OR 3.07, 95% CI 1.51–6.30, p = 0.002) was the sole risk factor for neonatal hypoglycemia.
When should CPR compressions begin for a neonatal patient quizlet?After performing the initial steps of resuscitation, you assess a newborn and note that its respirations are poor and its pulse rate is 50 beats/min. You should: begin chest compressions if the heart rate remains below 60 beats/min after 30 seconds of effective positive-pressure ventilation.
Which of the following is often observed in a newborn with jitteriness but not with a seizure?Benign neonatal sleep myoclonus is characterized by rhythmical myoclonic jerks seen only during sleep. It is common and frequently misdiagnosed as seizures.
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