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Introduction
Preserving the skin integrity of the neonate is important to maintain the function of the skin, protect
against potential wounds and avoid skin disorders in the future.
Aim
Definition of Terms
Preterm baby Less than 37 weeks gestational age
Term baby 37- 40 weeks gestational age
Neonate Less than 4 weeks age (post term)
Infant Young children, 1 month to 12 months age
TEWL Trans Epidermal Water Loss
Atopy Predisposition toward developing certain allergic hypersensitivity reactions
Emollient A substance that softens & moisturizes the skin
Erythema Redness of the skin
Stratum Corneum (SC) The outermost layer of the epidermis acting as a mechanical barrier
Xerosis Skin dryness
Assessment
Assess skin condition on admission and commencement of each shift (and at each nappy change as
needed). Be proactive. Observe and clean areas such as the neck, behind the ears, axillae and groin.
Dry, red or itchy skin is an indication that skin integrity may be impaired. If a pustular, vesicular or purulent
skin lesion is noted, communicate with the appropriate medical team for management.
Consider the following factors that may increase the risk of skin trauma and breakdown;
Prematurity
Adhesive removal
Environmental humidification
Nappy rash
Nutritional status
Management
To maintain skin integrity and minimise heat loss consider the following -
Bathing
Ensure vital signs and temperature are stable before first bath
Newborns may be bathed after 1 hour of age when appropriate care is taken to support
thermal stability. To minimise heat loss after first bath, immediately put a nappy and hat on and
wrap in warm blankets. When infant temperature is within normal limits (after approximately 10
minutes) dress and re wrap in dry warm blankets
Use a water depth deep enough to allow the infants' shoulders to be well covered
Carefully dry the skin folds including armpits, groin, neck and behind the ears
Keep cord area clean with water. No need for alcohol wipes
Cleanse with water and pH neutral cleanser if soiled with urine or stool
The cord usually separates from the baby 7 to 10 days after birth
Emollients
At the first sign of dryness, fissures or flaking, apply an emollient twice a day or as
needed
Emollients should not be shared and always dispensed from a hospital pharmacy in
patient-specific containers
Spoon emollient on to paper towel prior to use (to maintain sterility of the container)
Emollients are safe to be used for infants under radiant heat or for infants receiving
treatment such as phototherapy
Assess neonate for risk factors for skin breakdown. ie. loose stools, frequent stooling,
drug withdrawal, medications that alter stool frequency or composition. Monitor skin condition
closely
Nappy wipes may cause irritation and should be reserved for healthy looking skin
Gently clean nappy area with water and Rediwipes or cotton wool
A pH neutral cleanser, sorbolene cream, aqueous Cream or olive oil may be used to help
cleanse the nappy area
To maintain skin integrity, apply a thick barrier cream that contains zinc oxide at every
nappy change
Complete removal of barrier ointments with nappy changes is not necessary, rather apply
another layer
Assess for presence of infection ie candida albicans, and need for topical antifungal
Do not use creams with fragrances or unnecessary additives such as tea tree oil
If the area is red, a mild hydrocortisone 1% ointment may need to be applied bd, prn e.g.
Sigmacort 1% ointment. A prescription is not needed for this
Examples of appropriate barrier creams: 10% Olive Oil in Zinc Paste, Covitol, Desitin, Sudocream,
Bepanthan Nappy Ointment
Adhesives
A semipermeable dressing should be used between the skin and adhesive to secure
nasogastric tubes, intravascular devices, nasal cannulas or central venous catheters
Barrier films should not be used on premature neonates or infants < 4 weeks of age (ie.
Smith & Nephew Skin Prep Protective Barrier Wipes, Convacare Protective Barrier Wipe, 3M
Cavilon No Sting Barrier Film )
Gently and slowly remove adhesives with warm water soaked cotton balls, peeling back
parallel to the skin surface. Avoid solvents
Solvents (ie. Convacare wipes) must not be used on premature neonates. If required to
aid adhesive removal on term neonates, the area should be rinsed with warm water immediately
after use
Use wraps such as stretchy gauze or Koban to anchor probes, electrodes or limbs to arm
boards
Ensure vital signs and temperature are stable before the first bath.
Neonates <1000g or < 32 weeks sponged in plain water only every 3-4 days.
Use soft materials such as cotton balls. Avoid rubbing. Consider immersion
bathing for stable infants >1800g
Emollients should not be part of routine care for infants 23-30 weeks'
gestation. TEWL may be reduced by other means ie. Humidity
No nappy wipes. Cotton wool and olive oil /water only to cleanse the
nappy area
Extravasation Care
Wound Care
A common condition affecting as many as half of all full term newborn infants. 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.
Treatment: The infant is otherwise well and requires no treatment.
Neonatal Milia
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.
Treatment: Lesions will heal spontaneously within a few weeks of birth.
Arises from occlusion of the sweat ducts. In infants lesions commonly appear on the neck, groins and
armpits, but also on the face.
Clinical features: 1-3mm papules (vesicular or papular).
Treatment: Remove from heated humid environment or adjust incubator temperature. Cool bathing or
apply cool compresses. Topical steroids may be used to facilitate relief while the condition resolves.
Pityrosoprum folliculitis
Infantile acne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the
newborns' 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.
Treatment: Will resolve within weeks without treatment or may be treated with ketoconozole shampoo
(eg. Sebizole shampoo) diluted 1:5 with water, applied with a cotton bud twice a day. Rinse off with water
after 10 minutes. Or apply Hydrozole cream bd to the affected areas until the rash has resolved.
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal___Infant_Ski
n_Care/
The Royal Children's Hospital Melbourne