Skin Of Premature Infants Research Articles

Review Article: Skin Condition and Skin Care in Premature Infants

Background: The majority of newborn skin care recommendations focus on concerns for healthy, full-term infants. Compared to mature infants, the skin of premature infants, those who are born at the gestational age of 37 weeks, is more vulnerable to injury, transepidermal water loss (TEWL), and transepidermal intoxication. There are no established guidelines for premature infant skin care. Discussion and review regarding this topic are needed. Purpose: To review the literature on skin conditions and skin care in premature infants. Review: The barrier function of premature skin is significantly compromised because the stratum corneum does not fully mature until late in the third trimester. Premature infants have immature skin with impaired barrier function characterized by high TEWL, increased absorption of chemicals, and increased risk of infection. Some particular issues in premature infant skin are controlling TEWL, avoiding mechanical damage, proper sterilization to control infection, awareness of percutaneous drug toxicity, appropriate bathing and umbilical cord care, and appropriate management of skin problems. Conclusion: Premature infant skin is more vulnerable due to immature development. Skin care for premature infants requires careful attention.

Biomarkers of neonatal skin barrier adaptation reveal substantial differences compared to adult skin

BackgroundThe objective of this study was to measure skin characteristics in premature (PT), late preterm (LPT), and full-term (FT) neonates compared with adults at two times (T1, T2).MethodsSkin samples of 61 neonates and 34 adults were analyzed for protein biomarkers, natural moisturizing factor (NMF), and biophysical parameters. Infant groups were: <34 weeks (PT), 34–<37 weeks (LPT), and ≥37 weeks (FT).ResultsForty proteins were differentially expressed in FT infant skin, 38 in LPT infant skin, and 12 in PT infant skin compared with adult skin at T1. At T2, 40 proteins were differentially expressed in FT infants, 38 in LPT infants, and 54 in PT infants compared with adults. All proteins were increased at both times, except TMG3, S100A7, and PEBP1, and decreased in PTs at T1. The proteins are involved in filaggrin processing, protease inhibition/enzyme regulation, and antimicrobial function. Eight proteins were decreased in PT skin compared with FT skin at T1. LPT and FT proteins were generally comparable at both times. Total NMF was lower in infants than adults at T1, but higher in infants at T2.ConclusionsNeonates respond to the physiological transitions at birth by upregulating processes that drive the production of lower pH of the skin and water-binding NMF components, prevent protease activity leading to desquamation, and increase the barrier antimicrobial properties.ImpactNeonates respond to the transitions at birth by upregulating processes that drive the production of lower pH of the skin and NMF, prevent protease activity leading to desquamation, and increase the antimicrobial properties of the barrier.The neonatal epidermal barrier exhibits a markedly different array of protein biomarkers both shortly after birth and 2–3 months later, which are differentially expressed versus adults.The major biomarker-functional classes included filaggrin processing, protease inhibitor/enzyme regulators, antimicrobials, keratins, lipids, and cathepsins.The findings will guide improvement of infant skin care practices, particularly for the most premature infants with the ultimate goals mitigating nosocomial infection.

Premature infant skin barrier maturation: status at full-term corrected age.

To evaluate the effects of gestational age (GA) and postnatal age on skin barrier integrity by comparing premature infants at full-term corrected age with infants born at term. Parallel comparison of chest skin in 36 premature infants with 39 full-term infants using daily measures of transepidermal water loss (TEWL), skin pH, erythema and rash, over 2 weeks. Chest skin pH was significantly lower for premature infants, indicating that acid mantle formation had occurred in the premature versus full-term infants. Chest TEWL was significantly higher for premature versus full-term infants over 2 weeks, suggesting that even 7-8 weeks after birth, skin integrity is poorer in premature infants. Skin barrier properties of premature infants at adjusted full-term age differ from full-term infants, suggesting that epidermal barrier development depends on GA and time from birth. These maturational differences may influence premature infant response to topical agents.

The science behind wet wipes for infant skin: Ingredient review, safety, and efficacy.

In the diapered area, the continuous exposure to excess moisture and irritants from urine and feces weakens the stratum corneum, making the skin more susceptible to irritation. The use of wet wipes for infants (baby wipes) is a common practice to clean skin after urine or a bowel movement, and this practice even extends to cleaning the hands and face, resulting in repeated daily use. Therefore, ensuring that baby wipes contain ingredients that are safe and mild on skin is important to help minimize skin irritation and discomfort. While disposable baby wipes have been shown to be effective and gentle at cleaning infant skin, even the skin of premature infants, there is growing public concern regarding their safety and tolerability. Not all products are made the same, as differences exist in manufacturing processes, ingredients, materials, safety, and quality testing. Therefore, it is important that healthcare professionals have accessible evidenced‐based information on the safety and tolerability of common ingredients found in baby wipes to optimally educate their patients and families. Herein, we provide a review on best practices for ingredient selection, safety, and efficacy of baby wipes.

Implications of chlorhexidine use in burn units for wound healing.

Chlorhexidine is known to be a potent antiseptic with evidence of a beneficial role in burn care. Nevertheless, several in vitro studies have reported cytotoxicity on cultured cells, while in vivo and clinical data seem to show more controversial results. In the frame of this work, we aimed to evaluate the use of chlorhexidine in burn units worldwide be sending a survey to professionals of the field. We associated survey results to those perspectives reported in the literature to update recommendations for the use of chlorhexidine in specific protocols for burn management. The survey results showed that there is no clear consensus on the use of chlorhexidine regarding the concentrations, the type of excipient and the cleansing after application. Literature searches showed evidence that the skin of premature infants appears to be more sensitive to chlorhexidine that adult skin, with more reported cases of adverse effects. It was also determined that aqueous formulations of chlorhexidine do not appear to be necessarily less efficient than with alcohol as an excipient, and that lower concentrations are as efficient as higher concentrations. In view of this study, we have adjusted our protocols for the use of aqueous formulations at low concentrations and investigated further the role of washing after application in order to standardize the indication of chlorhexidine and minimize the probability of adverse effects.

Benefits of Using an Appropriately Formulated Wipe to Clean Diapered Skin of Preterm Infants.

The skin of premature infants is underdeveloped rendering it more prone to break down and irritation. Therefore, special care is needed to protect premature skin and ensure it is not adversely affected. Many health care professionals advise using just water and cloth to clean diapered skin after a bowel movement despite evidence that shows improved infant skin health with the use of modern appropriately formulated baby wipes. This article describes the unique physiology of premature infant skin, reviews clinical evidence comparing use of baby wipes to water and cloth, and describes attributes of appropriately formulated baby wipes.

An in vitro Skin Penetration Model for Compromised Skin: Estimating Penetration of Polyethylene Glycol [14C]-PEG-7 Phosphate

Background/Aims: Establishing dermal penetration rates is important to better understand the safety of topically applied materials, especially for premature infant skin with compromised skin barrier function. Skin prematurity involves thinner stratum corneum and underdeveloped epidermis/dermis resulting in decreased barrier function, higher transepidermal water loss and greater chemical penetration, when compared to healthy full-term neonate/adult skin. Methods: We developed an in vitro skin penetration model using human ex vivo skin to estimate penetration for premature/compromised skin barrier conditions by tape stripping. Skin barrier deficiency was characterized by transepidermal water loss. Baby wipe lotion containing 5 mg/cm² [¹⁴C]-PEG-7 phosphate was applied 5 times to human skin samples of intact, moderately or highly compromised skin barrier and once at 25 mg/cm² over 24 h. Results: Overall penetration of [¹⁴C]-PEG-7 phosphate was low (<5%) even for highly compromised skin. The absorption rate was higher (p < 0.001) for compromised skin versus intact skin. No significant difference was seen between moderately and highly compromised skin by repeated dosing. Under single-dose conditions, penetration through highly compromised skin was significantly higher compared to intact skin (p = 0.001). Conclusion: Our model demonstrates that even under highly compromised skin conditions, penetration of [¹⁴C]-PEG-7 phosphate is low (<5%) and only 4-6 times higher compared to mature/intact skin and does not approach 100%. Penetration was unaffected by single or multiple dosing conditions.

317 The Effect of Human Red Cells Storage Time on the Microcirculation of Preterm Infants

Background: Red blood cell (RBC) transfusion practices for neonates are controversial, variable, and based on limited scientific information. To decrease donor exposure satellite packs are used leading to the transfusion of older RBCs. Transfusion of stored RBCs in a hemodiluted animal resulted in significant malperfused and underoxygenated microvasculature that was not detected at the systemic level. Objective: Does the age of transfused erythrocytes influence functional vessel density (FVD) in the skin in premature infants?. Design Methods: 17 preterm infants with birth weight < 1500g received RBC transfusion, 11 infants repeatedly from the same donor. The age of RBCs at repeated transfusions was significant higher than at the first transfusion. Using Sidestream Dark Field Imaging all preterm infants were examined before and 2, 24 and 48 hours after transfusion. Images were blinded and analyzed with Microvision Analysis Software. Results: FVD before first and repeated transfusion did not differ. In the 2nd, 24th and 48th hour after the treatment the Functional Vessel Density (FVD) was significantly lower after the repeated transfusion with longer storage time (2nd: 250 vs. 238 cm/cm2, p=0.045; 24th: 259 vs. 231 cm/cm2, p=0.001; 48th: 234 vs. 220 cm/cm2, p=0.035). The proportion of vessels with altered sluggish blood flow was also significantly higher when older RBCs were transfused (24h: 0.3% vs 2.5%, p=0.017; 48h: 1% vs. 3.3%, p=0.013). Conclusions: Similar to the animal model longer storage of the red blood cells reduces functional vessel density in the skin of premature infants and more vessels display sluggish blood flow.

Tratamiento con vaselina estéril para lesión por extravasación en un prematuro

The skin of premature infants is an ineffective barrier. The stratum corneum is thinner than that found in full-term infants. We report on a premature patient with extravasation injury from sodium bicarbonate. Daily treatment with sterile petrolatum resulted in restitutio ad integrum.

Effect of Less Frequent Bathing on Premature Infant Skin

To evaluate the effect of less frequent bathing on skin flora of premature infants. Randomized clinical trial comparing the impact of every other day bathing to every 4th day bathing on skin flora type and colony count. University of California, San Francisco, Medical Center Level IV neonatal intensive-care unit. Fifty-three premature infants less than 37 weeks gestational age, 14 days or older, and receiving a bath. Premature infants were randomized to either every other day bathing (control group, n = 28) or every 4th day bathing (intervention group, n = 25). Skin flora type and colony count obtained weekly. Repeated-measures ANOVA was used to test the main effect of group, time, and Group x Time interaction. These factors were not statistically significant; group F(1,21) = 1.842, p = .189; time F(3,63) = 1.359, p = .263; Group x Time interaction F(3,63) = 0.753, p = .525. None of the infants developed an infection as a result of participating in the study protocol. Every 4th day bathing of premature infants appears to be safe.

Fiberoptic and conventional phototherapy effects on the skin of premature infants

To evaluate the effects of conventional phototherapy and fiberoptic phototherapy on trans-epidermal water loss in preterm infants with and without skin ointment application, 20 infants were randomly assigned to receive conventional or fiberoptic phototherapy for non-hemolytic hyperbilirubinemia. After conventional phototherapy, there were no significant differences in trans-epidermal water loss between ointment-treated and untreated areas. After fiberoptic phototherapy, trans-epidermal water loss significantly increased from ointment-treated and untreated areas, but the increase was less in treated areas. (J Pediatr 2001;138:438-40)

Neonatal dermatology.

Recent advances in neonatology and dermatology have provided us with a better understanding of neonatal and premature infant skin. The problems associated with immature skin become evident immediately after birth and require constant attention throughout the neonatal period. As advances in neonatal care push the gestational age of viability lower, skin maturation and function become increasingly important clinical problems. Premature skin immaturity contributes to elevated water loss, problems with electrolytes and thermoregulation, increased risk of local or systemic infection, increased uptake of potentially toxic agents, and vulnerability to trauma. This review discusses the unique nature of dermal structure and function in very low birth weight infants, evidence of mechanical fragility, toxicity of various topical agents, and the use of emollients. The opinions expressed are those of the authors and do not necessarily represent the views of the Navy or Department of Defense.

Dynamic programming approach for newborn's incubator humidity control

The anatomy, physiology, and biochemistry of the human skin have been studied for a long time. A special interest has been shown in the water permeability of the premature infant's skin, which is known to be an important factor in the maintenance of a controlled water and heat balance. The rate of evaporative heat exchange between the skin surface of a very premature infant and the surrounding incubator air may be so high that evaporative heat loss alone may exceed the infant's total metabolic heat production. However, it has been demonstrated in several investigations published in recent years that basal evaporative water loss can be consistently reduced by increasing the ambient humidity. Nevertheless, the passive humidification system (water reservoir) used in most incubators cannot achieve high and steady humidity levels. In this paper, we propose an active humidification system. The algorithm is based on a combination of optimal control theory and dynamic programming approach. The relative-humidity (R.H.) regulation is performed in range of 35-90% at 33 degrees C with small oscillations (+/- 0.5% R.H.) around the reference value (i.e., prescribed R.H.).

Wound healing in neonates.

An outline of skin development in the fetus and potential causes of injury to the skin of premature infants, with a discussion of strategies for minimising the damage

Percutaneous Drug Absorption in the Newborn: Hazards and Uses

The newborn infant's skin is not a complete barrier to the absorption of externally applied agents, particularly if it is damaged, diseased, or immature. Immaturity is the most important factor that determines percutaneous absorption. Very immature infants in the early neonatal period have a poorly developed epidermis, which is readily permeable to drugs. The main consequences of percutaneous absorption are hazardous. Topically applied agents are absorbed, causing toxic systemic effects that may result in illness and even death without the cause being recognized. No drug or antiseptic agent should be applied to the premature infant's skin without consideration of the effects that might result from percutaneous absorption. On a more optimistic note, the relatively permeable skin could be an advantage to the preterm infant by providing an alternative method of drug administration. The drug theophylline for example can be absorbed and produce therapeutic blood levels for up to 3 days after a single topical application. There is a need for the development of transdermal drug delivery systems for the newborn infant similar to those currently used for therapy in adults.

Development and care of the premature infant's skin.

Recent advances in neonatal care have greatly decreased mortality and morbidity in premature infants. Those who survive, however, often have significant cutaneous abnormalities. This has led to enhanced understanding and care of the premature infant's skin. Future dermatologic research may develop methods both to control epithelial maturation and to deliver therapy through the skin.

Cutaneous absorption of hexachlorophene in low-birth-weight infants

Five low-birth-weight infants bathed daily with a diluted 3 per cent hexachlorophene solution for 21 to 56 days had blood hexachlorophene concentrations of 0.21 to 1.1 μg per milliliter, with a mean of 0.482 μg per milliliter. Although the infants did not have abnormal neurologic signs, the highest value was comparable to those reported in hexachlorophene-fed rats who developed edema and cystic changes of the cerebral white matter. This suggests that appreciable amounts of hexachlorophene can be absorbed through the skin of premature infants, who may also have a limited ability to metabolize and/or excrete it. Daily bathing of low-birth-weight infants with hexachlorophene, as currently practiced, should be discontinued. Five low-birth-weight infants bathed daily with a diluted 3 per cent hexachlorophene solution for 21 to 56 days had blood hexachlorophene concentrations of 0.21 to 1.1 μg per milliliter, with a mean of 0.482 μg per milliliter. Although the infants did not have abnormal neurologic signs, the highest value was comparable to those reported in hexachlorophene-fed rats who developed edema and cystic changes of the cerebral white matter. This suggests that appreciable amounts of hexachlorophene can be absorbed through the skin of premature infants, who may also have a limited ability to metabolize and/or excrete it. Daily bathing of low-birth-weight infants with hexachlorophene, as currently practiced, should be discontinued.