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Warmth and moisture help keep preterm neonates'skin healthy.


Tub bathing, emollients, and even plastic dressings can protect the fragile skin of preterm infants during the first few crucial weeks of extrauterine life.

The skin of premature infants is very fragile and can take up to 4 weeks to become cornified. Until then, it's apt to rapidly lose water and heat, putting babies at risk of hypothermia, dehydration, and electrolyte imbalances, Ayan Kusari and his colleagues wrote in Pediatric Dermatology.

The team examined evidence-based skin care in these tiny patients, extracting recommendations from a metaanalysis of 68 studies.

"There are a number of unifying features that distinguish preterm skin from term skin," wrote Mr. Kusari, a clinical research associate at the Rady Children's Hospital-San Diego, and his associates. "Preterm skin is thinner, making preterm neonates more susceptible to skin infections and caustic agents. The vernix caseosa is typically thicker in preterm neonates [though thinner in extremely preterm neonates]. Accordingly, there are a number of general principles that can guide skin care for most preterm neonates."


The team identified eight studies of bathing preterm neonates and concluded that a daily bath isn't necessary.

"Colonization by pathogenic bacterial strains, size of the total bacterial population, and incidence of skin infection do not vary between preterm infants bathed every 2 days and preterm infants bathed every 4 days in all studies," the authors wrote.

These less frequent baths appear to decrease the risk of temperature variability, and tub baths are preferable to sponge baths. "In sponge bathing, wet skin is more exposed to ambient air, which is typically colder than body temperature. Physiological and behavioral parameters in preterm infants are often disrupted during sponge bathing. In contrast, tub bathing results in less variability in body temperature and warmer temperatures after bathing," Mr. Kusari and his associates found.

However, premoistened baby wipes appeared beneficial, lowering skin pH, which might help "facilitate acid mantle development, infection control, and barrier repair," they wrote.


Seven studies and one meta-analysis examined the use of emollients in preterm infants; there was agreement that emollients do improve skin condition. Plant-based emollients appeared superior to petrolatum-based products.

"In developing countries where oil massage of infants and children is traditional, there appears to be a clear benefit to massage with some oils. In developed countries, research has emphasized petrolatum-based creams and ointments, whose benefits are tempered by the increased risk of serious infections with some products," Mr. Kusari and his colleagues wrote.

Sunflower seed oil was particularly beneficial in studies carried out in developing countries. A mixture of 70% lanolin and 30% olive oil proved better than olive oil alone. Coconut oil also displayed positive impact on skin condition.

"In contrast, multiple studies show an increased risk of sepsis with the application of petrolatum ointment to preterm neonates," they noted.

In one study, following the adoption of a new skin care protocol involving regular application of petrolatum-based ointments for extremely low birth-weight neonates, researchers in Texas observed a significant, 200% increase in the incidence of systemic candidiasis. A study in Saudi Arabia replicated this finding. The largest study of a petrolatum-based ointment on premature babies was conducted in Vermont and found a statistically significant increase in infection with coagulase-negative staphylococcus (CoNS). "This ... study appears to be the driving force in a Cochrane Database meta-analysis, which concludes that topical emollients are associated with increased CoNS infection in preterm neonates," the authors wrote.

Temperature regulation

It's notoriously tough to maintain core temperature in preterm newborns. Six studies in the meta-analysis tackled this issue using impermeable plastic wraps or garments after birth and semipermeable barriers in the weeks after.

"Plastic wraps or bags can help neonates to retain their body heat, and greater skin coverage with plastic devices appears to be associated with a better outcome. In infants less than 28 weeks' gestational age, the use of polyethylene occlusive wraps prevents heat loss after delivery and results in higher NICU admission temperatures and a lower incidence of hypothermia," Mr Kusari and his associates wrote.

Semipermeable wraps can be used for an extended period after birth to reduce transepidermal water loss. Seven studies examined this technique, using both adhesive and nonadhesive polyurethane dressings.

"These studies show that semipermeable adhesive membranes decrease water loss, reduce skin breakdown, and decrease erythema while applied, but may strip superficial skin layers when they are removed, leading to a transient post-removal increase in transepidermal water loss. Furthermore, due to their semipermeable design, application of these adhesive membranes does not appear to decrease fluid requirement or affect electrolyte status in preterm neonates; however, skin barrier function is disrupted following removal of plastic tape, with increased transepidermal water loss at sites of tape removal," the investigators wrote.

Pectin-based dressings and those containing hydrocolloid or acrylate can damage preterm neonatal skin by inflicting medical adhesive-related skin injury, the team wrote; this can involve epidermal stripping, tension injury, shearing, maceration, folliculitis, or contact dermatitis.

Skin sterilization

There's little consensus when it comes to sterilization choices for preterm neonatal skin about to undergo a venipuncture or other procedure. Popular methods are povidone-iodine and Chlorhexidine, with gestational age affecting choice. Iodine-based antiseptics have been associated with thyroid disruption and Chlorhexidine with chemical burns.

"Some studies suggest 0.2% Chlorhexidine gluconate may be an attractive alternative to povidone-iodine for the very and extremely preterm," the authors wrote. One study they examined compared Chlorhexidine gluconate 0.2% and 0.5% in extremely preterm infants, showing a significant decrease in skin irritation in the lower-concentration group.

But a randomized trial following this finding, which compared 0.2% Chlorhexidine gluconate with 10% aqueous povidone-iodine, found no differences in any infection outcome or skin irritation, but there was more thyroid suppression in the povidone-iodine group.

More research is needed, the team concluded.

Cord care

Tincture of time may be the best alternative here.

The investigators examined a metaanalysis of 21 umbilical cord care studies and found that cleaning the cord with antiseptic prolonged the time to cord separation, compared with simple air drying.

"Interestingly, one study does suggest that one-time cleansing with chlorhexidine reduces neonatal mortality when compared to dry cord care; however, most of the existing evidence suggests that antiseptic treatment does not offer a benefit over dry cord care," they wrote.

"Further studies, particularly in the very preterm and extremely preterm neonates, with an emphasis placed on subclassifying the preterm patient population based on gestational age, are needed to further examine and validate the real-world utility of these interventions," Mr. Kusari and his associates concluded. "In the meantime, it may be useful to establish practice guidelines based on the evidence we have presented here."

The authors reported no relevant financial disclosures.

SOURCE: Kusari A et al. Pediatr Dermatol. 2018 Dec 12. doi: 10.1111/pde.13725



An old pediatric adage states that children are not little adults. From a skin standpoint, this can be further modified to: Premature infants are not little children. In the first weeks of life, premature skin may lack a cornified layer, and it certainly lacks full homeostatic competence. Kusari et al. have derived helpful guidance from 68 studies in the present meta-analysis. Less-frequent bathing decreased infection risk and lessened the chance of temperature instability that can attend a bath. Plant-based emollients were deemed superior to petroleum products; they were sufficiently hydrating and may not pose an equivalent infection risk. Kusari also cautions that there is no consensus regarding preprocedure skin sterilization with common products such as Chlorhexidine gluconate 0.5% or povidone iodine, as each can have risks (for example, irritation, thyroid suppression). More definitive is the recommendation for air drying the cord as opposed to antiseptic cleansing, which can delay separation. Guidelines for the care of premature skin, with attention to resource-limited populations, are needed.


Caption: MR. KUSARI

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Author:Sullivan, Michele G.
Publication:Dermatology News
Date:Jun 1, 2019
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