Journal of Perinatology (2014) 34, 161163

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PERINATAL/NEONATAL CASE PRESENTATION

Clinical experience with Leptospermum honey use for treatment of
hard to heal neonatal wounds: case series
V Boyar1,2, D Handa1, K Clemens3 and D Shimborske3

Preterm, critically ill neonates represent a challenge in wound healing. Many factors predispose infants to skin injuries, including
decreased epidermaldermal cohesion, decient stratum corneum, relatively alkaline pH of skin surface, impaired nutrition and
presence of multiple devices on the skin. We present a case series describing the use of medical-grade honeyLeptospermum
honey (Medihoney), for successful treatment of slowly healing neonatal wounds, specically stage 3 pressure ulcer, dehiscent and
infected sternal wound, and full-thickness wound from an extravasation injury.

Journal of Perinatology (2014) 34, 161163; doi:10.1038/jp.2013.158

Keywords: Medihoney gel; prematurity; skin breakdown; wound healing; wound dehiscence

INTRODUCTION
There is an increased awareness that premature babies and
neonates born with congenital defects are at increased risk for
skin breakdown. Many factors predispose neonates to skin injuries,
including decreased epidermaldermal cohesion, decient stra-
tum corneum, more alkaline pH of skin surface, poor nutrition,
relatively immature immune system and large areas exposed to
equipment. As technology brings cure, it also brings risk factors,
such as adhesives that strip epidermal layers, catheters that
increase risk for extravasations and devices that place pressure
and friction stress on vulnerable skin.
In our experience, hydrogel covered with hydrocolloid or
silicone dressing is often sufcient to heal neonatal skin break-
down, but occasionally stalled or difcult-to-treat wounds present
a diagnostic challenge. Recently medical honey gained attention
in the adult community as a treatment for various dermatologic
conditions. We introduce a new approach (for the neonatal
community) to treatment of various neonatal skin breakdowns
using active Leptospermum honey, a medical-grade honey
(Medihoney Derma Sciences, Princeton, NJ, USA), the only honey
cleared by FDA for treatment of various dermatologic conditions
in adults. There are no known contraindications for pediatric or
neonatal use, other than allergy to honey. We present three
successfully treated cases, including stage 3 pressure ulcer,
dehiscent and infected sternal wound, and extravasation-related
full-thickness wound.
CASE
Case 1. Stage 3 pressure ulcer
Three-month old, former 28-week gestation male born with
double outlet right ventricle, VSD and right ventricular outow
tract obstruction. On DOL#80, he was taken to the catheterization
lab for ballooning of the pulmonary valve. After the procedure he
experienced decreased pulses on the right lower extremity with
delayed capillary rell. Treatment included low-dose heparin,
followed by low molecular weight heparin. Two weeks into this
1
Division of Neonatal-Perinatal Medicine, Department of Pediatrics, New Hyde Park, NY, USA; 2Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA and 3Department
of Nursing Cohen Childrens Medical Center of New York, New Hyde Park, NY, USA. Correspondence: Dr V Boyar, Department of Pediatrics/Neonatology, Steven & Alexandra
Cohen Childrens Medical Center of NY, North Shore LIJ System, 269-01 76 Ave, New Hyde Park, NY 11040, USA
Received 28 June 2013; revised 22 October 2013; accepted 23 October 2013
treatment, a right leg stage 3 pressure ulcer was noted in the
lower right calf (Figure 1a). His initial treatment involved
application of hydrogel covered by a hydrocolloid dressing. After
two weeks of such treatment and minimal improvement,
Medihoney gel, covered with Medihoney infused hydrocolloid
(MHCS) and an outer dressing was initiated. Medihoney gel
was applied every three days for the rst two weeks. By the
end of the second week substantial granulation and new
epithelialization was noted. The dressing application was changed
to once a week, and by the end of the fourth week the wound was
closed, with increasing natural pigment distribution and soft scar
(Figure 1b).
Case 2. Dehisced and infected surgical wound
Three-month old, former 36-week gestation female was born with
a diagnosis of hypoplastic left heart syndrome, double outlet right
ventricle, unbalanced AV canal and partial trisomy 16. Following
the rst stage Norwood repair and Sano shunt placement at two
weeks of age, she developed a sternal wound dehiscence and
secondary bacterial infection. The wound measured 2  11 cm
with slough, exudate and sternum exposure. Initially hydrogel
covered by silicone dressing was used without success. After 10
days, continuous negative pressure wound therapy at 50 mm Hg
was started. Minimal slough removal and few new granulation
areas were noted after two weeks (Figure 2a). Negative pressure
wound therapy was discontinued. Medihoney gel along with
MHCS were applied to the area and covered with silicone dressing.
The dressing was changed every three days. Noticeable improve-
ment was seen in the rst week and the wound had completely
healed by week three (Figure 2b).
Case 3. Full-thickness wound from extravasation injury
Three-week old former 26-week female was born due to preterm
labor and maternal sickle cell disease crisis. At three weeks of age,
a stage 4 right ankle peripheral IV extravasation injury was found.
For the rst 24 h it presented as a large, uid-lled bulla. The bulla
 Clinical experience with Leptospermum honey in neonatal wound healing
V Boyar et al
162
Figure 1. (a) Stage 3 pressure ulcer: minimal healing after 2 weeks of
hydrogel and silicone dressing. (b) At the end of 4 weeks with
Medihoney: note pigmented epidermis.
ruptured the following day and evolved into full-thickness wound,
with areas of slough and exudate. Medihoney gel was started on
day 2, covered by a hydrocolloid dressing. It was reapplied every 3
days for the rst 10 days. New granulation tissue and decrease in
exudate were noted by day 6. Less discomfort with motion and
less periwound edema was noted as well. After 10 days dressing
was changed once weekly, and by 3 weeks the wound had healed
with full range of motion and soft pink scar.
DISCUSSION
Preterm neonates represent a unique group of patients as their
immature skin, compromised perfusion, limited mobility, sub-
optimal nutritional status and need for multiple devices may lead
to slow wound healing. Treatment for pressure ulcers, extravasa-
tion injuries and dehisced wounds often involves application of
hydrogel/hydrober, covered by ether hydrocolloid or silicone
dressing. The aim is to ll dead space, maintain moist wound
environment, induce new epithelial tissue growth and protect the
wound from infection and trauma. Stage 1 and 2 pressure ulcers
or partial thickness wounds should show evidence of healing
within 1 to 2 weeks, while stage 3 and 4 ulcers/full-thickness
wounds should show evidence of healing within 2 to 4 weeks.13
Specically for ulcers it has been demonstrated that healing less
than 0.1 cm per week predicts high risk for non-healing at 6
months.4 There are various reasons for poor healing, including
impaired perfusion and oxygenation, non-resolved inammation,
presence of proteases and recurrent physical trauma.
The use of medical-grade honey in wound healing has been
traced many centuries back to Medieval Europe and ancient
Egypt. The unique properties of medical honey explain its ability
to treat various types of skin injuries.57 Honey is a mixture of bee
Journal of Perinatology (2014), 161 163
Figure 2. (a) Sternal wound after 2 weeks of negative pressure
therapy and 2 weeks of hydrogel/silicone dressing combination:
Slough present. Sternal bone is visible. (b) Week 3 with Medihoney
gel and MHCS: complete healing. MHCS, Medihoney infused
hydrocolloid.
saliva and nectar. We know that honey is about 20% water and
80% sugar, with certain enzymes added by the bees.8 Medihoney
Antibacterial Wound gel consists of 80% Leptospermum honey,
15% Myristyl Myristate and 5% Plantacare (natural vegetable
derived esters for emulsication and stability). Leptospermum
honey is known to possess specic properties that make it an ideal
therapeutic agent. It possesses antimicrobial activity due to its
high osmolality (high sugar content) which suppresses bacterial
growth. One of the enzymes added, glucose oxidase, converts
glucose to gluconic acid, making the honeys pH (3.5 to 3.9) too
acidic for bacteria.79 Bees add natural hydrogen peroxide to the
honey and naturally occurring phytochemicals also are thought to
be antibacterial. Honey decreases natural biolm formation. It has
an anti-inammatory activity because the high osmolality of the
honey draws water out of the wound and reduces edema. Lastly, it
is autolytic because it creates moist environment that enhances
autolysis; increasing lymph uid that delivers plasminogen.
Plasminogen is converted to plasmin thereby increasing degra-
dation of brin strands in the slough. Medihoney undergoes
gamma irradiation to inactivate any microorganisms that may be
present, such as Clostridial spores.10
During our case series, we dealt with very compromised,
critically ill preterm babies. Medihoney products demonstrated
ease of use, decreased pain with dressing changes, timely wound
closure and no side effects in our patients. For these reasons,
Medihoney was added to our formulary. Recently, we started
using honey products as a rst-line therapy for stage 2 and higher
pressure ulcers, extensive extravasation injuries and open surgical
wounds. Time to closure seems superior to previous practice
(hydrogel plus secondary dressing). This may translate to cost
advantages. We recommend considering medical-grade honey
when faced with difcult-to-treat neonatal/pediatric wounds.
& 2014 Nature America, Inc.

CONFLICT OF INTEREST
The authors declare no conict of interest.
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