The planning and delivery of nursing care to critically ill neonates is a complex process that necessitates thorough, ongoing evaluation to determine effectiveness of both nursing and medical therapies. This unique evaluation takes into account (1) the frequent introduction of new treatment modalities, (2) the lack of verbal communication with the patient, (3) the narrow margin between safe and adverse responses to therapy, (4) the lack of disease-specific symptoms because of immature development, and (5) the patient’s extreme vulnerability, particularly in the most premature or sick infants.
Neonatal nursing involves a variety of unique functions, skills, and responsibilities that are essential in assessing, understanding, and safely supporting the newborn infant and family during this critical time. Neonatal intensive care unit (NICU) nurses must anticipate problems and systematically evaluate the infant and all the support systems to identify any new problems as early as possible. Each nurse completes the following head-to-toe assessment and prepares the associated documentation at least every 8 to 12 hours:
Observes physical characteristics such as color, tone, skin integrity, perfusion, and edema
Assesses organ systems, including chest auscultation, peripheral pulses, heart sounds, urine output, bowel sounds, and presence of reflexes
Checks patency and function of all intravascular devices and security of endotracheal tubes and other invasive devices
Verifies presence and appropriate function of all respiratory equipment and monitors
Assesses neurobehavioral activity, including level of pain or discomfort in relation to treatment
Describes parental contact and attachment behaviors
Thorough assessment by the NICU nurse is followed by the identification of specific patient problems that require either nursing or medical intervention. Once problems are identified, the process of planning and implementing of interventions is undertaken. The signs and signals that nurses perceive may be the first indication that a major problem is beginning.
The nurse is also responsible for the safe and appropriate use of technical equipment in the care of these critically ill newborns. Since the 1970s, the number of electrical devices used for a single patient has steadily increased, beginning with the use of a single warming device (the incubator) and progressing to the current standard use of 10 to 12 devices per patient. The nurse is responsible for using these devices with a level of expertise such that problems can be recognized. An essential component of the nursing role involves the relationship between the nurse and the parents and family of each infant. Because initial phases of attachment develop during this time of crisis, the whole family is in a vulnerable position as members begin to establish their relationship with the baby. The neonatal nurse assists the parents in beginning to know and appreciate their baby in a highly technical environment where touching and holding are sometimes difficult to accomplish (see Chapter 8 ). The modeling of communication and interaction with fragile newborns is a particularly effective method of assisting parents with this process. The explanation of the treatments and continual reinforcement of information provided by the infant’s physicians regarding current condition and prognosis are necessary during this crisis. Nurses often become a major source of social support, especially during long or complicated hospitalizations.
As the nurse cares for both the infant and the family, there is a delicate balance to achieve in preventing the mother from feeling jealous as well as inept. A positive comment by the nurse describing a caretaking task in which the mother was successful will certainly improve her self-esteem. Interviews of mothers following their baby’s discharge from the premature nursery often describe both jealousy toward the nurses caring for their infants and pleasure at how devoted and skilled the nursing staff was.
Neonatal nurses play a major role as protector, advocate, and, at times, nurturer to the infant in the NICU. Because the nurse’s scope of responsibility is limited to a small number of patients at any given time (generally two to three), and because of the need to be almost constantly present at the bedside of these patients, the nurse’s observations and evaluations often guide any interventions. For example, an observation regarding an infant’s adverse reaction to noise or handling may guide the team to alter interventions or physical examination. Nurses provide a vital link between the patient and the health care team through their knowledge, proximity to the patient, and skill at interpreting physiologic, behavioral, and technical information. The following discussion provides an overview of nursing practice that currently exists in the NICU, touching on four areas: developmental care, skin care, venous access, and iatrogenic complications.
A significant aspect of providing nursing care to infants in the NICU is to create an environment that reduces noxious stimuli, promotes positive development, and minimizes the negative effects of illness, early delivery, and separation from parents. Neonatal nurses have become increasingly concerned about the negative effects of the NICU environment and have begun to identify preventive strategies and integrate changes in this highly technical, over-stimulating environment.
Developmental care is the term used to describe interventions that can minimize the stress of the NICU environment. These include elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursing and medical interventions, and positioning the infant using swaddling or containment techniques. The Newborn and Infant Developmental Care and Assessment Program (NIDCAP) was designed to combine these elements in a way that is specific to individual infants, using a detailed assessment system.
Studies using NIDCAP methodology have reported improved developmental and medical outcomes for premature infants cared for in a developmentally supportive environment with caregivers specially educated in assessing premature infant behavior and modifying care practices to reduce negative or stressful responses. A Cochrane Systematic Review of 36 randomized controlled trials involving four major groups of developmental care reported limited benefit to preterm infants in the following areas: decreased moderate to severe chronic lung disease, decreased incidence of necrotizing enterocolitis, and improved family outcome. An increase in mild chronic lung disease and length of stay with developmental care compared to controls was also reported. There is limited evidence of improved neurodevelopmental behavioral performance. Reviewers identified a significant methodologic concern with these studies, in that the assessments were performed by non-blinded staff.
Despite ongoing skepticism and critique of developmental research, the modern NICU appears quite different than its predecessor: for example, dimmed lights, crib covers, swaddling and supported positioning, and dB meters are becoming familiar sights. The reactions of staff to reduced noise are reported to be positive, although reduced light levels are not as favorable.
Future research to better understand the effects and contributions of each intervention for the infant and NICU staff may provide more information about the impact of these interventions. The following section addresses the effects of noise, light, positioning, and handling during routine care, and it suggests modifications in each area that can reduce the detrimental effects.
Noise in the Neonatal Intensive Care Unit
Much of the technology used to support the newborn in the NICU generates a significant amount of noise and activity. Excessive noise can over-stimulate the premature or ill term newborn and lead to agitation and crying. This agitation has been shown to cause decreased oxygenation, increased intracranial pressure, elevated heart and respiratory rates, and increased apnea. Autonomic nervous system arousal using skin conductance measurements in response to a noise stimuli has been reported in premature infants, and correlates with increases in heart rate. Noise also disrupts the sleep-wake cycle and may delay recovery and the ability to have positive interactions with parents and caregivers because of fatigue and overwhelming overstimulation. Noise levels in the NICU range from 50 to 80 dB. Inside the incubator even higher levels are reached. Damage to delicate auditory structures has been associated with prolonged exposure to greater than 90 dB in adults. In neonates, the dB levels that result in hearing damage have not been identified.
Incubator motors generate an average of 55 to 60 dB; equipment and activity inside or around the incubator can add an additional 10 to 40 dB. Routine care activities such as placing glass formula bottles on the bedside table, closing storage drawers, or opening packaged supplies have been recorded at sound levels from 58 to 76 dB; alarms from intravenous (IV) pumps and cardiorespiratory monitors have also measured 57 to 66 dB. Noise from respiratory therapy equipment, monitors, staff talking, and infant fussiness also contribute to higher sound levels. The American Academy of Pediatrics Committee on Environmental Health expressed concern that exposure to environmental noise in the NICU may result in cochlear damage and may disrupt normal growth and development. The Committee to Establish Recommended Standards for Newborn ICU Design advises that average noise levels not exceed 45 dB, and intermittent high levels not reach 65 dB or greater. However, several studies report levels that are consistently higher despite renovations and other measures to address noise levels. Noise awareness educational programs may improve staff knowledge about the problem of noise in the NICU and result in strategies that improve environmental modifications.
Interventions to Reduce Noise Levels
Modify staff behaviors such as loud talk and playing radios near radiant warmers and incubators.
Institute “quiet hours” several times each day when noise-producing activities are curtailed and lights are dimmed.
Measure dB levels to identify baseline sounds as well as any problem areas and times.
If possible, avoid overhead paging systems.
Remove loud devices from patient care areas.
Observe carefully individual infant’s responses to auditory stimulation such as music boxes and tape recorders.
Consider offering only one sensory stimulus at a time, such as talking or singing without visual, tactile, or vestibular stimuli.
Gently open and close isolette doors.
Pad doors and drawers of storage closets.
Design NICUs with noise-absorbing materials.
The intensity of sound is expressed in dB and measured on a semi-logarithmic scale, which means that an increase of about 10 dB represents a doubling of the sound intensity. The 2006 Recommended Standards for Newborn ICU Design calls for NICU sound levels to remain below 50 dB the majority of the time. Infant sleep is usually not disturbed at this level. Much of the “background” noise in a typical NICU comes from the building itself —audible sound or vibrations from activity outside the hospital and from machinery within the hospital, and sounds generated by airflow through the heating, ventilation, and air conditioning system (HVAC). Without sufficient attention to these sources, the background noise in a NICU, even before any equipment or personnel are brought in, can be greater than 40 dB. Ventilators, CPAP, and compressed air all add to the noise levels as do monitors, alarms, telephones, and the staff talking and carrying out their duties. Hence, the recommended hourly loudness equivalent (Leq) of 45dB of acceptable noise (dBA), L10 of 50dBA and Lmax of 65dBA remains an elusive goal.
Light in the Neonatal Intensive Care Unit
The effect of continuous light exposure is another topic of interest when providing an environment that is developmentally supportive for babies in the NICU. Premature infants have thin, translucent eyelids that are ineffective in blocking light transmission, and have limited capacity for pupil constriction to modulate light; both of these deficits can interfere with sleep and rest.
Cycled lighting, involving periods of time with greater light intensity with periods of dim light, has been studied in the NICU population, and findings include increased organization of physiologic functions such as heart rate, respiratory rate, and energy expenditure. Thus, cycling of light periods should be considered in nurseries to help infants begin their regulation of sleep-wake periods.
Safe levels of light in the NICU have not yet been established and further research is needed to define the optimal approaches for lighting the immediate environment for the NICU patient. However, shielding infants from light in incubators or on warming tables is relatively easy and may prove beneficial in promoting rest, behavioral stability, and recovery. The use of fabric incubator and crib covers is common practice in today’s NICU, although the type of cover may be an important factor in reducing the light levels. One study found that covers made with dark fabrics are more effective than those made from light-colored or bright-patterned fabrics.
Interventions to Reduce Light Levels
Shade head of table, crib, or incubator whenever possible using cloth crib covers, blankets, or quilts; tenting over the head can be used if constant visual observation of the infant is needed.
When infants are stable, consider markedly reducing nursery light levels for 12-hour periods each day.
Consider individual lighting over each bedside with a dimmer switch to control light intensity and individualize lighting needs.
Because body alignment is known to affect many physiologic and neurobehavioral parameters, the positioning of neonates is important. Proper positioning can prevent postural deformities such as hip abduction and external rotation, ankle eversion, retracted and abducted shoulders, increased neck hyperextension and shoulder elevation, cranial molding, or dolichocephaly, and can improve neuromuscular development. Positioning can also alter respiratory physiology. Placing an infant in the prone position increases oxygenation, tidal volume, and lung compliance, and reduces energy expenditure when compared with the supine position.
Body position affects gastric emptying and skin integrity as well as neurobehavioral development. Activities such as hand-to-mouth ability, midline orientation, flexion, and self-soothing and self-regulatory abilities can be enhanced through facilitating body positions.
Head shape is also affected by positioning. Premature infants in particular are prone to develop dolichocephaly (narrow head shape) or plagiocephaly (asymmetrical head shape). These conditions can be avoided to some extent, or minimized by careful positioning. All infants should be placed in supine position for sleep before discharge from the NICU. This may require an adjustment period for some infants before they are comfortably sleeping in the supine position, so this is best undertaken before discharge from the NICU. Positioning a sleeping infant with rolls, nests and other containment devices are not appropriate for unmonitored infants, and should be discontinued well before discharge. Implementation of these recommendations remains inconsistent in NICUs because of knowledge deficits about the guidelines, and routines such as prone position for sleeping. Gestational age, degree of illness, and use of neuromuscular blocking medications all influence positioning decisions. Global hypotonia in infants younger than 30 weeks’ gestation requires significant intervention. Critically ill premature and term infants cannot expend any energy to move and require assistance to attain any body position. Infants receiving neuromuscular blocking agents, such as pancuronium, must receive positioning assistance to maintain basic physiologic stability. Thus, selecting an appropriate body position and assisting the patient into it are important considerations for nurses in the NICU.
Interventions to Position Neonates
Change the infant’s position every 2 to 3 hours for extremely ill or immature infants.
Promote hand-to-mouth behavior by allowing the hands to be free when the caregiver is present; side-lying positioning also assists in this goal.
Attempt to “nest” the infant with blanket rolls or other positioning aids ( Fig. 9-1 ).
Place rolls under the infant’s hips when the infant is prone to prevent hip abduction.
Roll the infant’s shoulders gently forward with soft rolls when both prone and supine to prevent shoulder extension.
Use water- or air-filled pillows under the infant’s head to minimize cranial molding; frequent position changes (every 2 to 3 hours) from side to side and midline also facilitate this goal.
Support the infant’s soles of the feet with rolls to prevent ankle extension.
Swaddle the infant with blankets or buntings when the infant is stable to promote flexion and self-regulatory behavior.
Consider gentle massage to promote skin blood flow in infants on neuromuscular blocking agents; reposition the infant every 2 hours to prevent pressure sores.
Position infants with right side down or prone to promote gastric emptying. Prone position is best for minimizing effects of gastroesophageal reflux. In preterm infants, it improves oxygenation.
Elevate head of bed after feedings to reduce pressure of full stomach against the diaphragm and improve respiratory capacity.
Hold stable infants, even when on the ventilator; holding may be soothing and provides vestibular stimulation similar to fetal experience.
Protection and preservation of the skin of term and premature newborns are significantly important, because this organ acts as a barrier against infection and is a major contributor to temperature control. It is a challenge to maintain the integrity of this delicate organ when providing care to premature infants in the NICU. Trauma to skin can occur when life support or monitoring devices that have been securely attached to the skin are removed or replaced, or when procedures such as blood sampling and chest tube insertion penetrate the skin’s barrier. Repair of the skin after tissue injury also requires a large consumption of energy. When the skin is damaged, evaporative heat loss and the risk of toxicity from topically applied substances are increased. In addition, there is an increased portal of entry for microorganisms including common skin flora such as coagulase-negative Staphylococcus and Candida . Thus, significant morbidity and even death can potentially be attributed to practices that cause trauma or alterations in normal skin function.
Developmental Variations in Premature Skin
The term infant has a well-developed epidermis, although structurally different from adult skin; the stratum corneum, the uppermost layer of the epidermis, is 30% thinner and contains keratinocyte cells that are smaller. As measured by transepidermal water loss (TEWL) techniques, full-term newborns have been shown to have similar barrier function compared to adult skin. However, there is now some evidence that the stratum corneum does not function as well as adult skin throughout the first year of life. The premature infant has fewer layers of stratum corneum and is histologically thinner, with the cells of all strata more compressed. This results in increased permeability and transepidermal water loss. Clinical implications of these differences include increased evaporative heat loss, increased fluid requirement, and risk of toxicity from topically applied substances. Despite acceleration in the maturation of the stratum corneum during the first 10 to 14 days of life in premature infants, higher transepidermal water losses, and decreased barrier function may last up to 28 days. In infants of 23 to 25 weeks’ gestation, skin barrier function reaches mature levels more slowly, taking as long as 8 weeks after birth, or until the infants reaches 30 to 32 weeks’ postconceptional age, regardless of the postnatal age.
In premature infants, the numerous fibrils connecting the epidermis to the dermis are fewer and more widely spaced than in the term infant. Thus, premature infants are more vulnerable to blistering and a tendency toward stripping of the epidermis when adhesives are removed because the adhesives may be more firmly attached to the epidermis than the epidermis is to the dermis.
The functional capacity of the skin to form an “acid mantle” also differs. Normally in both adults and children, skin surface pH is less than 5. In the term newborn, the pH immediately after birth is alkaline, with a mean pH of 6.34, with a decline to 4.95 within 4 days. Premature infants have been shown to have a pH greater than 6 on the first day of life, decreasing to 5.5 over the first week and gradually declining to 5 by the fourth week. Bathing and other topical treatments transiently affect the skin pH, and diapered skin has a higher pH due to the combined effects of urine contact and occlusion. An acid skin surface is credited with bacteriocidal qualities against some pathogens and serves in the defense against infection. A shift in skin surface pH from acidic to neutral can result in an increase in total numbers of bacteria, a shift in the species present, and an increase in transepidermal water loss.
Another developmental variation affecting newborn skin is the presence of vernix caseosa. Vernix is a protective fetal skin covering, unique to humans, that acts as a chemical and mechanical barrier in utero and facilitates postnatal adaptation to the extrauterine, dry environment. Production of vernix begins at the end of the second trimester, accumulating on the skin in a cephalocaudal manner. Vernix detaches from the skin as levels of pulmonary surfactant rise, resulting in progressively more turbidity of the amniotic fluid. Vernix contains antimicrobial peptides and proteins that may be protective against bacteria, assist in pH development, and assist in cleansing. Studies about this important substance are generating interest in the possibility of using vernix as a prototype of a new barrier cream to facilitate the development of the stratum corneum in premature neonates.
Skin Care Practices
Skin care practices performed daily by nurses in the NICU include bathing, moisturizing with emollients, antimicrobial skin preparation, umbilical cord care, and affixation of adhesives for life support and monitoring devices. These activities have the potential for causing trauma and altering the skin pH, thereby disrupting the barrier function of the skin. In 2001, two national nursing organizations in the United States, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN) collaborated on the formulation of evidence-based neonatal skin care guidelines that encompass these and other aspects of providing skin care to newborns. In 51 nurseries, the overall skin condition of 2820 newborn infants was evaluated in terms of skin dryness, erythema, and breakdown using the Neonatal Skin Condition Score (NSCS), and was found to be improved after each nursery implemented the evidence-based practices. The Neonatal Skin Care Guideline has recently been revised to include new studies pertinent to neonatal skin and skin care practices.
The daily bath is traditionally administered to all hospitalized patients, including newborns in the NICU. Newborns are bathed to remove waste materials, improve general aesthetic qualities, and reduce microbial colonization. Bathing full-term infants immediately after delivery can potentially compromise temperature regulation and cardiorespiratory stability, and should be delayed until the infant has achieved thermal and cardiorespiratory stability, and has had time for skin-to-skin contact with the mother.
Cleansers that are used for routine bathing include alkaline soaps, neutral pH synthetic detergents, and deodorant-type cleansers that contain antimicrobial properties. Bathing infants has been shown to cause an increase in the skin’s pH and a decrease in its fat content, most significantly with alkaline soap. Skin surface pH is enhanced if vernix is retained and not mechanically removed, even after bathing with a mild cleanser. Although some studies involve bathing with water alone in the first week of life, a comparison of four different bathing regimens including water alone, water plus washing gel, and water plus moisturizer—with or without the wash gel—fail to show significant influences on skin parameters, although the use of the moisturizer did transiently improve barrier function measurements. Water hardness, pH, and osmolarity are also potential irritants. In addition, washing with water alone may not remove some substances that soil the skin, are not water soluble but fat soluble, and there may be benefit from using a mild cleanser. Routine bathing should be no more frequent than every other day, as bathing does not reduce skin colonization with pathogenic microorganisms, leads to drier skin surfaces, and may lead to behavioral and physiologic instability. Premature infants less than 32 weeks are recommended to have water bathing only for the first 2 weeks of life due to considerations for their overall skin immaturity, as well as the potentially physiologic instability that may occur as a result of bathing.
Although the first and subsequent baths in many hospitals are sponge baths, tub or immersion bathing may be beneficial. Immersion bathing places the infant’s entire body, except the head and neck, into warm water (100.4° F), deep enough to cover the shoulders. A randomized controlled trial of immersion versus sponge bathing in 102 newborns for their first bath and subsequent baths showed that the immersion-bathed infants had significantly less temperature loss, appeared more content, and their mothers reported more pleasure with the bath; there was no difference in umbilical cord healing scores between immersion or sponge bathing. Bathing is also an opportunity to educate parents about how to physically care for their babies as well as integrating information about neurobehavioral status and social characteristics. Infants who may benefit from immersion bathing include healthy, full-term newborns with the umbilical clamp in place, and stable preterm infants after umbilical catheters are discontinued.
The degree of hydration in the stratum corneum is related to the capacity of this layer to absorb and retain water. Moisturizers improve skin function by restoring intercellular lipids in dry or injured stratum corneum. These are products such as emollients, creams, lanolin, mineral oil, or lotions; many include petrolatum as an ingredient because of its excellent hydrating and healing qualities.
Although there may be beneficial effects of routine emollient use in premature infants younger than 33 weeks’ gestation, an association has been shown between routine (twice daily) applications of petrolatum-based emollient and S. epidermidis blood stream infections in a randomized, controlled trial of 1191 premature infants less than1000 grams.
Routine use of an emollient to prevent or treat excessive drying, skin cracking, or fissures is not recommended. However, dry, scaling, or cracking skin will benefit from an emollient that is free of perfumes or dyes; products containing perfumes or dyes that can be absorbed and may result in later sensitization or toxicity are not recommended.
Use of skin disinfectants before invasive procedures is commonplace in hospitalized full-term and premature newborns. The most common disinfectants that are used in newborns include 70% isopropyl alcohol, povidone-iodine, and chlorhexidine gluconate, both an aqueous solution and one combined with 70% isopropyl alcohol. There have been anecdotal reports of skin blistering, burns, and sloughing from isopropyl alcohol and chlorhexidine gluconate products in premature infants. Povidone-iodine has been associated with case reports of high iodine levels, iodine goiter, and hypothyroidism. Several prospective studies of routine povidone-iodine use in neonatal intensive care units found elevated urinary iodine levels and alterations in thyroid function in premature infants because of iodine absorption through the skin.
A sequential study of 254 premature and term infants in the NICU found IV catheter colonization to be reduced in sites prepared with 0.5% chlorhexidine in alcohol solution compared with povidone-iodine.
Because of the risk of skin injury from isopropyl alcohol and methanol-containing chlorhexidine gluconate products, there is currently no single disinfectant that can be recommended for all neonates. Aqueous 2% chlorhexidine gluconate is available in 4 ounce bottles and must be poured onto a sterile gauze sponge for application, and 2% chlorhexidine gluconate in 70% isopropyl alcohol is available in single-use products but is approved by the U.S. Food and Drug Administration (FDA) only in infants older than 2 months of age. Although some nurseries elect to use this product “off-label,” there is significant risk of skin injury in prematures infants. Many nurseries continue to use 10% povidone-iodine. When any of the skin disinfectant solutions are used, it is necessary to remove the preparation completely when the procedure is finished. Water or saline is preferred for removing disinfectants to reduce the risk of further skin injury from these caustic preparations.
Adhesive Application and Removal
Traumatic effects of adhesive removal for premature infants include reduced barrier function, increased transepidermal water loss, increased permeability, erythema, and skin stripping. Solvents have been used in hospitals for a number of years to remove tape and adhesives. Although effective, these products should not be used in the premature infant because of the risk of toxicity from absorption and because of the potential for skin irritation and injury. Bonding agents that increase the adherence of adhesives may also cause more skin stripping and damage because they form a stronger bond between the adhesive and the epidermis than the fragile bond between epidermis and dermis, especially in the premature infant. Plastic polymer skin protectants are available to protect skin from adhesives and do not increase adhesive aggressiveness. Products that do not contain isopropyl alcohol are preferred because the alcohol can also irritate newborn skin.
Skin barriers made from pectin and methylcellulose are used between skin and adhesive; they mold well to curved surfaces, and maintain adherence in moist areas. Although there is less visible trauma to skin with pectin barriers, evaporimeter measurements of skin barrier function shows that pectin causes a similar degree of trauma as commonly used plastic tape. Even more mature newborns are at risk for trauma from adhesive removal. However, hydrocolloid products continue to be helpful in the hospitalized newborn owing to improved adherence as the product warms to skin temperature, and the ability to mold to surfaces better than many other products. These adhesives do require care on removal, similar to adhesive tapes.
Transparent adhesive dressings made from polyurethane are impermeable to water and bacteria but allow the free flow of air, thereby enabling the skin to “breathe.” Uses for transparent dressings include securing IV catheters, percutaneous catheters, and central venous lines, nasogastric tubes, and nasal cannulas. They can also be used to prevent skin breakdown over areas that have the potential for friction burns or pressure sores, such as the knees, elbows, or sacrum, or as a dressing over surface injuries. Semipermeable dressings have proven to be very beneficial for selective taping procedures, such as IV and central venous catheter dressings, nasogastric tubes, and chest tubes. The potential for skin damage when removed is similar to other adhesive tapes.
Preventing trauma from adhesives can be accomplished by minimizing use of tape when possible, dabbing cotton on tape to reduce adherence, using hydrogel adhesives for electrodes, and delaying tape removal for more than 24 hours when the adhesive attaches less well to skin. Removal can be facilitated by applying warm water or an emollient or mineral oil if reapplication of adhesives at the site is not necessary. Slowly pulling adhesives at a very low angle, parallel to the skin surface, while holding the surrounding skin in place may reduce epidermal stripping. Silicone-based adhesives are primarily used in wound care products, although silicone tapes are also available and have been shown to improve adherence to wounds and reduce discomfort when removed. This technology holds promise for developing future adhesive products for newborns.
Skin Care Recommendations
Bathing: Use neutral pH cleansers on infants. Bathe the infant with cleansers infrequently—two to three times per week; at other times, use warm water baths. For infants with very immature skin, less than 32 weeks’ gestation, clean with warm water and cotton balls for the first week.
Moisturizers: Use a petrolatum-based, water-miscible emollient that does not contain perfume or dyes. Apply moisturizer sparingly to cracked or fissured areas on an as-needed basis. If the infant’s skin is colonized with Candida , use antifungal ointment instead of petrolatum-based ointment. Routine use of emollients in infants less than 1000 grams is not recommended.
Antimicrobial skin preparation: Use aqueous chlorhexidine or povidone-iodine solution before any invasive procedure that penetrates the skin surface; remove the solution completely with water or saline. Avoid the use of isopropyl alcohol to remove skin disinfectants.
Adhesives and adhesive removal: Limit the amount of tapes and adhesives used to secure equipment. Do not use solvents, but remove tape with water-soaked cotton balls. Tincture of benzoin and other bonding agents are not routinely recommended for very immature infants because this can create a stronger bond of adhesive to the epidermis than the bond between epidermis and dermis. Consider use of hydrocolloid adhesives, such as pectin barriers, between tape and skin for better adherence. Use hydrogel adhesives for electrodes, soft gauze wraps for pulse oximeter probes, and transparent adhesive dressings to secure IV catheters, central venous catheters, nasogastric tubes, or oxygen cannulas.